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Tuesday, June 6, 2023

When correcting dysfunction - is it necessary to activate individual muscles or can we use larger integrated exercises alone to correct movement patterns?

Brent Brookbush

Brent Brookbush


Panel Discussion: When correcting dysfunction - is it necessary to activate individual muscles or can we use larger integrated exercises alone to correct movement patterns?

Is it necessary to "fix the pieces before we assemble the puzzle"?

This question has significant impact on our exercise selection so I want to be clear on the intent of this discussion, so here is an example -

If someone has "knee's bow in" during movement assessments, after I do my mobility work (if necessary):

Should I activate the gluteus medius and gluteus maximus with isolated activation before performing a squat to row, or could I do a squat with a fit loop around my knees and get the same result?

Moderated by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS

This Panel Discussion was originally posted on my facebook page - https://www.facebook.com/brent.brookbush - on March 1st, 2014

Melinda Reiner Simple answer: integration…it's how the body works. Also, not so sure you can truly "isolate" most muscles in the human body.

Brent Brookbush So are you saying that activating the gluteus medius alone is ineffective or unnecessary in the example above? What about relative flexibility and compensation patterns?

Melinda Reiner I am saying that exercises for glute medius are not truly isolated. For example, clams and tube walking make use of other muscles to help assist in these movement. i.e. other external rotators of the hip.

Melinda Reiner While you are strengthening glute medius, you are also activating nearby muscles that perform similar movement. This is good, as this is what happens in real life. It's all motor learning, with strength work thrown in.

Brent Brookbush Fair enough Melinda Reiner, but our intent is to increase activity of a group, or single group of muscles. There are other approaches that shy away from this practice all together, as in my example above, they attempt to fix the problem as a whole with 1 - 3 movement "corrective exercises". For example, someone might try to fix their upper body dysfunction with rolling patterns and holding tubing during an overhead squat for resistance similar to the standing scaption exercise. The question becomes which approach is right. Do we need "relatively isolated activation" or should we try to correct the patterns as a whole?

Melinda Reiner Depends where the client is at. Start with "relative isolation" and progress rather quickly on to more complex movements, as you said, to correct "movement patterns." We're definitely on the same page.

Brent Brookbush So do you think there is a point were "relatively isolated activation" exercises become unnecessary, or do you think that there will always be a couple of these movements in your warm-up before performing your integrated movement patterns?

Melinda Reiner Yes. Once the isolated activity starts to become "easy," it's time to institute coordinated muscles into the new motions.

Robert Gazso Gary Gray has what he calls isolated integration exercises where he will “tweak in a muscle” to emphasize it in a functional pattern. He tends to do this in gravity or in a functional pattern which makes more sense to me. Grey Cook uses RNT for an isolated integration. Vladimir Janda says that “the test is the exercise and the exercise is the test.” In the earlier stages of working with someone I may use a muscle test that the client tested weak/underactive on for the exercise in order to achieve muscle balance and then as this is achieved I work this as quickly as possible into a functional/sports specific movement pattern.

Scott Mitchell More often than not, integrated movement will do the job. Load the body three dimensionally and with gravity (ie: standing). This is what the nervous system wants and needs. In life muscles don't function in an isolated fashion, but as an integrated unit. Although some pathologies, injuries, etc. may call for some isolated work prior to.

Brent Brookbush Nice Robert Gazso,

I like it, I think from a practical standpoint, as optimal movement is more of a journey than an actual destination, I always find myself using some "isolated activation" techniques followed by integration techniques as part of every routine.

Melinda Reiner I think we're all on the same page. Great comments by Robert and Scott.

Brent Brookbush Scott Mitchell, as faculty of NASM, how do you correlate that comment with the NASM CES model - Release, lengthen, ACTIVATE, integrate?

Robert Gazso Hey Scott- I respectfully disagree. First we would need to find the reason why the muscle is inhibited or underactive to begin with. This must be addressed. Just using an exercise to activate the muscle will most frequently result in strengthening a compensation pattern.

Robert Gazso Grey Cook calls this putting strength on top of dysfunction.

Brent Brookbush So to my initial question Robert Gazso you would say we do have to "Fix the pieces before we assemble the puzzle"?

Maurice D. Williams The research speaks for itself is my simple answer. For example, read this quick blurb:http://www.kineticthreesixty.com/online-courses/online-courses/services/injury-management/injury-management-services/case-study/ . I was looking for the full article, but b/c of NASM's Corrective Exercise approach, which does incorporate "isolated" or to activate a particular muscle(s), Shaq was able to improve his game. I can say the same for Grant Hill whose career was resurrected/saved b/c of NASM's Corrective Exercise approach.

Robert Gazso We have to fix the pieces -yes. There may be a way to do this in an integrated fashion.

Barbara Fralinger Hmmm… I am just wondering where isometric contraction comes into play with this. Any thoughts?

Robert Gazso For example- what if we released an overactive TFL which was causing altered reciprocal inhibition and decreased neural drive to the Gmax as we exercised the Gmax.

Jamie Wolf Both can be appropriate in different circumstances. However, positional weakness needs to be corrected or compensation will likely occur. Progression to dynamic movement is great, but what happens when we try to progress just a little fast and something gets tweaked? Then we have to go back to fixing the pieces.

Brent Brookbush Hey Robert Gazso, I don't understand why releasing the TFL would reduce neural drive to the glute max… can you explain?

Robert Gazso It would increase neural drive to the Gmax. Did I state that correctly?

Robert Gazso So an overactive TFL=decreased neural drive to Gmax.

Robert Gazso NASM and NKT are 2 systems I use which address this relationship.

Brent Brookbush So its a typo in your previous post Robert Gazso?

I agree, but I would say that you need to follow release and lengthening with activation for the glute max, and possibly reactive activation before we can ensure better recruitment during multi-joint patterns.

Brent Brookbush Great comment Jamie Wolf, I have definitely reassessed with an integrated pattern to find I left something behind that needs to be addressed.

Brent Brookbush Thanks for the link Maurice D. Williams, nice post.

Robert Gazso My experience is they do not have to be separate steps Brent. Since I am an LMT i am able to use ART/pin and stretch on the TFL as they are going through the movement. The result I find is that when I then perform a muscle test on the Gmax that I find a "stronger" test. Basically because we have better neural drive to the muscle.

Jamie Wolf We are only as strong as we are stable. If we aren't stable, then compensation has a great chance at working it's magic in tweaking a joint. However, if proper warm up including a combination of inhibit, lengthen, activate, integrate is incorporated the opposite can happen equaling positive progression. The right combination seems to vary from person to person and which movement system we are addressing.

Robert Gazso Would everyone agree that this not a strength issue but instead a neural issue? If so we do not want to apply a strength solution to a neurological problem. This is why I prefer how the NASM and NKT systems approach this underactive muscle/movement.

Robert Gazso Jamie - Agree. I think stability and mobility are inversely and interdependently related.

Robert Gazso Hi Barbra - I have seen that Mike Clark uses isometrics but need to be more aware of the research on this. I think using isometric while stretching of the antagonist that is creating altered reciprocal inhibition will increase the neural drive to the Gmax if you gave it resistance in this position.

Ryan Chow i think in most cases it is a neural issue but in some less common cases it is a strength issue. Take a person who had optimal biomechanics but became bed ridden and then weak and overweight due to inactivity (for a reason unrelated to lower extremity problems). If you ask them to do a step up, they may no longer have the glute max strength to perform the movement optimally anymore. Going forward you may need to strengthen the glute max to allow for optimal biomechanics again. If that is not done, they will step up however they can and they may adapt a poor motor pattern due to the glute max's weakness. Aside from a special case like this, I have had some experience correcting functional movement patterns without activation (but with the rest of the corrective exercise continuum) but with a lot of verbal cuing, tactile cuing, and strengthening (via large multi joint movements, not isolated) over time. With just body weight, it seems compensation isn't always reinforced and can be altered with enough practice and training.

Robert Gazso Yes - MAT has great positional isometrics. The problem is they are not addressing the reason the muscle is inhibited in the first place. They are looking at half of the equation. They look at stability.

8 hours ago · Like

Ryan Chow i should also note that during the reeducation of the unloaded functional movement, I would ask the client if they felt the underactive muscle contracting, and each successive session they would feel more and more, so it is hard to differentiate if the improved movement was due to increased strength or if there was a learned training effect (neural)

Robert Gazso You can get much faster gains with addressing the neural dysfunction. If done properly a muscle that previously tested weak will test strong after a few min of treatment.

Robert Gazso Also when there is decreased neural drive to a muscle then over time this will lead to atrophy.

Brent Brookbush Hey Robert Gazso, so I agree with your assessment of the TFL glute max relationship, but we have to ask what is optimal. If you don't activate through the new available range and potentially consider timing and integration I think we get less carry-over session to session. In general I find that manual techniques provide the most instant relief (and most being geared toward mobility - like "pin-stretch"), but it is the activation, stabilization and integration work that they get with me and in their home exercise program that creates the carry over.

I also think we need to be very careful calling this a neural issue… when PT's talk about neural issues we are thinking stroke, spinal cord, neuropathy, MS, etc… these are problems stemming from a damaged nervous system… however, I get where you are coming from. In essence, we are all looking for a certain amount of neural plasticity, but when we address orthopedic issues we look for changes in muscle length and activity, changes in joint mobility and potentially fascial congruity… we hope that these changes alter afferentation and slowly change how we move.

Ryan Chow again i think it depends on the situation…a few minutes of treatment won't change a severely atrophied muscle's ability to produce enough force to say…extend the hip and the whole upper body in a step up

Jamie Wolf I think we as professionals should be very careful with negating the quality of another reputable form of continuing education. At the end of the day, I'm in the business of helping people move better and get results. I'm results focused. Upon greater research in these disciplines; MAT, NASM-CES, there is scientific validity for both. There's unfortunately some Guru's out there with way too much I'm right your wrong. The question is the tool safe and tied to research and assessment of your client. Getting involved in the latter makes the fitness field very confusing for new trainers. I have had the opportunity to be trained in many techniques and use them all as appropriate.

Robert Gazso Yes thanks Jamie.

Brent Brookbush Here you go Jamie Wolf - One step ahead of you

Just becuase you're right; doesn't mean I'm wrong

Just because you’re right, doesn’t mean I’m wrong | Brent Brookbush


Robert Gazso Good point Brent " In general I find that manual techniques provide the most instant relief (and most being geared toward mobility - like "pin-stretch"), but it is the activation, stabilization and integration work that they get with me and in their home exercise program that creates the carry over."

Jamie Wolf That's great, Brent!

Robert Gazso Thanks for the great article Brent.

Jamie Wolf Brent, your contributions in your free web page are awesome!

Robert Gazso Perhaps "motor control" would be more accurate Brent? Thanks.

Chris Ross · Friends with Nick Chertock and 9 others

There could be nine million reasons a muscle is inhibited. Thinking your going to know all of those reasons is a not realistic IMO. Food allergies , systemic stress, adrenal fatigue, mineral deficiencies, etc. etc. can all play into this. Saying a therapy is only half effective because they don't get to the "cause" is short sided at best.

I am glad to see more of an emphasis on neuromuscular approaches/therapies . Lets not think any one

Approach is better.

There is a lot more we don't know than we do know by a lot.

Scotty Butcher Phd The short answer to your scenario is: neither. The shortsightedness of 'corrective' exercise is both the lack of integration and transfer-ability and the lack of emphasis on movement control and awareness. Corrective methods can reinforce proper movement patterning as supplemental work, but if someone moves poorly (resulting in what most people call muscle inactivation), the baseline movement pattern is way more important than 'corrective' exercise. Fix the movement pattern then immediately apply it to whole body loading.

Nick Chertock And when going about fixing the pattern do you not look at muscle groups that may be inhibited?

Robert Gazso Scotty-"Fix the movement pattern then immediately apply it to whole body loading." - How?

Jamie Wolf Scotty- that would be assuming we didn't integrate back to the basic movement pillars. Cex makes you better at traditional movements such as deadlifts.

Scotty Butcher Phd Nick - Not really, no. What does "look at" mean and what does "inhibited" mean? Both views are assuming that somehow we have control over an individual's ability to selectively isolate muscles and that even if this were possible that they can develop the motor patterning to apply this to more integrated movement. Inhibition is really just 'lack of use' with poor movement patterns that develop. Think about what we used to think about PF pain and VMO contraction. "Inhibited" VMO is a symptom of poor hip control/femur positioning. All the VMO isolation work is completely useless if you don't correct the hip control. And if you do correct the hip control issues, better patellar tracking results in VMO "facilitation".

Brent Brookbush Hey Chris,

I have heard some of these rationales before, but I think there is a logical error in assuming that "Food allergies , systemic stress, adrenal fatigue, mineral deficiencies, etc. etc." are playing a primary role in a dysfunction. That is, these are systemic issues, that if they were the root of the problem would cause wide spread dysfunction and not specific dysfunction. That is not to say that general health and wellness is not important, but simply that if someone comes in with shoulder impairment limiting their performance or causing pain I am not going to send them on a relaxing vacation with a mineral supplement. I may educate on general health, but my intervention will be focused on fixing the upper body dysfunction at the root of their problem.

Robert Gazso Good points Chris. I consider many of the things you listed. I can't find the reason all the time but am still interested in finding the cause.

Scotty Butcher Phd Jamie - corrective exercise is only effective if it is supporting more basic work in movement patterning (in which case it is the movement control work, not the corrective exercise itself that improves whole body function). I've seen many "corrective" specialists demonstrate or take clients through Cex with piss poor underlying movement. It isn't the exercise itself (nor the muscle itself) that is the problem/solution.

Brent Brookbush Hey Scotty Butcher Phd,

I would agree that our ability to affect the VMO is not great, but this is a practical issue of not being able to isolate the VMO from the other quad muscles. You mention going after the hip, how would you do that? We may be arguing rationale rather than practical application.

For example, most knee pain I see stems from lower leg dysfunction - that includes excessive hip internal rotation, potentially anterior and/or superior glide of the femur, excessive plantar flexion and eversion at the ankle complex. I would look at the muscle lengths and activities implied by this dysfunction and correct these before working on integrated movement patterns and slowly increasing the intensity in a conditioning program.

Lower Leg Dysfunction (LLD) | Brent Brookbush


Scotty Butcher Phd Jamie - Motor control training with reinforcement and progression in a whole body lift. Corrective 'work' is purely supplemental.

Jamie Wolf Scotty- good therapists/bad therapists…good trainers/bad trainers…if applied incorrectly it wouldn't be effective. Have you had experience with someone applying these tools effectively? It's life changing.

Scotty Butcher Phd Brent - agreed that the lower leg positioning/movement can be an issue and I do agree that we may be arguing rationale vs. practical application. In terms of how we fix this - of course it can be quite complex (and other times very simple), but I have yet to see someone's patella tracking improve simply and only with VMO facilitation. This, in my experience, also applies to many of the other 'dysfunctional' movement patterns we tend to see.

Scotty Butcher Phd Jamie - I have and I argue that this is the movement control that is reinforced with better patterning. Cex is only one method of reinforcement. I guess this also comes down to definitions as well. To me, what I've seen to be ineffective is an overreliance on the use of loading in Cex. Personally, I've found better success with unloaded movement training progressed into integrated exercises rather than loading the supplemental exercises.

Jamie Wolf The example I think of is this: A coach yelling at a football player for not getting low enough over and over again and not considering that they don't have the ability to get into that position without corrective work. Once stability has been created. Getting low with good form comes much more easily. Keep in mind this person has little external load…

Robert Gazso Scotty - I like the unloaded to loaded progression.

Scotty Butcher Phd Jamie - I agree with that example completely. I think where I see a disconnect is how that corrective work is applied.

Scotty Butcher Phd Robert - at what point do you draw the line and say that it is time to integrate? How much loading (assuming you meant loading corrective movements) is enough? If this is done along with integrated movements, I think it can be a useful reinforcement, but in my mind, the integrative movement training is way more important.

Jamie Wolf It sounds like the opinion of choosing one tool vs another. If it works your way. Great. I'm cool with that. If it doesn't, let's look at other options and vice versa.

Scotty Butcher Phd I don't disagree, Jamie.

Scotty Butcher Phd Those who move quite poorly need more reinforcement and Cex is very useful as supplemental/accessory work, IMO. But usually not in place of the whole body movement training.

Sue Hitzmann I think we all should just move in different ways daily. Wiggle, bend, twist, go forward, maybe take some steps back or to the side, reach up… If what you want is an answer to what one thing is best… answer = NOTHING. I like Jamie's comment above. Build a good foundation and try lots of stuff and learn new things. Seems a simple answer to your puzzle analogy of the human body. Support it however you can. Learn lots of ways to remain healthy for your lifetime and I'd say, you are good to go - There's my Saturday commentary. Thanks all for inviting me to this thread Brent Brookbush!

Tony Susnjara My background is yoga so my perspective might be different but I would most often work on a "whole - part - whole" basis. Use the whole movement or position diagnostically, focus on the parts that were not flexible or stable or strong enough and then gradually reintegrate back into the whole. And just on a conceptual level - how do you define 'the whole' and 'the part’??? There is no movement that activates everything and there is no absolute 'part' that operates or functions autonomously. I see these as a series of continuums without any absolute demarcation.

Ryan Crandall I like what Sue said….it reminded me of the work of Feldenkrais. Furthermore, the brain doesn't operate on a muscle by muscle basis (as we all know). The brain knows patterns of function (push, pull, squat, gait, etc). Sometimes we have to regress some things in the clinic such as "frozen shoulder" patients who present with nasty upper trap contraction. Sometimes a little contract relax and positional release techniques help. Sometimes applying kineseotape can also help drive function neurally.

Move in different ways and daily, love that Sue Hitzmann!

"Mind body" practices are great and should be more of a part of out (rehab and fitness) such as yoga (3d yoga), tai chi, Feldenkrais, Alexander techniques…

Brent Brookbush Activation does not change CNS output alone, part of the change is driven by sensory stimulation. Better input = better output.

Ryan Crandall ^true

Brent Brookbush This has been a great conversation thanks for eveyone's contribution - Ryan Crandall, Ryan Chow, Tony Susnjara, Jamie Wolf, Robert Gazso, Sue Hitzmann, Scotty Butcher Phd, Scott Mitchell, Chris Ross, Melinda Reiner and Maurice D. Williams.

Brent Brookbush Where I stand -

The question above started with one of my quotes I use during teaching the "Advancement in Exercise Selection" workshops

I simply rephrased the following quote into a question:

"You have to fix the pieces before you assemble the puzzle."

Without correcting the length and activity of the muscles involved, arthrokinematic dyskinesis, and the fascial restrictions that are the result of postural dysfunction; the CNS will be forced to create a compensation pattern around restriction and inhibition and be victim to synergistic dominance and hypertonicity.

Excerpt from my article - "Introduction to Postural Dysfunction and Movement Impairment"

"Order of Treatment

Based on common practices, the NASM CES model, and various other sources (1-10).

As inflammation, pain, and fascial changes may affect afferentation, muscle activity, and arthrokinematics; mitigation of these factors should precede other techniques (1,5,6,8,10). This would include, ice, heat, Grade I – II mobilizations, scar tissue massage, interferential electric-stimulation, edema taping, and potentially fascial techniques. Note: this would precede the treatment of altered muscle length and activity and falls under the scope of liscenced professionals only.

The NASM CES model (2) recommends flexibility (mobility) techniques precede activation, strengthening and neuromuscular reeducation; although, this is not an original concept. The premise is based on altering length tension relationships, reducing altered reciprocal inhibition and improving arthrokinematics; making the lost ROM available for use during activation. In essence, you cannot train an individual to use a ROM they do not currently possess. This includes trigger point release, active release, positional release, instrument assisted soft-tissue techniques, static stretching, active stretching and mobilizations Grade III – V.

Note: As mentioned in this course a relationship exists between soft tissue release and mobilization of joints, in which one may facilitate change in the other. Placing release techniques first in the model below is only based on making self-administered mobilization techniques more effective (generally speaking, self-administered mobilization techniques are not great). In practice, manual mobilization may need to precede soft tissue techniques in order to reduce hypertonicity of the muscles one is trying to affect.

Neural Mobility: These techniques should follow the soft tissue release discussed above for those individuals incensed to address neural involvement in orthopedic issues. As Butler mentions, if you treat the tunnels you may not need to treat the nerve.

Activation and Integration (Neuromuscular Re-education) is next and placed in order of intensity and complexity. Initially specific structures are targeted (2), followed by integrating under-active muscle synergies (this could be viewed from the perspective of motor control, i.e. Richardson et. al (10), followed by improving firing rate (2), and finally cued practice and facilitation of integrated functional tasks. Included in this category would be activation, reactive activation, rhythmic perturbation, core activation, PNF, RNT, stability integration, subsystem integration, and functional training for optimal performance of ADL’s, and potentially taping techniques.

Based on the discussion above, the following order may be extrapolated:

⦁ Pain management, fascial mobilization, edema control

⦁ Release

⦁ Mobilize

⦁ Neural Mobility (when appropriate)

⦁ Stretch

⦁ Isolated Activation

⦁ Core Activation

⦁ Inter-muscular Coordination/Stability Integration (Optional)

⦁ Intra-muscular Coordination/Reactive Integration (Optional)

⦁ Subsystem Integration (Optional)

⦁ Functional Tasks (may be integrated into steps 8-10)

Reinforce with taping, home exercise program, educational materials, and follow-up.

Brookbush Institute - Integrated Warm-up Template (For use by all professionals):




Mobilize (When Appropriate)

Activation & Integration (Perform each exercise for 12-20 reps, in circuit, for 1-3 sets):

Isolated Activation

Core Support (Optional)

Stability Integration (Optional)

Reactive Integration (Optional)

Subsystem Integration"

As you can see, I am an integrationist and use a variety of techniques to achieve optimal movement. In the post I embedded a link to the articles that detail the majority of the activation techniques I use

New York City - Advancements in Exercise Selection - Lower-Leg Dysfunction

Advancements in Exercise Selection - Lower Leg Dysfunction "A routine is only as effective as the exercises selected and the quality of their execution." In this workshop series we will refine our …

Scotty Butcher Phd Hey Brent, interesting system. I like the way you've laid it out, even if I don't agree with everything. Nice work!

Brent Brookbush Thanks Scotty Butcher Phd,

Just trying to integrate ideas with in a system based on evidence, logic, and outcomes. Interestingly, outside of NASM, I feel I am one of the few who has discussed order of techniques, or how to assemble a variety of techniques into a session. Very strange. At the end of the day it is what everyone of us does.

Maurice D. Williams Brent Brookbush: you're definitely one of the few(I'd add Justin Price & Anthony Carey) outside of NASM from a "global" standpoint. A few of us try to hold it down locally within our respective sphere of influences.

Brent Brookbush You keep holdin' it down Maurice D. Williams!

Barbara Fralinger I'm one of the few too - in many different areas.

Brian Sutton I haven’t read the entire thread, but I love the fact that many approaches are coming forth in this discussion.

I remember having a conversation a while back with Mike Clark about this; when he was rehabilitating a well-known athlete after a severe ankle sprain. In simple terms, he had to focus on the injured site and surrounding musculature to regain mobility and neural activation. However, he couldn’t neglect the entire kinetic chain and only rehabilitate the ankle. Since gluteal activation is shown to be diminished following an ankle sprain, performing activation techniques at the hip was also necessary.

Logically it makes a lot sense, no matter if its rehabilitation for an injury (for all you AT’s and PT’s) or addressing muscle imbalance for all the CPT’s out there. If we want to improve function, neuromuscular activation and restore length-tension relationships, a comprehensive approach works rather well. I’m not saying it’s the only way, but I do know it works.

Yes, the body performs movement using muscle synergies rather than individual muscles. However, we can emphasize and target a particular muscle (or small group of muscles) using isolated strengthening, positional isometrics or manual therapy. But… the overall goal is progress into total-body, compound, and dynamic activities to improve total-body neuromuscular efficiency.

I equate it back to the philosophy of the OPT model. The OPT model incorporates all forms of exercise into a progressive system. We as fitness professionals do not need to discredit varying approaches. We can combine them all, as long as it is systematic and progressive and tailored to the individual.

© 2014 Brent Brookbush

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