Introduction: Electromyographic Analysis of Infraspinatus and Scapular Muscles During External Shoulder Rotation with Different Weight Loads and Positions

How Does This Relate to Brookbush Institute Content: Shoulder Muscle Recruitment Pattern During Common Rotator Cuff Exercise

Introduction: Selective Activation of the Infraspinatus Muscle

Study Summary: Selective Activation of the Infraspinatus Muscle

How This Study Contributes to the Body of Research: Selective Activation of the Infraspinatus Muscle

How the Findings Apply to Practice: Selective Activation of the Infraspinatus Muscle

How Does This Study Relate to Brookbush Institute Content: Selective Activation of the Infraspinatus Muscle

Introduction: Electromyographic Analysis of Rotator Cuff and Deltoid Musculature During Common External Rotation Exercises

Study Summary: Electromyographic Analysis of Rotator Cuff and Deltoid Musculature During Common External Rotation Exercises

How This Study Contributes to the Body of Research: Electromyographic Analysis of Rotator Cuff and Deltoid Musculature During Common External Rotation Exercises

How the Findings Apply to Practice: Electromyographic Analysis of Rotator Cuff and Deltoid Musculature During Common External Rotation Exercises

Study Summary: Electromyographic Analysis of Infraspinatus and Scapular Muscles During External Shoulder Rotation with Different Weight Loads and Positions

How Does This Study Relate to Brookbush Institute Content: Electromyographic Analysis of Rotator Cuff and Deltoid Musculature During Common External Rotation Exercises

How This Study Contributes to the Body of Research: Electromyographic Analysis of Infraspinatus and Scapular Muscles During External Shoulder Rotation with Different Weight Loads and Positions

How the Findings Apply to Practice: Electromyographic Analysis of Infraspinatus and Scapular Muscles During External Shoulder Rotation with Different Weight Loads and Positions

How Does This Study Relate to Brookbush Institute Content: Electromyographic Analysis of Infraspinatus and Scapular Muscles During External Shoulder Rotation with Different Weight Loads and Positions

Introduction: Shoulder Muscle Recruitment Pattern During Common Rotator Cuff Exercise

Study Summary: Shoulder Muscle Recruitment Pattern During Common Rotator Cuff Exercise

How This Study Contributes to the Body of Research: Shoulder Muscle Recruitment Pattern During Common Rotator Cuff Exercise

How the Findings Apply to Practice: Shoulder Muscle Recruitment Pattern During Common Rotator Cuff Exercise

Comparing Shoulder External Rotation Exercises

NASM

ACSM

ProCert

AFAA

NCBTMB

CanFitPro

PTAGlobal

ISSA

REPS

REPSI

PACE

YOGA

WITS

CIMSPA

AUSPHYSIO

TPTA

NYPT

AOTA

Comparing Shoulder External Rotator Exercises

Sasaki, et al. (2017). Electromyographic Analysis of Infraspinatus and Scapular Muscles During External Shoulder Rotation with Different Weight Loads and Positions

Original Citation: Sasaki, S., Kenmoku, T., Otera, A., Miyajima, G., Nagura, N&#x2026;Takahira, N. (2017). Electromyographic analysis of infraspinatus and scapular muscles during external rotation with different weight loads and positions. Journal of orthopaedic science, 28(1), 154-158 - <a href="https://www.sciencedirect.com/science/article/pii/S0949265818301374?via%3Dihub" target="_blank" rel="noopener">ARTICLE</a>
Resisted external rotation is commonly used as a strengthening exercise for the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> rotator cuff musculature (1,2). Lighter loads are often recommended with the intent of optimizing <a id="posture" data-tip="1660" target="_blank" href="/glossary-term/posture" class="glossary">form</a> and reducing the recruitment of <a href="https://brookbushinstitute.com/glossary/synergists/" target="_blank" rel="noopener">synergistic</a> muscles. This 2017 study by Japanese researchers, compared the electromyographic (EMG) activity of the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a>, <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">posterior deltoid</a>, <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius</a>, and <a href="https://brookbushinstitute.com/article/arm-muscles" target="_blank" rel="noopener">bicep brachii</a> during seated and <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a> resisted external rotation with varying loads. The study findings suggest seated external rotation using a higher load, with 0&#xBA; of <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> abduction and 90&#xBA; of elbow flexion, may result in the greatest <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> activity.
<a href="https://www.datocms-assets.com/25800/1646156803-figure-1-1b-rotator-cuff_side-view.jpeg"><img src="https://www.datocms-assets.com/25800/1646156803-figure-1-1b-rotator-cuff_side-view.jpeg"></a>
Musculature surrounding the shoulder

Introduction

<table>
 <tbody>
 <tr>
 <td width="40%">Study Design</td>
 <td>Observational/Comparative study</td>
 </tr>
 <tr>
 <td>Level of Evidence</td>
 <td>III - Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies</td>
 </tr>
 <tr>
 <td>Participant Characteristics</td>
 <td>Demographics
 <ul>
 <li>Number of participants: 16
 <ul>
 <li>A total of 30 shoulders were tested</li>
 </ul>
 
 </li>
 <li>Gender: 8 males, 8 females</li>
 <li>Male mean age: 26.1</li>
 <li>Female mean age: 25.9</li>
 </ul>
 Inclusion Criteria:
 <ul>
 <li>All participants were asymptomatic, with no pain in the shoulder tested.</li>
 </ul>
 Exclusion Criteria:
 <ul>
 <li>Shoulders with any pre-existing pain or pathology.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Methodology</td>
 <td>
 <ul>
 <li>Electrodes were inserted into the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a>, <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">posterior deltoid, </a><a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius,</a> and <a href="https://brookbushinstitute.com/article/arm-muscles" target="_blank" rel="noopener">bicep brachii</a>.</li>
 <li>Participants were instructed to perform external rotation with 0&#xBA; of shoulder abduction and 90&#xBA; of elbow flexion.</li>
 <li>Participants performed 8 different testing conditions.
 <ul>
 <li>A seated position using:
 <ul>
 <li>no weight</li>
 <li>.5-kilogram</li>
 <li>1-kilogram</li>
 <li>2-kilograms</li>
 </ul>
 
 </li>
 <li>A <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a> position using:
 <ul>
 <li>no weight</li>
 <li>.5-kilogram</li>
 <li>1-kilogram</li>
 <li>2-kilograms</li>
 </ul>
 </li>
 </ul>
 </li>
 </ul>
 
 <ul>
 <li>The isometric external rotation movement for each testing position was held for 5-seconds at end range to gain an accurate EMG reading.</li>
 <li>A 1-minute rest period was used between each set.</li>
 <li>3 sets were used for each condition being tested.</li>
 <li>A 5-minute rest period was used before switching <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> conditions.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Data Collection and Analysis</td>
 <td>Data Collection
 <ul>
 <li>Maximal EMG data was collected for 5 seconds during %MVIC testing.</li>
 <li>The maximal isometric strength was measured using a handheld dynamometer.</li>
 <li>The highest EMG activity was collected for each condition.</li>
 </ul>
 Data Analysis
 <ul>
 <li>EMG values were determined by averaging the middle third of the 5-second isometric contractions.</li>
 <li>A two-factor analysis of variance was used to compare differences among each condition tested.</li>
 <li>A Tukey&apos;s <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> was used to compare the significance at a P=0.05.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Outcome Measures</td>
 <td>
 <ul>
 <li>Peak EMG activity for all four muscles was measured during each testing condition.</li>
 <li>%MVIC of the four loads tested was measured in the seated and <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a> testing conditions.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Results</td>
 <td>
 <ul>
 <li>EMG activity varied significantly among the 8 conditions.</li>
 <li>%MVIC was significantly higher <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> higher (20.83) in a seated position with the 2-kg load.</li>
 <li>%MVIC was significantly higher for all muscles tested when participants used a 2-kg load when compared to lighter loads.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Our Conclusions</td>
 <td>The findings of this study indicate that external rotation exercises performed with a higher load can increase the activity of the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a>. This implies that load should be increased in a progressive manner to maximize <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> recruitment and strength.</td>
 </tr>
 <tr>
 <td>Researchers&apos; Conclusions
 
 </td>
 <td>EMG activity varied significantly among the eight conditions tested. Muscular recruitment, specifically activity in the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a>, can be increased through a gradual change in load. The seated external rotation exercise with a 2-kg load (large load tests) resulted in the most <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> activity (20.83 %MVIC). Therefore, using these greater loads may be an effective progression to integrate into an external rotation exercise program for strengthening the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a>.</td>
 </tr>
 </tbody>
</table>
<a href="https://www.datocms-assets.com/25800/1646156845-shoulder-external-rotation-300x198.png"><img src="https://www.datocms-assets.com/25800/1646156845-shoulder-external-rotation-300x198.png"></a>
External rotation activation

Study Summary

This study compared the activity of the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus,</a> <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">posterior deltoid</a>, <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius</a>, and <a href="https://brookbushinstitute.com/article/arm-muscles" target="_blank" rel="noopener">bicep brachii</a> during seated and <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a> external rotation exercises with varying loads. Additional research has demonstrated that body position may effect shoulder and scapular <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment (2, 8, 10). The results of this study demonstrated that seated external rotation resulted in greater <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment than <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a> external rotation and that larger loads resulted in greater recruitment of all muscles, especially the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a>.

How This Study Contributes to the Body of Research

The results of this study suggest that body position and load may have an impact on <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment. Human movement professionals should consider assessing external rotator strength and the ability to perform the desired <a id="exercise-progression" data-tip="1181" target="_blank" href="/glossary-term/exercise-progression" class="glossary">exercise progression</a> with good <a id="posture" data-tip="1660" target="_blank" href="/glossary-term/posture" class="glossary">form</a>. Once an ideal starting <a id="exercise-progression" data-tip="1184" target="_blank" href="/glossary-term/exercise-progression" class="glossary">progression</a> and load is determined, <a id="exercise-progression" data-tip="1184" target="_blank" href="/glossary-term/exercise-progression" class="glossary">progression</a> of exercise and load may be ideal for optimizing <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment and strength.
Strengths
<ul>
 <li>The exercise used in this study is commonly used in practice, increasing the applicability of the findings.</li>
 <li>Multiple muscles were tested simultaneously, allowing for direct comparison during all <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> conditions.</li>
 <li>Although it is odd, determining the effect load had on recruitment was not previously studied. This study filled a gap in the body of research.</li>
</ul>
Weakness and limitations
<ul>
 <li>Only healthy and pain-free shoulders were studied. This may limit the applicability of findings to an injured population.</li>
 <li><a href="https://brookbushinstitute.com/article/supraspinatus" target="_blank" rel="noopener">Supraspinatus</a> and <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">middle deltoid</a> activity were not measured in this study. These muscles may contribute to <a href="https://brookbushinstitute.com/glossary/compensation-pattern/" target="_blank" rel="noopener">compensation</a> during external rotation exercises with higher loads.</li>
 <li>Only one exercise was used in the study. Clinicians often use several variations of external rotation in the course of a treatment plan. Further research should investigate the effect load has on <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment during a variety of commonly used exercises.</li>
</ul>

How the Findings Apply to Practice

The Brookbush Institute (BI) continues to refine and develop predictive <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a> of dysfunction, including <a href="https://brookbushinstitute.com/article/upper-body-dysfunction-ubd" target="_blank" rel="noopener">Upper Body Dysfunction (UBD)</a>, with the intent of optimizing <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a> education and practice. This study helps to demonstrate the relationship load has on <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> recruitment during a seated and <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a> external rotation exercise. The BI has refined interventions for <a href="https://brookbushinstitute.com/video/shoulder-external-rotator-activation-progression" target="_blank" rel="noopener">external rotator activation</a> by integrating the findings of this study with other studies investigating/comparing rotator cuff exercises. The BI will continue to pursue <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> practice by integrating research, with practical application and outcomes, in pursuit of refining recommendations and exercise selection for <a href="https://brookbushinstitute.com/article/upper-body-dysfunction-ubd" target="_blank" rel="noopener">UBD</a>.

How Does This Study Relate to Brookbush Institute Content

Shoulder External Rotator Activation
<iframe src="https://player.vimeo.com/video/82872991" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Shoulder External Rotator Activation Progression
<iframe src="https://player.vimeo.com/video/82854675" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Shoulder External Rotator Reactive Activation
<iframe src="https://player.vimeo.com/video/76687897" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Combined Deep Cervical Flexor and External Rotator Activation
<iframe src="https://player.vimeo.com/video/306486599" frameborder="0" allowfullscreen="allowfullscreen"></iframe>

Bibliography

Dark, et al. (2007). Shoulder Muscle Recruitment Pattern During Common Rotator Cuff Exercise

Original Citation: Dark, A., Ginn, K.A., &amp; Halaki, M. (2007). Shoulder <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment patterns during commonly used rotator cuff exercises: An electromyographic study. Physical Therapy, 87 (8), 1039-1046. - <a href="https://www.ncbi.nlm.nih.gov/pubmed/17578940" target="_blank" rel="noopener">ABSTRACT</a>
Shoulder pain is the third most common musculoskeletal reason for seeking primary care; affecting an estimated 16-26% of the population (1). Rotator cuff pathology is one common cause of shoulder pain (2), and rotator cuff exercise is a commonly recommended intervention. This 2007 Canadian study, investigated the recruitment pattern of shoulder musculature during external and internal rotation exercises, during both concentric and eccentric phases, with low-, moderate- and high-load. All of the muscles capable of performing the joint actions tested were active at all loads, demonstrating a proportional increase in activity as loads increased. This may suggest that these commonly recommended exercises recruit additional musculature, and may not be appropriate if the intent was to preferentially target the smaller rotator cuff musculature.

<table>
 <tbody>
 <tr>
 <td width="40%">Study Design</td>
 <td>Observation/Comparative Research</td>
 </tr>
 <tr>
 <td>Level of Evidence</td>
 <td>III Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies</td>
 </tr>
 <tr>
 <td>Participant Characteristics</td>
 <td>Demographics
 <ul>
 <li>Gender: 11 females; 4 males</li>
 <li>Number of participants: 15</li>
 <li>Average Age: 27 (range 18-42)</li>
 </ul>
 Inclusion Criteria:
 <ul>
 <li>All participants had no pain in their non-dominant shoulder for at least 2 years
 <ul>
 <li>Defined as the shoulder opposite to the one used for writing.</li>
 </ul>
 
 </li>
 <li>Never received treatment (medication, physical therapy, or surgery) on the non-dominant shoulder.</li>
 <li>Underwent a screening by a physical therapist to ensure participants had normal shoulder range of motion and scapulohumeral rhythm.</li>
 <li>No pain with maximum voluntary isometric contraction (MVIC) of both internal and external rotation of the shoulder.</li>
 </ul>
 Exclusion Criteria:
 <ul>
 <li>Previous injuries to the non-dominant shoulder</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Methodology</td>
 <td>
 <ul>
 <li>Participants performed internal and external rotation exercises with a full range of motion with arms positioned by the side and elbow flexed to 90 degrees.</li>
 <li>Participants performed 3 maximum voluntary isometric contractions (MVICs).
 <ul>
 <li>The MVIC&#x2019;s were sustained for 3 seconds.</li>
 </ul>
 
 </li>
 <li>The highest EMG levels observed were used.</li>
 <li>A total of 6 exercise conditions were performed in a randomized order for each participant.
 <ul>
 <li>Internal rotation
 <ul>
 <li>Low-intensity</li>
 <li>Medium-intensity</li>
 <li>High-intensity</li>
 </ul>
 
 </li>
 <li>External rotation
 <ul>
 <li>Low-intensity</li>
 <li>Medium-intensity</li>
 <li>High-intensity</li>
 </ul>
 
 </li>
 </ul>
 
 </li>
 <li>The 3 attempts with the highest <a id="torque" data-tip="1294" target="_blank" href="/glossary-term/torque" class="glossary">torque</a> were recorded as maximum rotational strength.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Data Collection and Analysis</td>
 <td>Data Collection
 <ul>
 <li>Intramuscular wire electrodes were inserted by 23-gauge hypodermic needles into the following shoulder musculature:
 <ul>
 <li><a href="https://brookbushinstitute.com/article/supraspinatus" target="_blank" rel="noopener">Supraspinatus</a></li>
 <li><a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">Infraspinatus</a></li>
 <li><a href="https://brookbushinstitute.com/article/subscapularis" target="_blank" rel="noopener">Subscapularis</a></li>
 <li><a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">Latissimus Dorsi</a></li>
 <li><a href="https://brookbushinstitute.com/article/pectoralis-major" target="_blank" rel="noopener">Pectoralis Major</a></li>
 </ul>
 
 </li>
 <li>Load cell placed in series with the pulley system measured force output.</li>
 <li>The signal from the load cell was amplified and acquired in synchrony with the EMG signals.</li>
 <li>Overhead digital cameras captured the movements of the participants at 25 frames per second.</li>
 </ul>
 Data Analysis
 <ul>
 <li>Each participant&#x2019;s EMG patterns were analyzed for each <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a>.</li>
 <li>The <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity levels were averaged.</li>
 <li>The camera recordings of each participant&apos;s movements were analyzed to ensure proper movement occurred.</li>
 <li>An ANOVA was conducted to determine differences in the average <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity levels for each exercise intensity and each <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a>.
 <ul>
 <li>This analysis was done separately for both internal and external rotation and for both concentric and eccentric contractions.</li>
 </ul>
 
 </li>
 <li>A post-hoc <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> was conducted to determine any differences among EMG levels at an alpha level of .05.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Outcome Measures</td>
 <td>
 <ul>
 <li>Percent of maximum voluntary isometric contraction (%MVIC) for concentric contraction in low-, medium- and high-grade resistance.
 <ul>
 <li>Internal Rotators:
 <ol>
 <li><a href="https://brookbushinstitute.com/article/subscapularis" target="_blank" rel="noopener">Subscapularis</a></li>
 <li><a href="https://brookbushinstitute.com/article/pectoralis-major" target="_blank" rel="noopener">Pectoralis Major</a></li>
 <li><a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">Latissimus Dorsi</a></li>
 </ol>
 
 </li>
 <li>External Rotators:
 <ol>
 <li><a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">Infraspinatus</a></li>
 <li><a href="https://brookbushinstitute.com/article/supraspinatus" target="_blank" rel="noopener">Supraspinatus</a></li>
 <li><a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">Posterior Deltoid</a></li>
 </ol>
 
 </li>
 </ul>
 </li>
 <li>Percent of maximum voluntary isometric contraction (%MVIC) for eccentric contraction in low-, medium- and high-grade resistance.
 <ul>
 <li>Internal Rotators:
 <ol>
 <li><a href="https://brookbushinstitute.com/article/subscapularis" target="_blank" rel="noopener">Subscapularis</a></li>
 <li><a href="https://brookbushinstitute.com/article/pectoralis-major" target="_blank" rel="noopener">Pectoralis Major</a></li>
 <li><a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">Latissimus Dorsi</a></li>
 </ol>
 
 </li>
 <li>External Rotators:
 <ol>
 <li><a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">Infraspinatus</a></li>
 <li><a href="https://brookbushinstitute.com/article/supraspinatus" target="_blank" rel="noopener">Supraspinatus</a></li>
 <li><a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">Posterior Deltoid</a></li>
 </ol>
 
 </li>
 </ul>
 </li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Results</td>
 <td>
 <ul>
 <li>All internal rotators increased activity with increasing resistance.
 <ul>
 <li><a href="https://brookbushinstitute.com/article/subscapularis" target="_blank" rel="noopener">Subscapularis</a> and <a href="https://brookbushinstitute.com/article/pectoralis-major" target="_blank" rel="noopener">pectoralis major</a> showed similar levels of activation throughout the various levels of resistance.
 <ul>
 <li><a href="https://brookbushinstitute.com/article/subscapularis" target="_blank" rel="noopener">Subscapularis</a> peaked at 51 +/- 14% of the MVIC in the high-resistance condition.</li>
 <li><a href="https://brookbushinstitute.com/article/pectoralis-major" target="_blank" rel="noopener">Pectoralis major</a> peaked at 51 +/- 9% of the MVIC in the high-resistance condition.</li>
 </ul>
 </li>
 <li><a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">Latissimus dorsi</a> activity increased in each condition.
 <ul>
 <li><a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">Latissimus dorsi</a> peaked at 28 +/- 6% of the MVIC in the high-resistance condition.</li>
 </ul>
 </li>
 <li>There was little activity in any of the external rotators during concentric internal rotation.</li>
 </ul>
 
 </li>
 </ul>
 <ul>
 <li>All external rotators increased activity with increasing resistance.
 <ul>
 <li><a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">Infraspinatus</a> activity was significantly greater at all resistance levels (peaking at 70 +/- 14% of the MVIC in high-resistance conditions.</li>
 <li>There was little activity in any of the internal rotators during concentric external rotation.</li>
 </ul>
 
 </li>
 <li>For both internal and external rotators, eccentric contraction %MVIC was much lower than the concentric contraction.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Our Conclusions</td>
 <td>All of the muscles capable of performing the joint actions tested were active at all loads, demonstrating a proportional increase in activity as loads increased. This may suggest that these commonly recommended exercises recruit additional musculature, and may not be appropriate if the intent was to preferentially target the smaller rotator cuff musculature.</td>
 </tr>
 <tr>
 <td>Researchers&apos; Conclusions
 
 </td>
 <td>The results indicate, in people who are healthy and asymptomatic, the motor strategy used to deal with increasing rotation resistance with neutral shoulder position is a gradual increase in activity of all shoulder rotation torque-generating muscles.</td>
 </tr>
 </tbody>
</table>
<a href="https://www.datocms-assets.com/25800/1646156845-shoulder-external-rotation-300x198.png"><img src="https://www.datocms-assets.com/25800/1646156845-shoulder-external-rotation-300x198.png"></a>

This experimental study examined the recruitment pattern of the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">rotator cuff</a>, as well as the <a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi</a>, <a href="https://brookbushinstitute.com/article/pectoralis-major" target="_blank" rel="noopener">pectoralis major</a>, and <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">posterior deltoid</a> during internal and external rotation exercises with low, medium, and high loads. The results of this study demonstrate that all shoulder muscles are recruited during resisted internal and external rotation and that the activity of all muscles increases to accommodate larger loads. These findings are supported by previous research (3), and aid in establishing the normal recruitment pattern to be expected from a healthy shoulder. More research is needed to determine if pain alters recruitment during these exercises.

Internal and external rotation exercises, in a shoulder neutral position, are commonly recommended in a clinical setting for rotator cuff pathology. Although this study used asymptomatic participants, it may infer that resisted internal and external rotation performed at 0&#xB0; of flexion or abduction, recruit additional <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> musculature with increasing load, and may not be appropriate if the intent is to preferentially target the smaller rotator cuff musculature. Modifications to these exercises may be necessary if targeting under-active rotator-cuff musculature is the intent of the practitioner. Further, this study and the study by Jenp et al. (3) may be useful in establishing a standard <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> of healthy shoulder <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment, that can be used in <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> and re-assessment for those recovering from shoulder pathology.
Strengths:
<ul>
 <li>Each participant underwent a thorough screening exam, reducing the likelihood of confounding variables.</li>
 <li>Intramuscular EMG (as opposed to surface EMG) was used to measure activity increasing the <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> of the data collection.</li>
 <li>All rotation was measured by an overhead camera to ensure a full range of motion was achieved during all repetitions.</li>
 <li>All concentric and eccentric tempos were standardized at a 4-second interval measured by a metronome, aiding in standardizing force output, and increasing the repeatability of the study.</li>
</ul>
Weakness and Limitations:
<ul>
 <li>This study did not compare symptomatic and asymptomatic participants, reducing the usefulness of findings. Note, the exercises in the study are commonly recommended to symptomatic individuals in a clinical setting.</li>
 <li>Additional testing of unloaded external rotation and internal rotation may have provided additional data on recruitment patterns. For example, it is possible that all loads used were significant enough to recruit all <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a>, and that loads lighter than &quot;low-load&quot; may be accomplished using different recruitment strategies.</li>
 <li>Greater diversity among participants may have aided in increasing transferability, and establishing a baseline for <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> recruitment in the healthy shoulder.</li>
</ul>

The Brookbush Institute (BI) continues to refine and develop predictive <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a> of dysfunction, including <a href="https://brookbushinstitute.com/article/upper-body-dysfunction-ubd" target="_blank" rel="noopener">Upper Body Dysfunction (UBD)</a>, with the intent of optimizing <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a> education and practice. This study demonstrates that internal and external rotation exercises, with neutral shoulder position, do not preferentially recruit rotator cuff musculature. This may imply that modification to these exercises is necessary if targeting these muscles is the goal. The BI has refined recommended interventions for <a href="https://brookbushinstitute.com/article/upper-body-dysfunction-ubd" target="_blank" rel="noopener">UBD</a> by integrating research demonstrating altered recruitment of rotator cuff musculature, the findings from this study, and the findings of additional studies that compare common rotator cuff exercises. The BI will continue to refine recommendations with the goal of optimizing the exercises described in <a href="https://brookbushinstitute.com/article/corrective-exercise-articles/activation/external-rotators/" target="_blank" rel="noopener">External Rotator Activation</a>.

How Does this Study Relates to Brookbush Institute Content

External Rotator Activation
<iframe src="https://player.vimeo.com/video/82872991" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
External Rotator Activation Progression
<iframe src="https://player.vimeo.com/video/82854675" frameborder="0" allowfullscreen="allowfullscreen"></iframe>

 Ha, et al. (2013). Selective Activation of the Infraspinatus Muscle

Original Citation: Ha, S., Kwon, O., Cynn, H., Lee, W., Kim, S., &amp; Park, K. (2013). Selective activation of the infraspinatus <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a>. Journal of athletic training, 48(3), 346-352. - <a href="https://www.ncbi.nlm.nih.gov/pubmed/23675794" target="_blank" rel="noopener">ABSTRACT</a>
The rotator cuff (RTC) muscles are commonly targeted during shoulder rehabilitation programs. Specifically, preferential activation of the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> is desired to address the assessed weakness of the external rotators. This 2013 study, by Korean researchers, compared the electromyographic (EMG) activity of the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a>, <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">posterior deltoid</a>, and <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">middle trapezius</a> muscles during four commonly recommended RTC strengthening exercises. The study findings suggest external rotation with the arm supported at 90&#xBA; of flexion increases <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> activity and reduces recruitment of the <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">posterior deltoid</a> and <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">trapezius</a> muscles.
<a href="https://www.datocms-assets.com/25800/1646157343-infraspinatus-muscle.png"><img src="https://www.datocms-assets.com/25800/1646157343-infraspinatus-muscle.png"></a>

<table>
 <tbody>
 <tr>
 <td width="40%">Study Design</td>
 <td>Comparative/observational study</td>
 </tr>
 <tr>
 <td>Level of Evidence</td>
 <td>III - Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies</td>
 </tr>
 <tr>
 <td>Participant Characteristics</td>
 <td>Demographics
 <ul>
 <li>Number of participants: 30</li>
 <li>Gender: 24 males, 6 females</li>
 <li>Mean age: 22</li>
 </ul>
 Inclusion Criteria:
 <ul>
 <li>All participants were asymptomatic collegiate students within the physical therapy program.</li>
 <li>All participants were right arm dominant.</li>
 </ul>
 Exclusion Criteria:
 <ul>
 <li>Previous injuries or history of shoulder/neck pain.</li>
 <li>Neuromuscular conditions which prevent full shoulder external rotation.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Methodology</td>
 <td>
 <ul>
 <li>Participants were familiarized with the four external rotation exercises being tested.</li>
 <li>Electrodes were inserted into the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a>, <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">posterior deltoid</a>, and <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">middle trapezius</a> to <a id="assessment" data-tip="1486" target="_blank" href="/glossary-term/assessment" class="glossary">assess</a> activity during the study.</li>
 <li>A maximal voluntary isometric contraction (MVIC) for each <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> was recorded.</li>
 <li>For each exercise, participants sustained an isometric contraction for 5 seconds while maintaining contact on a target bar.</li>
 <li>3 sets of each exercise were performed, in a randomized order, while using a 1-kilogram dumbbell.</li>
 <li>A 1-minute recovery time was given between each set.</li>
 <li>A 3-minute recovery time was given between each exercise.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Data Collection and Analysis</td>
 <td>Data Collection
 <ul>
 <li>Maximal EMG data was collected for 5 seconds during MVIC testing.
 <ul>
 <li>The average EMG activity of the three trials was collected for each exercise.</li>
 <li>The first and last second of the MVIC was discarded.</li>
 <li>The middle three seconds was used as the average MVIC%.</li>
 </ul>
 
 </li>
 <li>EMG activity of each <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> was collected during each of the four exercises.</li>
 </ul>
 Data Analysis
 <ul>
 <li>EMG differences among the four exercises were tested for significance using a 1-way repeated-measures analysis for each <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> with an alpha level set at 0.05.</li>
 <li>When a difference was found the Bonferroni adjustment was used with an alpha level set at .013.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Outcome Measures</td>
 <td>
 <ul>
 <li>Peak EMG activity was measured in all three muscles during the following exercises:
 <ul>
 <li>Prone horizontal abduction and external rotation (PER).</li>
 <li>Side-lying with 90&#xBA; of shoulder flexion (SWE).</li>
 <li>Side-lying with the shoulder in a neutral position at their side (SER).</li>
 <li>Standing external rotation with arm abducted to 90&#xBA; (STER).</li>
 </ul>
 
 </li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Results</td>
 <td>
 <ul>
 <li>EMG activity varied significantly among the four exercises.</li>
 <li>All data was expressed as a percentage of maximum voluntary isometric contraction (MVIC).
 <ul>
 <li>SWE demonstrated the largest EMG activity in the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> (55.98% MVIC) and the lowest EMG activity in the <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">posterior deltoid</a> (7.01% MVIC) and <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">middle trapezius</a> (6.55% MVIC).</li>
 <li>SER showed the lowest EMG activity in the <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">posterior deltoid</a> (4.11% MVIC), but had the greatest activity of the <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">middle trapezius</a> (24.14% MVIC).</li>
 <li>PER had similar <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> activity as SER but greater <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">posterior deltoid</a> activity (46.14% &#xB1; 15.65%)</li>
 <li>STER demonstrated the lowest EMG activity in the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> (26.11% MVIC) out of the four exercises tested.</li>
 </ul>
 
 </li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Our Conclusions</td>
 <td>The findings of this study indicate that external rotation exercises should be performed at 90&#xBA; of supported shoulder flexion if the intent is to strengthen <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> and minimizing <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">posterior deltoid</a> and <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">middle trapezius</a> activity,</td>
 </tr>
 <tr>
 <td>Researchers&apos; Conclusions
 
 </td>
 <td>EMG activity varied significantly among the four exercises. Side-lying external rotation with supported shoulder flexion produced the greatest amount of EMG activity in the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> (55.98% MVIC). Therefore, this would be an effective exercise to integrate into RTC rehabilitation programs for preferential recruitment of the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a>.</td>
 </tr>
 </tbody>
</table>
<h3><a href="https://www.datocms-assets.com/25800/1646157477-combined-deep-cervical-flexor-and-external-rotator-activation.png"><img src="https://www.datocms-assets.com/25800/1646157477-combined-deep-cervical-flexor-and-external-rotator-activation.png"></a></h3>

This study compared the activity of the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus,</a> <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">posterior deltoid</a>, and <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">middle trapezius</a> during four external rotation exercises. The results of this study are congruent with additional research that demonstrates exercise selection has a significant impact on shoulder <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment (4, 11). All muscles were recruited during all four exercises; however, shoulder position had a significant effect on activity. For example, side-lying external rotation with supported shoulder flexion at 90&#xBA; (SWE) resulted in the most <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> activity (55.98% MVIC) and standing external rotation (STER) resulted in the least (26.11% MVIC). Further, side-lying external rotation (SER) and <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> horizontal abduction with external rotation (PER) resulted in similar <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> activity, however, these exercises also resulted in the most <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">trapezius</a> and <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">posterior deltoid</a> activity. Although research correlating dysfunction and altered EMG activity may be used to hypothesize which of these exercises is ideal, research is needed to compare the effects of exercise selection on patient/client outcomes.

The results of this study suggest that exercise selection may have an impact on relative <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment. Based on findings during movement <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>, the human movement professional may be able to modify exercise selection to reduce the recruitment of over-active muscles, and better target the intended under-active <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a>. For example, external rotation at 90&#xB0; of shoulder flexion increases recruitment of the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> while decreasing activity of the <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">deltoid</a> and <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">trapezius</a> musculature.
Strengths
<ul>
 <li>A detailed methodology for all manual <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> testing and EMG placement was provided, improving the repeatability of the study.</li>
 <li>The study included common exercises used in the clinic for rotator cuff strengthening, improving generalizability.</li>
 <li>The authors recruited more participants than comparable research, increasing confidence in findings.</li>
</ul>
Weakness and limitations
<ul>
 <li>The participants used a 1-kg dumbbell regardless of their strength or body mass. This could have a significant impact on %MVIC during EMG testing.</li>
 <li>Researchers evaluated end-range isometric activity and not activity throughout range. This may limit the applicability of the findings.</li>
 <li>Only healthy, pain-free, collegiate-aged athletes were studied. This may limit the applicability of findings to an injured or older population.</li>
</ul>

The Brookbush Institute (BI) continues to refine and develop predictive <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a> of dysfunction, including <a href="https://brookbushinstitute.com/article/upper-body-dysfunction-ubd" target="_blank" rel="noopener">Upper Body Dysfunction (UBD)</a>, with the intent of optimizing <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a> education and practice. This study helps to demonstrate the relationship shoulder positioning has on the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a>, <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">deltoid</a>, and <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">trapezius</a> <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity during four common exercises. The BI has refined interventions for <a href="https://brookbushinstitute.com/article/upper-body-dysfunction-ubd" target="_blank" rel="noopener">UBD</a> by integrating the findings of this study, with other rotator cuff activation studies for the <a href="https://brookbushinstitute.com/video/shoulder-external-rotator-activation-progression" target="_blank" rel="noopener">progression of external rotator exercises</a>. The BI will continue to pursue <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> practice by refining recommendations and exercise selection for <a href="https://brookbushinstitute.com/article/upper-body-dysfunction-ubd" target="_blank" rel="noopener">UBD</a>.

How Does This Study Relates to Brookbush Institute Content

Shoulder External Rotator Activation
<iframe src="https://player.vimeo.com/video/82872991" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Shoulder External Rotator Activation Progression
<iframe src="https://player.vimeo.com/video/82854675" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Shoulder External Rotator Reactive Activation
<iframe src="https://player.vimeo.com/video/76687897" frameborder="0" allowfullscreen="allowfullscreen"></iframe>

<ol>
 <li>Kendall F.P., McCreary, E.K., Provance, P.G., Rodgers, M.M., &amp; Romani, W.A., (2005). Muscles: testing and function with posture and pain. 5th ed. Baltimore, MD: Williams &amp; Wilkins.</li>
 <li>Blackburn, T.A., McLeod, W.D., White, B., &amp; Wofford, L. (1990). EMG analysis of posterior rotator cuff exercises. Athletic Training Journal, 25 (1), 40-45.</li>
 <li>Reinold, M.M., Escamilla, R.F., &amp; Wilk, K.E. (2009). Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. Journal of Orthopedic Sports Physical Therapy, 39(2), 105-117.</li>
 <li><a href="https://brookbushinstitute.com/article/electromyographic-analysis-of-rotator-cuff-and-deltoid-musculature-during-common-external-rotation-exercises" target="_blank" rel="noopener">Reinold, M.M., Wilk, K.E., &amp; Fleisig, G.S. (2004). Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. Journal of Orthopedic Sports Physical Therapy, 34(7), 385-394.</a></li>
 <li>McMahon, P.J., Debski, R.E., Thompson, W.O., et al. (1995). Shoulder muscle forces and tendon excursions during glenohumeral abduction in the scapular plane. Journal of Shoulder and Elbow Surgery, 4(3), 199-208.</li>
 <li>Townsend, H., Jobe, F.W., Pink, M., &amp; Perry, J. (1991). Electromyographic analysis of the glenohumeral muscles during a baseball rehabilitation program. American Journal of Sports Medicine, 19(3), 264-272.</li>
 <li>Yamamoto, A., Takagishi, K., Osawa, T., Yanagawa, T., Nakajima, D., Shitara, H., &amp; Kobayashi, T. (2010). Prevalence and risk factors of a rotator cuff tear in the general population. Journal of Shoulder and Elbow Surgery, 19(1), 116-120.</li>
 <li>Minagawa, H., Yamamoto, N., Abe, H., Fukuda, M., Seki, N., Kikuchi, K., &hellip; &amp; Itoi, E. (2013). Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: from mass-screening in one village. Journal of orthopaedics, 10(1), 8-12.</li>
 <li>Luime, J. J., Koes, B. W., Hendriksen, I. J. M., Burdorf, A., Verhagen, A. P., Miedema, H. S., &amp; Verhaar, J. A. N. (2004). Prevalence and incidence of shoulder pain in the general population; a systematic review. Scandinavian journal of rheumatology, 33(2), 73-81.</li>
 <li>Jenp Y, Malanga GA, Growney ES, An K. (1996). Activation of the rotator cuff in generating isometric shoulder rotation <a href="https://brookbushinstitute.com/glossary/torque/" target="_blank" rel="noopener">torque</a>. The American Journal of Sports Medicine. 24 (4), 477-85.</li>
 <li><a href="https://brookbushinstitute.com/article/shoulder-muscle-recruitment-pattern-during-rotator-cuff-exercise" target="_blank" rel="noopener">Dark, A., Ginn, K.A., &amp; Halaki, M. (2007). Shoulder muscle recruitment patterns during commonly used rotator cuff exercises: An electromyographic study. Physical Therapy, 87 (8), 1039-1046</a></li>
</ol>

Reinold, et al. (2004). Electromyographic Analysis of Rotator Cuff and Deltoid Musculature During Common External Rotation Exercises

Original Citation: Reinold, M. M., Wilk, K. E., Fleisig, G. S., Zheng, N., Barrentine, S. W., Chmielewski, T., &#x2026; &amp; Andrews, J. R. (2004). Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. Journal of orthopaedic &amp; sports physical therapy, 34(7), 385-394. - <a href="https://www.ncbi.nlm.nih.gov/pubmed/15296366" target="_blank" rel="noopener">ABSTRACT</a>
Shoulder pain and rotator cuff tears are common orthopedic issues with an estimated prevalence between 14 - 40% dependent on population, activity, and age group (1 - 6). Treatment of shoulder pain and rotator cuff tears often involves the recommendation of exercises for strengthening the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus and teres minor</a>. This 2004 study, by American researchers, compared the electromyographic (EMG) activity of rotator cuff muscles during commonly recommended external rotation exercises performed by asymptomatic individuals. The findings of this study suggest that variations with 0&#xB0; of shoulder abduction result in higher <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus and teres minor</a> activity and less synergistic <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity.
<a href="https://www.datocms-assets.com/25800/1646157675-infraspinatus_muscle_1-300x225.jpeg"><img src="https://www.datocms-assets.com/25800/1646157675-infraspinatus_muscle_1-300x225.jpeg"></a>
By Anatomist90 - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=17900187

<table>
 <tbody>
 <tr>
 <td width="40%">Study Design</td>
 <td>Comparative/Observational Study</td>
 </tr>
 <tr>
 <td>Level of Evidence</td>
 <td>III - Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies</td>
 </tr>
 <tr>
 <td>Participant Characteristics</td>
 <td>Demographics
 <ul>
 <li>Number of participants: 10</li>
 <li>Gender: 5 males, 5 females</li>
 <li>Mean age: 28.1</li>
 </ul>
 Inclusion Criteria:
 <ul>
 <li>All participants were asymptomatic with no history of shoulder injury, <a id="stability" data-tip="1193" target="_blank" href="/glossary-term/stability" class="glossary">instability</a> or pain.</li>
 </ul>
 Exclusion Criteria:
 <ul>
 <li>Previous injuries to the shoulder</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Methodology</td>
 <td>
 <ul>
 <li>Electrodes were inserted into the <a href="https://brookbushinstitute.com/article/supraspinatus" target="_blank" rel="noopener">supraspinatus</a>, <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus, teres minor</a>, <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">posterior deltoid, and middle deltoid</a> to <a id="assessment" data-tip="1486" target="_blank" href="/glossary-term/assessment" class="glossary">assess</a> activity during the study.</li>
 <li>Maximal voluntary isometric contraction (MVIC) for each <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> was found by having the participants maintain a maximum effort contraction for 5 seconds while EMG data was collected.</li>
 <li>Participants then performed 10 repetitions of seven commonly used rotator cuff strengthening exercises in random order.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Data Collection and Analysis</td>
 <td>Data Collection
 <ul>
 <li>Peak maximal voluntary isometric contractions were recorded for each <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a>.
 <ul>
 <li>Maximal EMG data was collected for 5 seconds during the maximal voluntary isometric contraction (MVIC).</li>
 <li>The first and last second of the MVIC was discarded.</li>
 <li>The middle three seconds was used as peak MVIC.</li>
 </ul>
 </li>
 <li>EMG activity of each <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> was collected during each of the seven exercises.
 <ul>
 <li>EMG activity was recorded after the third repetition of each exercise.</li>
 </ul>
 
 </li>
 </ul>
 Data Analysis
 <ul>
 <li>EMG differences among the seven exercises were tested for significance using a 1-way repeated-measures analysis for each <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a>.</li>
 <li>The Tukey <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> was used for post hoc analysis to compare exercises with significance set at P&lt;.05.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Outcome Measures</td>
 <td>Peak EMG activity was measured in all five muscles during the following exercises:
 <ul>
 <li>The exercises used were:
 <ul>
 <li>Prone horizontal abduction at 100&#xB0; with full external rotation.</li>
 <li>Prone external rotation at 90&#xB0; of abduction.</li>
 <li>Standing external rotation at 90&#xB0;of abduction.</li>
 <li>Standing external rotation in the scapular plane (45&#xB0; of abduction and 30&#xB0; of horizontal adduction).</li>
 <li>Standing external rotation at 0&#xB0; of abduction.</li>
 <li>Standing external rotation at 0&#xB0; of abduction with a towel <a id="roll" data-tip="1602" target="_blank" href="/glossary-term/roll" class="glossary">roll</a> placed between the trunk and elbow.</li>
 <li>Side-lying external rotation at 0&#xB0; of abduction.</li>
 </ul>
 
 </li>
 <li>A one-second tempo was used for both concentric and eccentric movements, regulated by a metronome.</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Results</td>
 <td>
 <ul>
 <li>EMG activity varied significantly among the seven exercises.</li>
 <li>All data was expressed as a percentage of maximum voluntary isometric contraction (MVIC).
 <ul>
 <li>Side-lying ER produced the greatest amount of EMG activity for the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> (62% MVIC) and<a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener"> teres minor</a> (67% MVIC).</li>
 <li>Prone horizontal abduction at 100 degrees with full ER produced the greatest amount of activity in the <a href="https://brookbushinstitute.com/article/supraspinatus" target="_blank" rel="noopener">supraspinatus</a> (82% MVIC), <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">middle deltoid</a> (87% MVIC), and <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">posterior deltoid</a> (88% MVIC).</li>
 <li>Standing external rotation variations with arms at 0 degrees produced the least amount of <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">deltoid</a> activity (11-38% MVIC) (Note, strangely this variation used a dumbbell, and not resistance opposing the rotator cuff muscles.)</li>
 </ul>
 </li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Our Conclusions</td>
 <td>The findings of this study indicate that programming with the intent of strengthening the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus and teres minor</a>&#xA0;while minimizing <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">deltoid</a> and <a href="https://brookbushinstitute.com/article/supraspinatus" target="_blank" rel="noopener">supraspinatus</a> activity, should consider exercise variations with 0&#xB0; of shoulder abduction.</td>
 </tr>
 <tr>
 <td>Researchers&apos; Conclusions
 
 </td>
 <td>EMG activity varied significantly among the 7 exercises. Sidelying ER produced the greatest amount of EMG activity for the infraspinatus (62% MVIC) and teres minor (67% MVIC). The greatest amount of activity of the supraspinatus (82% MVIC), middle deltoid (87% MVIC), and posterior deltoid (88% MVIC) was observed during prone horizontal abduction at 100&#xB0; with full ER.</td>
 </tr>
 </tbody>
</table>

This study compared the activity of the <a href="https://brookbushinstitute.com/article/supraspinatus" target="_blank" rel="noopener">supraspinatus</a>, <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">deltoid</a>, <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus, and teres minor</a> during 7 commonly recommended external rotation (ER) exercises. The results of this study demonstrate that all muscles may be recruited during resisted external rotation; however, exercise selection may alter the percent recruitment of rotator cuff and <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">deltoid</a> muscles. For example, Sidelying ER produced the most infraspinatus (62% MVIC) and teres minor (67% MVIC) EMG activity, while <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> horizontal abduction at 100&#xB0; with full ER resulted in the most supraspinatus (82% MVIC), middle deltoid (87% MVIC), and <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> deltoid (88% MVIC) EMG activity. The results of this study are supported by additional research demonstrating exercise variation may influence recruitment (8, 9). Further research is needed to investigate the effect exercise selection has on the recruitment of rotator cuff and shoulder musculature in a symptomatic population.

How this Study Contributes to the Body of Research

The results of this study demonstrate that different external rotation exercises may result in varying levels of <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment. This may have a significant impact on outcomes. For example, if the goal is to increase <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus and teres minor</a> activity while minimizing <a href="https://brookbushinstitute.com/article/supraspinatus" target="_blank" rel="noopener">supraspinatus</a> and <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">deltoid</a> activity then side-lying or standing variations with 0&#xB0; of abduction may be ideal. The selection of external rotation exercises should be based on treatment and performance goals and movement <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>.
Strengths
<ul>
 <li>Using intramuscular (hook wire) EMG was used to measure activity increasing the <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> of the data collection (reducing the potential for cross-talk).</li>
 <li>The study included common exercises used in the clinic for rotator cuff strengthening improving generalizability.</li>
 <li>The methodology was well documented, including the use of a metronome to regulate tempo and force output, increasing the repeatability of the study.</li>
</ul>
Weakness and limitations
<ul>
 <li>The small sample size may have decreased statistical <a id="power" data-tip="1399" target="_blank" href="/glossary-term/power" class="glossary">power</a>, reducing the ability of the study to differentiate EMG activity between various exercises.</li>
 <li>The participants in the study were asymptomatic. This reduces the applicability of study findings.</li>
 <li>The standing variation of <a href="https://brookbushinstitute.com/article/corrective-exercise-articles/activation/external-rotators/" target="_blank" rel="noopener">external rotator activation</a> exercises used a dumbbell rather than <a id="a-band" data-tip="1347" target="_blank" href="/glossary-term/a-band" class="glossary">a band</a> or cable, resulting in a force that did not directly oppose the direction of motion. It is likely this had a significant impact on the findings for that exercise, making it difficult compared to the other exercises in the study.</li>
</ul>

<ol>
 <li>Bergenudd, H. A. N. S., Lindg&auml;rde, F. O. L. K. E., Nilsson, B., &amp; Petersson, C. J. (1988). Shoulder pain in middle age. A study of prevalence and relation to occupational work load and psychosocial factors. Clinical orthopaedics and related research, (231), 234-238.</li>
 <li>Urwin M, Symmons D, Allison T, Brammah T, Busby H, Roxby M, et al. (1998). Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis.57, 649-55.</li>
 <li>Yamamoto, A., Takagishi, K., Osawa, T., Yanagawa, T., Nakajima, D., Shitara, H., &amp; Kobayashi, T. (2010). Prevalence and risk factors of a rotator cuff tear in the general population. Journal of Shoulder and Elbow Surgery, 19(1), 116-120.</li>
 <li>Minagawa, H., Yamamoto, N., Abe, H., Fukuda, M., Seki, N., Kikuchi, K., &hellip; &amp; Itoi, E. (2013). Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: from mass-screening in one village. Journal of orthopaedics, 10(1), 8-12.</li>
 <li>Luime, J. J., Koes, B. W., Hendriksen, I. J. M., Burdorf, A., Verhagen, A. P., Miedema, H. S., &amp; Verhaar, J. A. N. (2004). Prevalence and incidence of shoulder pain in the general population; a systematic review. Scandinavian journal of rheumatology, 33(2), 73-81.</li>
 <li>Frisch, K. E., Clark, J., Hanson, C., Fagerness, C., Conway, A., &amp; Hoogendoorn, L. (2017). High prevalence of nontraumatic shoulder pain in a regional sample of female high school volleyball athletes. Orthopaedic journal of sports medicine, 5(6), 2325967117712236.</li>
 <li>Jenp Y, Malanga GA, Growney ES, An K. (1996). Activation of the rotator cuff in generating isometric shoulder rotation <a href="https://brookbushinstitute.com/glossary/torque/" target="_blank" rel="noopener">torque</a>. The American Journal of Sports Medicine. 24 (4), 477-85.</li>
 <li><a href="https://brookbushinstitute.com/article/shoulder-external-rotation-more-infraspinatus-less-posterior-deltoid" target="_blank" rel="noopener">Ha S, Kwon O, Cynn H, Lee W, Kim S, Park K. (2013). Selective activation of the infraspinatus muscle. Journal of Athletic Training. 48 (3), 346-352.</a></li>
 <li><a href="https://brookbushinstitute.com/article/shoulder-muscle-recruitment-pattern-during-rotator-cuff-exercise" target="_blank" rel="noopener">Dark, A., Ginn, K.A., &amp; Halaki, M. (2007). Shoulder muscle recruitment patterns during commonly used rotator cuff exercises: An electromyographic study. Physical Therapy, 87 (8), 1039-1046</a></li>
</ol>

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Questions, comments, and criticisms are welcomed and encouraged

Copyright

A-Band - Refers to the part of the muscle cell that looks darker under a microscope.  This area of the cell is darker due to parallel arrangement of thicker filaments (myosin) and overlap with the thinner filaments (actin).
<ul>
 	<li>As a muscle contracts, the A-band is where actin and myosin interact.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Accuracy - the proportion of individuals correctly identified by the test results.
<ul>
 	<li>For example, a special test with perfect accuracy would imply a test has 100% specificity, 100% sensitivity, 100% positive predictive value and 100% negative predictive values.</li>
</ul>

Action Potential - A rapid change in voltage, resulting in a wave of excitation, that may result in stimulation of a nerve or muscle cell.
<ul>
 	<li>In order for an action potential to be initiated, the resting membrane voltage must exceed the excitation threshold, which then results in a cascade of depolarization and the "wave of excitation." Any stimulus below that threshold will not result in an action potential, and a stimulus greater than the threshold will not increase a single action potential, but may result in additional action potentials.  In this way, the action potential functions more like an on/off switch (all or none), and less like a dimmer switch.</li>
</ul>

A single-joint movement pattern (most often) designed to load a specific under-active muscle(s), while minimizing the contribution of over-active synergists via specific cues/joint motions.
<ul>
 	<li style="text-align: left;">Activation techniques/exercises are performed with the intent of addressing a muscle exhibiting a reduction in activity (tone) as a result of, or contributing to postural dysfunction.</li>
 	<li style="text-align: left;">Activation techniques/exercises cannot be multi-joint movement patterns due to relative flexibility, altered reciprocal inhibition, and synergistic dominance resulting in compensation patterns.</li>
</ul>
Example, <a href="https://brentbrookbush.com/articles/corrective-exercise-articles/activation/gluteus-medius-activation-progression/" target="_blank">gluteus medius activation</a> involves resisted hip abduction while minimizing the contribution of the TFL via hip extension.

Active stretching is a term used to describe a stretch that involves an active contraction of opposing musculature to lengthen a muscle to its end range. Generally these stretches are held for 2-5 seconds and repeated for 8-15 repetitions.

Adenosine triphosphatase (ATPase): is the enzyme responsible for catalyzing (initiating and accelerating) the decomposition of ATP to ADP.
<ul>
 	<li>This dephosphorylation (breakdown) reaction releases energy for processes like muscular contraction.</li>
</ul>

Adenosine triphosphate (ATP): The molecule that functions as a universal energy-transfer molecule, providing most of the energy associated with muscular contraction and human movement. ATP is composed of an adenine group, a ribose group, and three molecules of inorganic phosphates.
<ul>
 	<li>Energy is provided when hydrolysis results in the cleaving of a phophate group; resulting in adenosine diphosphate, an inorganigic phosphate group, and energy.</li>
</ul>

Algometry - measuring the amount of pressure to result in sensitivity or pain, using an algometer.
<ul>
 	<li>Generally, research uses algometry to establish a minimum pain pressure threshold (PPT), in which a lower PPT implies more sensitivity and pain, and a higher PPT implies less sensitivity and pain. PPT is a common outcome measure in trigger point research.</li>
</ul>
<a href="https://brentbrookbush.com/wp-content/uploads/2019/07/Algometer.jpg"><img class="aligncenter wp-image-140177" src="https://brentbrookbush.com/wp-content/uploads/2019/07/Algometer.jpg" alt="Image of an Algometer" width="500" height="333" /></a>

All-or-none principle - a nerve or muscle cell's response to a stimulus is independent of the strength of the stimulus. If that stimulus exceeds the threshold potential (threshold of an action potential), the nerve or muscle fiber will respond completely; otherwise, there is no response.

Example, when a motor unit in the biceps brachii is stimulated it contracts the same way whether a 10 lb or 50 lb dumbbell is lifted.  It is actually the number of muscle cells and the size of the motor unit that determines force output.

&nbsp;

The transition period between eccentric load and concentric contraction during a repetition of an exercise.  This term is most often used in reference to power/plyometric exercises, in which a shorter amortization phase is believed to be beneficial.  The shorter amortization phase may better use the stored energy from the elastic deformation of connective tissue and enhance synchronization of myotatic (stretch) reflex with maximum voluntary contraction.

Example, the athlete was cued to spend as little time as possible in the bottom of their squat stance (the amortization phase) during a set of box jumps.

Muscles that oppose the prime mover and synergists for a given joint action.

That is, all the muscles that can perform the opposing joint action.

Example: The triceps and anconeus are antagonists during elbow flexion.

An anatomical direction; toward the front

Example, the face is on the anterior aspect of the head

Appendicular Skeleton - referring to the bones the bones of the arms and legs, as well as the bones that support them. This includes the pelvis, clavicle and scapula. There are approximately 126 bones in the appendicular skeleton.
<ul>
 	<li>Etymology - Appendicular, as in appendage, "that which is appended to something as a proper part," 1640s, from <a class="crossreference" href="https://www.etymonline.com/word/append?ref=etymonline_crossreference">append</a> + <a class="crossreference" href="https://www.etymonline.com/word/-age?ref=etymonline_crossreference">-age</a>. - <a href="https://www.etymonline.com/word/appendage" target="_blank" rel="noopener">Etymology Online</a></li>
</ul>
"Appendicular skeleton" is a label referring to a set of bones whose function is distinct from the bones of the "<a href="https://brentbrookbush.com/glossary/axial-skeleton/" target="_blank" rel="noopener">axial skeleton</a>".

A reflexive decrease in muscle activity due to joint dyskinesis.
For example, a reduction in deep cervical flexor activity as a result of cervical spine dyskinesis.

Arthrokinematic Motion - Small amplitude motions between bone surfaces at a joint.  The arthrokinematic motions are roll, glide (slide or translation), spin, compression and distraction (traction). Arthrokinematic motions accompany osteokinematic motions to maintain joint congruence.
<ul>
 	<li>Example, arthrokinematic motion of the talus includes posterior glide on the tibia during ankle dorsiflexion.</li>
</ul>
Synonyms include: arthrokinematics, passive accessory motion, joint play and component motion

&nbsp;

Assessment - is the act of assessing, i.e. determining the importance, size, or value of -

In most cases, the results of an assessment are compared to normative data. If the individual exhibits values that are within normal parameters, it may be assumed that the aspect of health or motion assessed is not contributing to the patient's complaint, symptoms or movement impairment. If the results fall outside of normal parameters, it may indicate that the aspect of health or motion assessed is contributing to, or being affected by the patient/client's complaint, symptoms, or movement impairment. In some cases, the results of an assessment are compared to an "ideal model." In this case, deviations from the ideal are noted as potential issues. For example, deviations noted in the <a title="Introduction to the Overhead Squat Assessment" href="https://brentbrookbush.com/online-courses/articles/assessment/introduction-overhead-squat-assessment/" target="_blank">Overhead Squat Assessment</a> are compared to an "ideal model" of posture and motion.

Assessments used by human movement professionals can be divided into three broad categories:
<ul>
 	<li>"Clear" the Patient/Client for Intervention - These are tests, assessments and evaluations used to determine if a patient/client's issue may improve given the assessing professional's scope, skills, abilities and willingness to treat that individual.
<ul>
 	<li>For example, many of the special tests used in orthopedic medicine assist in determining the level of pathology or likelihood of a particular diagnosis. Certain issues and diagnoses are beyond the scope of the human movement professional, and are better treated by diagnostic professionals in the medical community (physicians, podiatrists, surgeons, etc.). A Calf Squeeze (Thompson) Test is one example, in which a positive sign may indicate a rupture of the Achilles tendon that may be better treated via surgical intervention.</li>
</ul>
</li>
 	<li>Highlight Contraindications - Tests, assessments and evaluations used to stratify risk or preclude a professional from addressing certain tissues, motions or using a particular technique.
<ul>
 	<li>For example, the Vertebral Artery Test (VBI) is often used to determine if high velocity thrust mobilizations (manipulations) are safe for a patient with cervical dysfunction.</li>
</ul>
</li>
 	<li>Refine Exercise/Intervention Selection: Tests, assessments and evaluations used to assist the professional in determining which techniques, modalities and exercises will best address a patient/client's complaints or desired goals.
<ul>
 	<li>Most movement assessments fall into this category. For example, a positive <a href="https://brentbrookbush.com/vimeo_videos/elys-test-rectus-femoris-flexibility-assessment/" target="_blank">Ely's Test</a> may indicate a need to release and/or lengthen the <a href="https://brentbrookbush.com/articles/anatomy-articles/muscular-anatomy/rectus-femoris/" target="_blank">rectus femoris</a>.</li>
</ul>
</li>
</ul>
Note: An assessment, or assessment result, may fall into more than one category. For example, although goniometry is an assessment most often used to Refine Exercise/Intervention Selection, if a range of motion is significantly altered, with an abnormal end-feel, and/or causes the patient or client/pain, the individual may need to be referred to a physician for further testing and Clearance to resume rehab activities.  Further, that same patient may return to the human movement professional with a list of Contraindicated Activities from the physician. - "When in doubt, refer out!"

Axial Skeleton - referring to the bones of the head, neck, trunk and spinal column (does not include pelvis). There are approximately 80 bones in the axial skeleton.
<ul>
 	<li>Etymology - Axial, as in "axis", referring to "imaginary motionless straight line around which a body (such as the Earth) rotates," from Latin axis "axle, pivot, axis of the earth or sky" - <a href="https://www.etymonline.com/word/axis" target="_blank" rel="noopener">Etymology Online</a></li>
</ul>
"Axial skeleton" is a label referring to a set of bones whose function is distinct from the bones of the "<a href="https://brentbrookbush.com/glossary/appendicular-skeleton/" target="_blank" rel="noopener">appendicular skeleton</a>".

Balance - The ability to maintain a body’s center of mass over its base of support. Balance can be static or dynamic.
<ul>
 	<li>For example, maintaining balance is harder on one leg because the center of mass must stay over a much smaller base of support.</li>
</ul>

A ball and socket joint (also called a spheroid joint or spheroidal joint) is a synovial joint in which the rounded or spherical end of one bone fits into a cup-like depression of another bone. The distal bone is capable of motion around an indefinite number of axes, which have one common center. Examples include the hip and shoulder (glenohumeral joint)

Base of support (BoS) - refers to the area beneath an object or person, and the area within the perimeter created by every point of contact that the object or person makes with the supporting surface. This may include the <a href="https://brentbrookbush.com/articles/anatomy-articles/muscular-anatomy/gluteus-maximus/" target="_blank" rel="noopener">glutes</a> of someone sitting on a chair, or the back of someone leaning against a wall.
<ul>
 	<li>For example, during a single leg balance the BoS is the area of the foot in contact with the surface; however, when a person is standing on two feet, the BoS is the area of both feet and the surface between them.</li>
</ul>

Pertaining to both sides

Example, bilateral rows are performed with both arms at the same time.

Case-control Study - a particular form of retrospective study that samples a matched group of people who have, and do not have the outcome being studied. A case-control study is a quasi-experimental design, often used in medicine to aid in determining potential contributing factors (cannot determine causality). In this study type exposure is the dependent variable and outcome is independent.
<ul>
 	<li>Example, in this retrospective case-control, medical records were investigated for trends correlated with cervical pain (1).
<ol>
 	<li>Mäkela, M., Heliövaara, M., Sievers, K., Impivaara, O., Knekt, P., &amp; Aromaa, A. (1991). Prevalence, determinants, and consequences of chronic neck pain in Finland. American journal of epidemiology, 134(11), 1356-1367.</li>
</ol>
</li>
</ul>

An anatomical direction; toward the tail, relative to humans this term is often used to refer to "in the direction of the tale (toward the feet)".

Example, to release the trapezius muscle the therapist used a force directed caudally.

Center of mass (CoM) - an object's mean position of mass; that is, a point that is perfectly surrounded by an equal amount mass in all directions.

Center of gravity (CoG) - point where gravity appears to act. Since the human body is so small compared to the earth, we can assume gravity acts uniformly on the body, and that CoG and CoM are the same.
<ul>
 	<li>Example, the CoM of the human body while lying down or standing straight up is close to our navel. However, it is possible that during a resistance exercise, the combination of the body's weight and the weight of the resistance will place the combined CoM outside the body. For example, during the mid-portion of a <a href="https://brentbrookbush.com/vimeo_videos/back-squat/" target="_blank" rel="noopener">back squat</a> the CoM would be several anterior to the naval.</li>
</ul>

An anatomical direction; toward the head (synonym: cranial)

Example, hip pain was felt with any force directed cephalad.

Cohort Study - a particular form of longitudinal study that samples a cohort (a group of people who share a defining characteristic), performing a cross-section at intervals through-out a period of time. A cohort study is a quasi-experimental design often used in medicine to aid in determining etiology or a cause-and-effect relationship. In this study type exposure is the independent variable and outcome is dependent.
<ul>
 	<li>Example, the study by Cholewicki et al. (1) investigated Yale Varsity Athletes (the cohort) with 2 and 3 year follow up (longitudinal design) and found that trunk muscle response time to off-loading was predictive of future low back injury.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/core/increased-trunk-muscle-latency-may-cause-rather-than-result-from-low-back-pain/" target="_blank" rel="noopener noreferrer">Cholewicki, J., Silfies, S., Shah, R., Greene, H., Reeves, N. Alvi, K., Goldberg, B. (2005). Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine. 30(23), 2614-2620</a></li>
</ol>

Comparable Sign: A combination of pain, stiffness and/or spasm during examination that is comparable to the patients symptoms.
<ul>
 	<li>One common error made during evaluation with special tests is attention given to any discomfort or pain, rather than attempting to identify the pain/discomfort related to the patient's complaint (concordant/comparable sign). Many special tests purposefully test tissue limits and are at least mildly uncomfortable in every individual. Basing your assessment on positive tests that resulted in "concordant/comparable signs" will improve your chances of arriving at the correct diagnosis.</li>
</ul>

An alternative movement pattern that has been adopted to compensate for dysfunction/impairment in the human movement system.
Example: A lack of calf extensibility may limit dorsiflexion, leading to the knees bowing inward (functional valgus) and excessive forward lean of the torso during a squat.

An arthrokinematic motion - the approximation of joint surfaces; that is, a force that directs one bone surface into another resulting in a reduction in intra-articular volume. Although widely thought of as a "destructive force", it is likely best to consider compression as a naturally occurring, stabilizing force. Any arthrokinematic force in excess (spin, glide, roll, traction) may be viewed as potentially deleterious.

For example, during a squat the femoral head is compressed into the acetabulum by muscular forces, bodyweight and any additional external load.

Concave (Concavity) - Having an outline or surface curved like the interior surface of a bowl or sphere - to cave-in or curve inward.
<ul>
 	<li>Example, the internal surfaces of the pelvis is concave, holding some of the bodies viscera.</li>
</ul>

Concordant Sign - The patient's specific pain, symptom or complaint. 
<ul>
 	<li>One common error made during evaluation with special tests is attention given to any discomfort or pain, rather than attempting to identify the pain/discomfort related to the patient's complaint (concordant/comparable sign). Many special tests purposefully test tissue limits and are at least mildly uncomfortable in every individual. Basing your assessment on positive tests that resulted in "concordant/comparable signs" will improve your chances of arriving at the correct diagnosis.</li>
</ul>

Conductivity: Stimulation results in more than a local effect (1).
<ul>
 	<li>For example, in a muscle cell the stimulation of a motor endplate results in a change in cell membrane polarity that rapidly propagates (is conducted) along the entire length of the muscle cell, stimulating all sacromere.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

A condyloid joint (also called condylar, bicondylar, ellipsoid, or ellipsoidal) is an ovoid articular surface, or condyle, that is received into an elliptical cavity.  These joints permit movement in two planes.  Examples include the knee, metacarpophalangeal joints and metatarsophalangeal joints.

Connective Tissue Cell - One of the four basic types of animal tissue, consisting mostly fibers and ground substance.  These cells are specialized to binds organs together, holds them in place, protect them from external forces, and may fill space in the body's cavities.

Example, the body's muscles are enclosed in durable connective tissue sheets known as the "epimysium", "perimysium", and "endomysium," which and in support and transmitting force.
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Contractility: The ability to shorten (1).
<ul>
 	<li>Contractility: Muscle cells are unique in the amount they can shorten when stimulated; this is this largerly due to the highly organized and unique arrangement of myofilaments (actin and myosin).</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Pertaining to the opposite side

Example, the external oblique muscle performs contralateral rotation; rotation to the opposite side.

Convex (Convexity) - Having an outline or surface curved like the exterior of a circle or sphere - to bulge or curve outward.
<ul>
 	<li>Example, the top of your head is shaped by the convex exterior surface of your skull.</li>
</ul>

Correlational Research - Non-experimental <a href="https://www.questionpro.com/blog/what-is-research/">research</a> method in which the statistical relationship between two variables is investigated.
<ul>
 	<li>In this research by Kwon et al., a correlation was noted between a decrease in extensibility during a hamstring length test (goniometry) and current knee pain (1).</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/correlation-patellofemoral-pain-syndrome-pfps-hamstring-activity/" target="_blank" rel="noopener">Kwon O, Yun M, and Lee W. (2014). Correlation between intrinsic patellofemoral pain syndrome in young adults and lower extremity biomechanics. J. Phys. Ther. Sci. 26: 961-964</a></li>
</ol>

Counter-nutation - posterior rotation of sacrum relative to ilium, and/or anterior rotation of ilium relative to sacrum.
<ul>
 	<li>The pelvic floor muscles are examples of muscle that may counter-nutate the sacrum.</li>
</ul>
[caption id="attachment_126335" align="aligncenter" width="400"]<a href="https://brentbrookbush.com/wp-content/uploads/2018/10/Nutation.png"><img class=" wp-image-126335" src="https://brentbrookbush.com/wp-content/uploads/2018/10/Nutation.png" alt="Nutation and Counter-nutation of the Sacroiliac Joint" width="400" height="967" /></a> Nutation and Counter-nutation of the Sacroiliac Joint[/caption]

&nbsp;

Crossover (Study) Design - A type of longitudinal, repeated measures quasi-experimental design in which each group receives both treatments, but at different times. It is named "crossover" due to the patients "crossing-over" to the other treatment or sham group after a specified period of time.
<ul>
 	<li>This type of study has the advantage of every individual serving as their own control, which may reduce the influence of confounding variables.</li>
 	<li>Unfortunately, the design itself introduces the chances that anyone receiving the experimental variable in the first period will continue to be effected in the second period.</li>
</ul>
In a study by Senna et al., a cross-over design was used to investigate the difference load made on inter-set rest intervals (1).
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/strength-training-research-corner/heavy-vs-light-load-single-joint-exercise-performance-with-different-rest-periods/" target="_blank" rel="noopener">Senna, G.W., Rodrigues, B.M., Sandy, Scudese, Bianco, A, &amp; Dantas, E.H.M. (2017). Heavy vs light load single-joint exercise performance with different intervals. Journal of Human Kinetics, 58, 197-206. </a></li>
</ol>

Cross-sectional Study - a research design that involves gathering data from a population or representative subset at a specific point in time.
<ul>
 	<li>Example, the study by Karimi-Mobarake et al.(1) investigated the prevalence of genu varum and genu valgum among school children 7-11 years old in Iran.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/low-prevalence-of-genu-varum-and-valgum-among-elementary-school-children/" target="_blank" rel="noopener noreferrer">Karimi-Mobarake, M., Kashefipour, A., Yousfnejad, Z. The prevalence of genu varum and genu valgum in primary school children in Iran 2003-2004. (2005) Journal of Medical Science 5(1). 52-54</a></li>
</ol>

Cytokine - A broad and loose category of small proteins that act through receptors, and are especially important to immune function (inflammation).
<ul>
 	<li>Cytokines include substances such as interferon, interleukin, and growth factors, which are secreted by certain cells of the immune system and have an effect on other cells. Their definite distinction from hormones is a topic of continued research.</li>
</ul>
&nbsp;

Dependent variable - in research, this is the variable that is changed by the independent variable, most often this is the "outcome" of the study.
<ul>
 	<li>Example, in the study by Cleland et al. (1), the independent variable is "thoracic manipulation," and the dependent variable is "lower trapezius muscle strength."</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/short-term-effects-lower-thoracic-manipulation-lower-trapezius-muscle-strength/" target="_blank" rel="noopener noreferrer">Cleland J, Selleck B, Stowell T, Brown L, Alberini S, St. Cyr H, Caron T. Short-term Effects of Thoracic Manipulation on Lower Trapezius Muscle Strength.  Journal of Manual &amp; Manipulative Therapy. 2004; 12(2): 82-90</a></li>
</ol>

An anatomical direction; further from the trunk or center of the body

Example, the foot is at the distal end of the leg.

An arthrokinematic motion - a force applied to a body part that may result in the separation of joint surfaces, a reduction in intra-articular pressure, and/or an increase in intra-articlar space.

For example, to hang from one's hands (i.g. in preparation for a pull-up) results in a traction force on the glenohumeral joint (shoulder).

An anatomical term of location; back or upper surface

Example, shoe laces may compress tissues on the dorsal surface of the foot

The "drawing-in" maneuver is a common cue used during exercise and rehabilitation programs. A light contraction of the <a href="https://brentbrookbush.com/articles/muscular-anatomy/transverse-abdominis/" target="_blank" rel="noopener">transverse abominis</a> (and potentially the entire <a href="https://brentbrookbush.com/articles/corrective-exercise-articles/core-subsystems/intrinsic-stabilization-subsystem/" target="_blank" rel="noopener">intrinsic stabilization subsystem</a>) achieved by gently pulling the lower abdominal region away from one's waist band. This should have minimal effect on breathing, and should not be confused with a maximal contraction of the <a href="https://brentbrookbush.com/articles/muscular-anatomy/transverse-abdominis/" target="_blank" rel="noopener">transverse abdominis</a> resulting in a "vacuum pose".
<ul>
 	<li>Research often refers to this maneuver as the "abdominal drawing-in maneuver"; abbreviated ADIM.</li>
</ul>
Development and introduction of this cue into practice is based on the pivotal research and resulting text:
<ol>
 	<li>Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004</li>
</ol>

Faulty or abnormal movement; an alteration of normal kinematics.

For example, joint stiffness or a reduction in arthrokinematics motion that results in limited osteokinematic range of motion - inadequate inferior glide of the femoral head resulting in limited abduction of the hip.

The seeping into, or abnormal collection of fluid in a body cavity.

For example, knee effusion describes swelling within the knee joint.

Note: the word "effusion" is used differently in medicine than it is used in reference to the movement (seeping out) of liquids and gases, for example in chemistry.

&nbsp;

A trait of body tissues that allows a tissue to return to its resting length or state after deformation or stretch.
Example:  Muscle is elastic tissue; many muscles will return to their resting length after being stretched to 150% of that length without any appreciable change in tissue quality.

Elasticity: Elasticity refers to the ability of a cell to return to its resting length after being stretched/lengthened.
<ul>
 	<li>Note: this term is often confused with extensibility. Elasticity is not the ability to stretch; it is the ability to return to normal length after being stretched. Muscle tissue, connective tissue and even nerve tissue have varying levels of elasticity.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Epithelial cell - One of the four basic cell types, found lining the body's cavities, blood vessels, organs and constitutes most gland tissue.  These cells are specialized to aid with absorption, secretion, or act as a barrier from foreign objects.
<ol>
 	<li>Saladin, K. S., &amp; Miller, L. (1998). Anatomy &amp; physiology. New York (NY): WCB/McGraw-Hill.</li>
</ol>

Equilibrium - a state in which opposing forces or influences are balanced.
<ul>
 	<li>For example, to maintain a neutral trunk while pushing or pulling a weight in one hand, your core musculature must balance the force by creating an equal amount of force in the opposite direction.</li>
</ul>

The study of causation, or origination. The word is commonly used in the medical professions, where it may refer to the study of why things occur, or the reason behind why things act a certain way.

For example, the etiology of low back pain is a complex subject, with multiple contributing factors and various structures implicated.

<div class="gs_citr" tabindex="0">Evidence-based medicine (practice) is the integration of best research evidence with clinical expertise and patient(client) values (2)."</div>
<ul>
 	<li class="gs_citr" tabindex="0">...the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients (clients).  It involves the integration of at least (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve (1).</li>
</ul>
&nbsp;
<ol>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Sackett, D. L., Rosenberg, W. M., Gray, J. M., Haynes, R. B., &amp; Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn't. Bmj, 312(7023), 71-72.</li>
 	<li class="gs_citr" tabindex="0">Sackett D et al. Evidence-Based Medicine: How to Practice and Teach EBM, 2nd edition. Churchill Livingstone, Edinburgh, 2000, p.1</li>
</ol>

Excitability: The ability of a cell to change in membrane conductance as a response to stimulation.

<ul>
 	<li>For example, muscle cells are specialized to react to a change in membrane potential with contraction, where as nerve cells are specialized to propagate a change in membrane potential along there axons and communicate that message to other tissues via neurotransmitters.
</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Excitation threshold: The level that a depolarization must reach for an action potential to occur.
<ul>
 	<li>The excitation threshold is a contributing factor to the "all-or-none" response of muscle and nerves cells to a stimulus.</li>
</ul>

Exercise Progression - Modification of an exercise with the intent of promoting adaptation by increasing demand. This can be accomplished by increasing reps, load, tempo, range of motion, complexity, and/or challenge to an individual's stability.
<ul>
 	<li>Because load, reps, tempo and complexity are often explicitly noted, the term "exercise progression" is most often used throughout Brookbush Institute (BI) content to refer to an exercise, or series of exercises that make it harder to maintain stability with good form.
<ul>
 	<li>Sample Exercise Progression: <a href="https://brentbrookbush.com/vimeo_videos/kneeling-chop-pattern/" target="_blank" rel="noopener">Kneeling Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/static-standing-chop-pattern/" target="_blank" rel="noopener">Standing Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/single-leg-chop-pattern/" target="_blank" rel="noopener">Single-leg Chop</a></li>
</ul>
</li>
</ul>

Exercise regression - The opposite of progression; that is, modification of an exercise with the intent of reducing demand. This can be accomplished by decreasing reps, load, tempo, range of motion, complexity, and/or challenge to an individual's stability. Generally, regressions are used to modify an exercise to the client's current level of ability, with the intent of improving form, motor learning and retention.
<ul>
 	<li>Because load, reps, tempo and complexity are often explicitly noted, the term "exercise regression" is most often used throughout Brookbush Institute (BI) content to refer to an exercise or series of exercises that make it easier to maintain stability with good form.
<ul>
 	<li>Sample Exercise Regression: <a href="https://brentbrookbush.com/vimeo_videos/single-leg-chop-pattern/" target="_blank" rel="noopener">Single-leg Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/static-standing-chop-pattern/" target="_blank" rel="noopener">Standing Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/kneeling-chop-pattern/" target="_blank" rel="noopener">Kneeling Chop</a></li>
</ul>
</li>
</ul>

Experimental Research - Studies in which the researchers introduce the variable to be studied, with the intent of observing the outcome. This is different than observational research which observes the effect of a variable already present. Many texts also assert that experimental research should include randomization and ideally a control group, as is seen in Randomized Control Trials. Studies in which the variable is introduced by the researchers, but participants are not randomized may be considered Quasi-experimental research.
<ul>
 	<li>In this study by Esformes, the experimental variable was squat depth and the outcome measures observed were various performance measures related to power (1).</li>
</ul>
<ol>
 	<li><a href="https://brookbushinstitute.com/article/back-squat-depth-lower-body-post-activation-potentiation/" target="_blank" rel="noopener">Esformes, J., &amp; Bampouras, T. (2013). Effect of back squat depth on lower-body postactivation potentiation. Journal of Strength and Conditioning Research, 27(11), 2997-3000.</a></li>
</ol>
&nbsp;

Extensibility: The ability of a cell to be stretched or lengthened without damage (1).
<ul>
 	<li>For example, most cells would rupture with even a modest stretch, but muscles can stretch up to 3 times their contracted length.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

False Negative - the proportion of negatives in a group that were assessed incorrectly (assessed as negative when the patient was actually positive)
<ul>
 	<li>Test Results: Although most tests/assessments result in either a positive or negative, the accuracy of a test is dependent on the number  of positives and negatives that are correct. Therefore, when the accuracy of a test is determined, their are 4 possible results, because a positive or negative result could be right (true) or wrong (false).</li>
</ul>

False Positive - the proportion of positives in a group that were assessed incorrectly (assessed as positive when the patient was actually negative)
<ul>
 	<li>Test Results: Although most tests/assessments result in either a positive or negative, the accuracy of a test is dependent on the number  of positives and negatives that are correct. Therefore, when the accuracy of a test is determined, their are 4 possible results, because a positive or negative result could be right (true) or wrong (false).</li>
</ul>

The function of fascia is to transmit force, provide support, and protect tissues. Fascia can effect motion by:
Transmitting force from one or more muscles (example: the thoracolumbar fascia)
Restricting motion in cases of adaptive shortening and/or adhesion to proximal structures (example: iliotibial band in cases of lower-leg dysfunction)
Elastic recoil after stretching can contribute to force production (example: plyometric exercise)

Note: There is evidence that fascia may house more receptors related to human movement than other tissues. In this way fascia may act as a motherboard for the nervous system

The fascial system does not contract or develop trigger points, and its capacity to adapt to stretching and or strengthening exercise is limited, especially when compared to the adaptive capacity of muscle tissue.

Fibromyalgia - A loosely defined diagnosis that is associated with a combination of widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. Consideration may also be given to the presence of psychosocial stressors and inflammatory disease in the patients history. Newer research suggests that fibromyalgia may be at least in part due to central sensitization of myofascial pain, often associated with trigger points (1 - 4).
<ol>
 	<li>Wolfe, F. (2018). Fibromyalgia Syndrome and Fibromyalgia Syndrome Criteria: Problems in Definition and Validity. Fibromyalgia Syndrome and Widespread Pain: From Construction to Relevant Recognition.</li>
 	<li>Wolfe, F., Smythe, H. A., Yunus, M. B., Bennett, R. M., Bombardier, C., Goldenberg, D. L., ... &amp; Fam, A. G. (1990). The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis &amp; Rheumatism: Official Journal of the American College of Rheumatology, 33(2), 160-172.</li>
 	<li>Alonso-Blanco, C., Fernandez-de-las-Penas, C., Morales-Cabezas, M., Zarco-Moreno, P., Ge, H. Y., &amp; Florez-García, M. (2011). Multiple active myofascial trigger points reproduce the overall spontaneous pain pattern in women with fibromyalgia and are related to widespread mechanical hypersensitivity. The Clinical journal of pain, 27(5), 405-413.</li>
 	<li>Staud, R., Nagel, S., Robinson, M. E., &amp; Price, D. D. (2009). Enhanced central pain processing of fibromyalgia patients is maintained by muscle afferent input: a randomized, double-blind, placebo-controlled study. PAIN®, 145(1-2), 96-104.</li>
</ol>
&nbsp;

Muscles that act to reduce or prevent movement at proximal joints to improve force transmission.
Example: The muscles of the core are important fixators; reducing motion of the spine/trunk to enhance force transmission between the extremities and environment.

An increase in joint stability via compressive forces resulting from muscular contraction and increased tension in fascial structures (1,2).
<ul>
 	<li>This term is most often used in reference to core intrinsic stabilizers, the thoracolumbar fascia and the sacroiliac joint; however, force closure and form closure have been mentioned in the literature referring to other joints.</li>
 	<li>Related term: Form closure</li>
</ul>
<ol>
 	<li>Andry Vleeming, Vert Mooney, Rob Stoeckart. Movement, Stability &amp; Lumbopelvic Pain: <a class="glossaryLink " title="Glossary: Integration" href="https://brentbrookbush.com/glossary/integration/" target="_blank" rel="noopener noreferrer" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Integration&lt;/div&gt;&lt;div class=glossaryItemBody&gt;Making a whole of parts.&lt;br /&gt;&lt;br /&gt;Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.&lt;/div&gt;">Integration</a> of Research and Therapy. (c) 2007 Elsevier Limited</li>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Vleeming, A., Pool-Goudzwaard, A. L., Stoeckart, R., van Wingerden, J. P., &amp; Snijders, C. J. (1995). The Posterior Layer of the Thoracolumbar Fascia| Its Function in Load Transfer From Spine to Legs. Spine, 20(7), 753-758.</li>
</ol>

The relative contribution of joint shape and structure to the stability of a joint (1,2).
<ul>
 	<li>This term is most often used in reference to the "rough" articulating surfaces of the sacroiliac joint and the wedge shape of the sacrum; however, force closure and form closure have been mentioned in the literature referring to other joints.</li>
 	<li>Related term: Force closure</li>
</ul>
<ol>
 	<li>Andry Vleeming, Vert Mooney, Rob Stoeckart. Movement, Stability &amp; Lumbopelvic Pain: <a class="glossaryLink " title="Glossary: Integration" href="https://brentbrookbush.com/glossary/integration/" target="_blank" rel="noopener noreferrer" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Integration&lt;/div&gt;&lt;div class=glossaryItemBody&gt;Making a whole of parts.&lt;br /&gt;&lt;br /&gt;Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.&lt;/div&gt;">Integration</a> of Research and Therapy. (c) 2007 Elsevier Limited</li>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Vleeming, A., Pool-Goudzwaard, A. L., Stoeckart, R., van Wingerden, J. P., &amp; Snijders, C. J. (1995). The Posterior Layer of the Thoracolumbar Fascia| Its Function in Load Transfer From Spine to Legs. Spine, 20(7), 753-758.</li>
</ol>

An arthrokinematic motion - linear motion across a joint surface parallel to the plane of the adjacent joint surface, just as your posterior moves relative to a "slide" in a park.

For example, the glide of facet joint in the spine during spinal flexion and extension, or the posterior glide of the humeral head that must accompany anterior roll to maintain congruence with glenoid fossa during shoulder horizontal adduction.

A plane joint (also called an arthrodial joint, gliding joint or plane articulation) is a synovial joint which allows only gliding movement in the plane of the articular surfaces. The opposed surfaces of the bones are flat or almost flat, with movement generally limited by tight capsules and ligaments. Plane joints are numerous, are most often small, and allow very little motion.  Examples include the carpal joints of the wrist, the tarsal joints of the ankle, and the facet joints of the spine.

"...refers to the measurement of angles, in particular the measurement of angles created at human joints by the bones of the body (1).

&nbsp;
<ol>
 	<li>Cynthia C. Norkin, D. Joyce White. Measurement of Joint Motion: A Guide to Goniometry 3rd Edition. Copyright (C) 2003 by F.A. Davis Company</li>
</ol>

Ground reaction force (GRF) - The force exerted by the ground on the body in contact with it.

For example, when a runner's foot strikes the ground with a force equal to the mass of the individual times their acceleration due to gravity, momentum and muscular exertion, the ground exerts an equal and opposite force on the runner's foot.
<ul>
 	<li>GRF is often measured in research studies using force plates as a means of quantitatively measuring the force generated by an individual.</li>
</ul>

H-Band - Refers to the central zone of a sarcomere that looks lighter under a microscope.  This area of the sarcomere is a lighter portion of the A-band where there is no overlap between the thinner filaments (actin), and the thicker filaments (myosin).
<ul>
 	<li>Example, when a muscle contracts, actin and myosin cross-bridging occurs in the region of the A-band until the H-band is reached where no overlap occurs.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

A hinge joint (also called a ginglymus) is a synovial joint in which the articular surfaces fit one another in a way that only permits motion in one plane. Examples include the elbow, the knee (unless considered a condyloid joint) and the interphalangeal joints.

Holism (holistic) (biological holism) - (from Greek holos "all, whole, entire") is the idea that systems and their properties should be viewed as wholes, not just as a collection of parts.
<ul>
 	<li>Summarized by Aristotle in his "Metaphysics": "The whole is more than the sum of its parts". However, the term "holism" was introduced into language by the South African statesman Jan Smuts as recently as 1926. (Smuts J. C. 1987 [1926]. Holism and evolution. Cape Town: N &amp; S Press.)</li>
</ul>
Example: The Brookbush Institute promotes a holistic approach to human movement science, in which the muscular, fascial, articular and neural systems are not viewed as separable and all proximal segments are considered.

Hormone: Chemical messengers produced by the endocrine system, transported via tissue fluids such as blood, to stimulate cells to "act."
<ul>
 	<li>Example: Growth hormone is secreted by the pituitary gland in the brain; stimulating growth, cell reproduction and cell regeneration in certain types of cells</li>
</ul>
The English physician E. H. Starling discovered in collaboration with the physiologist W. M. Bayliss secretin, the first hormone, in 1902. (1).
<ol>
 	<li>Henriksen, J. H., &amp; de Muckadell, O. S. (2000). Secretin, its discovery, and the introduction of the hormone concept. Scandinavian journal of clinical and laboratory investigation, 60(6), 463-472.</li>
</ol>

A range of motion achieved by the patient/client that is more than normal.
<ul>
 	<li>Note: Both hyper-mobility and hypo-mobility may adversely affect motion and may lead to deleterious effects on joints and soft tissue over time. There is no evidence to suggest that more or less flexibility than normal is beneficial.</li>
</ul>
Example: If an individual can place their forehead on their knees they are likely hypermobile at one, if not several joints

Example 2: 110° of shoulder external rotation would be considered hyper-mobile.

Hyperplasia is an increase in organic tissue size due to an adaptive increase in the number of cells per organ.
<ul>
 	<li>Although muscle hyperplasia has been noted in some animals, human muscle tissue does not seem to have this adaptive ability.</li>
</ul>

A condition of excessive tone of the skeletal muscles; increased resistance of muscle to passive stretching.  May be related to increased neural drive, synergistic dominance, trigger points, reflexive over-activity, and/or muscle length.
Example:  Individuals who exhibit ankle eversion and abduction during an overhead squat assessment likely have hypertonic fibularis (peroneal) muscles.

Muscular hypertrophy is an increase in muscle mass/size due to increase in the volume and cross-sectional area (CSA) of individual muscle cells. The increase in cross-sectional area can be attributed to an an increase in contractile proteins and structural elements (myofibrillar hypertophy), as well as an increase in glycogen storage and elements related to metabolism (sarcoplasmic hypertophy). Hypertrophy is an adaptation of both cardiac and skeletal muscle fibers in response to progressive increases in workload.
<ul>
 	<li>Note: Hypertrophy is not hyperplasia. Hyperplasia is an increase in muscle size due to an adaptive increase in the number of muscle fibers/cells per muscle. This type of adaptation does not occur in human muscle tissue.</li>
</ul>

A range of motion achieved by a patient/client that is less than normal.
<ul>
 	<li>Note: Both hyper-mobility and hypo-mobility may adversely affect motion and may lead to deleterious effects on joints and soft tissue over time. There is no evidence to suggest that more or less flexibility than normal is beneficial.</li>
</ul>
Example: If the end range of shoulder external rotation is reached and measured as 75° during goniometric assessment, the client/patient is exhibiting hypomobility of the glenohumeral joint (shoulder).

Hypothesis - a proposed explanation for a phenomenon; "scientific hypotheses" are generally constructed in a way that is testable or falsifiable.
<ul>
 	<li>Example: The hypothesis, "excessive knee valgus may be correlated with future knee pain and injury," has been the subject of several studies published over the last decade.</li>
</ul>

Diminished tone of skeletal muscles; diminished resistance of muscles to passive stretching.   May be related to inhibition, reciprocal inhibition, arthrokinematics inhibition and/or  increased resting length of muscle.
Example:  If your knees cave (hip adduction) during a squat or leg-press it is likely that your gluteus medius is hypotonic.

I-Band - Refers to the part of the muscle cell that looks lighter under a microscope.  This area of the cell is lighter due to parallel arrangement of thinner filaments (actin), and no overlap with the thicker filaments (myosin).
<ul>
 	<li>As a muscle contracts, the I-bands will decrease in width and move closer to one another.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Independent variable - in research, this is the variable or phenomenon being manipulated in the study.
<ul>
 	<li>Example, in the study by Ghanbari et al. (1), the independent variable is "knee joint mobilization", the dependent variable is "quadriceps muscle strength."</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/effect-knee-joint-mobilization-quadriceps-muscle-strength/" target="_blank" rel="noopener noreferrer">Ghanbari A. and Kamalgharibi S. (2013). Effect of knee joint mobilization on quadriceps muscle strength. International Journal of Health and Rehabilitation Sciences. 2(4): 186-191</a></li>
</ol>

An anatomical direction; toward the bottom (below)

Example, the mouth is inferior to the eyes

A reduction in neural drive, muscular activity, and or force output due to altered neuromuscular reflex.  Alterations in neuromuscular reflex may occur due to increases in muscle length (hypothesis: increased excitation threshold), altered reciprocal inhibition in response to increased antagonist tone, and or alterations in joint motion (arthrokinematics inhibition).

Making a whole of parts.

Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.

Intermuscular Coordination - Optimal timing and motor unit recruitment of agonists, antagonists, synergists, neutralizers, stabilizers and fixators.

Example: Role of Muscles during Hip Extension
<ul>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Prime Mover" href="https://brentbrookbush.com/glossary/prime-mover/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Prime Mover&lt;/div&gt;The muscle most responsible for a joint action under load -&lt;br /&gt;&lt;br /&gt;That is, the muscle that can produce the most force for a given joint action. Often this term is used synonymously with the term agonist. The prime mover as defined above, may or may not be the most active muscle for a joint action during activities of daily living.&lt;br /&gt;&lt;br /&gt;Example: the gluteus maximus is the most powerful hip extensor and therefore the prime mover; however, the hamstrings are likely the most active hip extensors during low level activities like walking or standing.">Prime Mover</a>:  <a href="https://player.vimeo.com/external/82855344.hd.mp4?s=54c3e7d98fb9d4e0af8d282c85ba9b3e">Gluteus maximus</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Synergists" href="https://brentbrookbush.com/glossary/synergists/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Synergists&lt;/div&gt;Muscles that assist the prime mover in performing a joint action.&lt;br /&gt;&lt;br /&gt;That is, all muscles that can perform a joint action that are not the prime mover, are termed synergists.&lt;br /&gt;Example: The rectus abdominis is the prime mover of spinal flexion. All other muscles that can perform spinal flexion are synergists including – external obliques, internal obliques and psoas.">Synergists</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/biceps-femoris/">Biceps femoris (long head)</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/semitendinosus-and-semimembranosus/">semitendinosus, semimembranosus</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/adductors/">posterior head of adductor magnus</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Antagonist" href="https://brentbrookbush.com/glossary/antagonists/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Antagonist&lt;/div&gt;Muscles that oppose the prime mover and synergists for a given joint action.&lt;br /&gt;&lt;br /&gt;That is, all the muscles that can perform the opposing joint action.&lt;br /&gt;&lt;br /&gt;Example: The triceps and anconeus are antagonists during elbow flexion.">Antagonists</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/psoas/">Psoas</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/iliacus/">iliacus</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/tensor-fascia-latae-tfl/">tensor fascia latae</a> (TFL),<a href="https://brentbrookbush.com/articles/muscular-anatomy/rectus-femoris/"> rectus femoris</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/adductors/">anterior adductors (especially pectineus)</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/sartorius/">sartorius</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Neutralizer" href="https://brentbrookbush.com/glossary/neutralizers/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Neutralizer&lt;/div&gt;Muscles that oppose unwanted joint motions created by the prime mover and/or synergists, and/or muscles that prevent unwanted ancillary motion.&lt;br /&gt;Example: The teres minor and infraspinatus neutralize the internal rotation force created by the pectoralis major during horizontal adduction of the shoulder.">Neutralizers</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-minimus/">Gluteus minimus</a> and <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-medius/">anterior fibers of gluteus medius</a> neutralize external rotation force of <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-maximus/">gluteus maximus</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Stabilizer" href="https://brentbrookbush.com/glossary/stabilizers/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Stabilizer&lt;/div&gt;Muscles whose primary role is to improve arthrokinematics by maintaining optimal alignment of joint surfaces.&lt;br /&gt;&lt;br /&gt;Most often these muscles are the most intrinsic muscles of a joint, have a larger percentage of Type I muscle fibers and are rich in proprioceptors.&lt;br /&gt;Example: The muscles of the rotator cuff act as stabilizers for most shoulder motions.">Stabilizers</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/deep-rotators-of-the-hip/">Deep rotators of hip</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Fixator" href="https://brentbrookbush.com/glossary/fixators/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Fixator&lt;/div&gt;Muscles that act to reduce or prevent movement at proximal joints to improve force transmission.&lt;br /&gt;Example: The muscles of the core are important fixators; reducing motion of the spine/trunk to enhance force transmission between the extremities and environment.">Fixators</a>: <a href="https://brentbrookbush.com/articles/core-subsystems/intrinsic-stabilization-subsystem/">Intrinsic stabilization subsystem</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/rectus-abdominis/">rectus abdominis</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/internal-obliques/">internal</a> and <a href="https://brentbrookbush.com/articles/muscular-anatomy/external-obliques/">external obliques</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/quadratus-lumborum/">quadratus lumborum</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/erector-spinae/">erector spinae</a></li>
</ul>
&nbsp;

Example from: <a href="https://brentbrookbush.com/articles/anatomy-articles/introduction-to-functional-anatomy/kinesiology-of-the-hip/" target="_blank" rel="noopener">Introduction to Functional Anatomy: Kinesiology of the Hip</a>

Intramuscular coordination refers to the coordinated recruitment of motor units within a single muscle. This concept is used to explain increases in maximal strength and power; however, the coordinated and sequential recruitment of motor units is also essential to strength endurance and smooth coordinated motion.  Related terminology may include; motor unit recruitment, preferential recruitment, rate coding, sequence, etc..

Example: It is hypothesized that the "shaking" noted during a novice exercisers attempt at an activity like the <a href="https://brentbrookbush.com/vimeo_videos/ball-crunch-and-progressions/" target="_blank">stability ball crunch</a> may be due to relatively poor intramuscular coordination. Rather than smooth, sequential firing of rectus abdominis motor units, groups of motor units turn on and off in an uncoordinated manner.

Pertaining to the same side

Example, the quadratus lumborum performs ipsilateral flexion; lateral flexion toward the same side as the muscle.

An isoform, or variant, is a member of a set of similar proteins, that originate from the same gene, or gene family.
<ul>
 	<li>Example, the variations in myosin heavy chain proteins (MHC I, MHC IIA, MHC IIB/X) that contribute to the characteristic differences between muscle fiber types.</li>
</ul>

“The Prime Assumption”
Everything crossing a joint will influence joint motion during every joint action.

A concept that has expanded over the past several decades to describe the integration of 4 body systems (muscle, joints, fascia and nerves), as well as, the coordinated function of various body segments (e.g. hip, knee and ankle) to produce motion. Kinetic referring to motion, and chain being an analogy for the interdependent link between systems.

Example, the posterior kinetic chain, refers to the integrated function of nerves, muscles, fascia and joints on the posterior side of the body.

The concept of the kinetic chain was originally adapted from the work of a mechanical engineer named Franz Reuleaux (Kinematics of Machinery (1875)) by Dr. Arthur Steindler in 1955 (Steindler A: Kinesiology of the Human Body. Springfield, IL, Charles C. Thomas Co.. 1955).

Latent Trigger Point - A myofascial trigger point that is not painful at rest, only painful when palpated, and may or may not exhibit a characteristic referral pain pattern when palpated.  Latent trigger points do result in an acute point of sensitivity, in a taut band of muscle, and may restrict range of motion (1).

Note: Based on the clinical experience, the Brookbush Institute suggests that latent trigger points (sometimes refereed to as Tender Points) are more common than active trigger points. Further, they are likely addressed more often than trigger points; being the intended target of many soft-tissue mobility techniques.
<ol>
 	<li>David G. Simons, Janet Travell, Lois S. Simons, Travell &amp; Simmons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition,© 1999 Williams and Wilkens</li>
</ol>

An anatomical direction; further from the midline

Example, the anterior deltoid is lateral to the pectoralis major

Length/Tension Relationship - The amount of force generated by a muscle is dependent on sarcomere length.
<ul>
 	<li>The ability of sarcomere to maximally produce force occurs when sarcomere length results in optimal overlap between actin and myosin. Stretching a sarcomere decreases overlap between actin and myosin filaments and reduces force production (1-3). When length is less than optimal, actin from opposite ends overlap and interfere with cross-bridging, and myosin filament are compressed as they contact the the Z-disk also reducing force (4)</li>
</ul>
<ol>
 	<li>Gordon, A. M., Huxley, A. F., &amp; Julian, F. J. (1966). The variation in isometric tension with sarcomere length in vertebrate muscle fibres. The Journal of physiology, 184(1), 170-192.</li>
 	<li>Edman, K. A. P. (1966). The relation between sarcomere length and active tension in isolated semitendinosus fibres of the frog. The Journal of Physiology, 183(2), 407-417.</li>
 	<li>Lieber, R. L., Loren, G. J., &amp; Friden, J. (1994). In vivo measurement of human wrist extensor muscle sarcomere length changes. Journal of neurophysiology, 71(3), 874-881.</li>
 	<li>Lieber, R. L. (2002). Skeletal muscle structure, function, and plasticity. Lippincott Williams &amp; Wilkins.</li>
</ol>
&nbsp;

Levels of Evidence - Relative to evidence-based practice, levels of evidence are an attempt to describe the strength of the results measured in a clinical trial or research study.  Note: levels of evidence do not supersede the critical evaluation of an experienced professional, and should be viewed as guidelines - a meta-analysis may be poorly constructed (Level IA), and a comparative study (Level III) may employ new technologies and a strong methodology.


The Levels of Evidence used by the Brookbush Institute, as described by Shekelle et al.(1):
<ul>
 	<li class="p1">IA - Evidence from meta-analysis of randomized controlled trials</li>
 	<li class="p1">IB - Evidence from at least one randomized controlled trial</li>
 	<li class="p1">IIA - Evidence from at least one controlled study without randomization</li>
 	<li class="p1">IIB - Evidence from at least one other type of quasi-experimental study</li>
 	<li class="p1">III - Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies</li>
 	<li class="p1">IV - Evidence from expert committee reports or opinions or clinical experience of respected authorities, or both</li>
</ul>
<ol>
 	<li>Shekelle, P. G., Woolf, S. H., Eccles, M., &amp; Grimshaw, J. (1999). Developing clinical guidelines. Western Journal of Medicine, 170(6), 348.</li>
</ol>

Likelihood Ratios - Likilihood ratios are used for assessing the value of performing a diagnostic test. They use sensitivity and specificity to determine whether a test result usefully changes the practitioner's chance (probability) of reaching the correct assessment. Calculation of likelihood ratios is based on Baye's theorem.
<ul>
 	<li>Positive Likelihood Ratio (LR+) - The ratio of a positive test result in people with the pathology to a positive test result in people without the pathology.</li>
 	<li>Negative Likelihood Ratio (LR-) - The ratio of a negative test result in people with the pathology to a negative test result in people without the pathology.</li>
</ul>

Longitudinal Study - a research design that involves observing the same variables, several times over a period of time.
<ul>
 	<li>Example, the study by Hewett et al. (1) is a type of longitudinal study called a "cohort study." This study investigated whether excessive knee valgus during landing was a predictor of knee injury risk in adolescent females over the course of a season.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/research-review-increased-valgus-during-landing-predicts-acl-injury-in-adolescent-female-athletes/" target="_blank" rel="noopener noreferrer">Hewett, T. E., Myer, G. D., Ford, K. R., Heidt, R. S., Colosimo, A. J., McLean, S. G., &amp; Succop, P. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes A prospective study. The American journal of sports medicine, 33(4), 492-501</a></li>
</ol>

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