Introduction: Relationship Between Hip Muscle Imbalance and Occurrence of Low Back Pain in College Athletes

How Does this Study Relate to Brookbush Institute Content: Increased Trunk Muscle Latency May Cause, Rather than Result From, Low Back Pain

Introduction: Trunk Muscle Weakness as a Risk Factor for Low Back Pain

Study Summary: Trunk Muscle Weakness as a Risk Factor for Low Back Pain

How this Study Contributes to the Body of Research: Trunk Muscle Weakness as a Risk Factor for Low Back Pain

How the Findings Apply to Practice: Trunk Muscle Weakness as a Risk Factor for Low Back Pain

How Does this Relate to Brookbush Institute Content: Trunk Muscle Weakness as a Risk Factor for Low Back Pain

Introduction

Study Summary

How This Study Contributes to the Body of Research

How the Findings Relate to Practice

Study Summary: Relationship Between Hip Muscle Imbalance and Occurrence of Low Back Pain in College Athletes

How Does this Study Relate to Brookbush Institute Content

How this Study Contributes to the Body of Research: Relationship Between Hip Muscle Imbalance and Occurrence of Low Back Pain in College Athletes

How the Findings Apply to Practice: Relationship Between Hip Muscle Imbalance and Occurrence of Low Back Pain in College Athletes

How Does this Relate to Brookbush Institute Content: Relationship Between Hip Muscle Imbalance and Occurrence of Low Back Pain in College Athletes

Introduction: Increased Trunk Muscle Latency May Cause, Rather than Result From, Low Back Pain

Study Summary: Increased Trunk Muscle Latency May Cause, Rather than Result From, Low Back Pain

How this Study Contributes to the Body of Research: Increased Trunk Muscle Latency May Cause, Rather than Result From, Low Back Pain

How the Findings Apply to Practice: Increased Trunk Muscle Latency May Cause, Rather than Result From, Low Back Pain

Does Movement Impairment Precede Low Back Injury?

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Relationship Between Hip Muscle Imbalance and Occurrence of Low Back Pain in College Athletes

Original Citation: Nadler, S. F., Malanga, G. A., Feinberg, J. H., Prybicien, M., Stitik, T. P., &amp; DePrince, M. (2001). Relationship between hip <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> imbalance and occurrence of low back pain in collegiate athletes: a <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a>. American journal of physical medicine &amp; rehabilitation, 80(8), 572-577. <a href="https://www.ncbi.nlm.nih.gov/pubmed/11475476" target="_blank" rel="noopener">ABSTRACT</a>
Introduction: The lifetime prevalence of low back pain (LBP) may be as high as 70% for men and 81% for women (1). Imbalances in hip <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> strength have been correlated with low back pain (LBP) (1-8), including reduced endurance and delayed firing of the <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> and <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> (10-14). In this <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a>, published in 2001 by US researchers, a correlation was demonstrated between an imbalance in hip extensor strength and the future onset of LBP. This may suggest that hip extensor <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> imbalance should be assessed and addressed in athletes prior to the onset of symptoms, with the intent of reducing the risk of LBP.

<table>
 <tbody>
 <tr>
 <td>Study Design</td>
 <td>Prospective 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>Subject Characteristics</td>
 <td>
 Demographics
 Number of participants: 163
 Gender: 100 males, 63 females
 Inclusion Criteria:
 <ul>
 <li>NCAA Division I college athletes</li>
 <li>Undergoing preparticipation sports physical</li>
 </ul>
 Exclusion Criteria:
 <ul>
 <li>Direct trauma to the low back region</li>
 <li>History of low back surgery</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Methodology</td>
 <td>Participants performed a strength test for hip extensor (<a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a>) and hip abduction (<a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a>) muscles during a routine sports physical.
 <ul>
 <li>The sequence of strength measurements by <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> was randomized</li>
 <li>The right hip musculature was evaluated first</li>
 </ul>
 The mean and maximum of 3 trials were taken for each measurement.
 Participants were observed prospectively over a one-year period for LBP unrelated to blunt trauma.
 </td>
 </tr>
 <tr>
 <td>Data Collection and Analysis</td>
 <td>Mean and maximum force measures were taken for hip extension (<a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a>) and hip abduction (<a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a>) via a commercial dynamometer (Chatillion, Lexington, KY) anchored to a table
 <ul>
 <li>Hip extensor strength was measured with the force plate 1-1.5 inches above the midthigh region</li>
 <li>Hip abductor strength was measured with the force plate placed 4 inches above the <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> aspect of the <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> thigh</li>
 </ul>
 Right (R) and left (L) side-to-side strength differences for each <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> tested were calculated as:
 <ul>
 <li>Hip abductor
 <ul>
 <li>The change in maximum abduction value (MA) equals the right MA minus the left MA</li>
 <li>&#x394;MA = RMA &#x2013; LMA</li>
 </ul>
 
 </li>
 <li>Hip Extensor
 <ul>
 <li>The change in maximum extensor value (ME) equals the right ME minus the left ME</li>
 <li>&#x394;ME = RME &#x2013; LME</li>
 </ul>
 
 </li>
 </ul>
 The percentage difference between the right (R) and left (L) sides for each <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> tested was calculated as:
 <ul>
 <li>Hip Abductor
 <ul>
 <li>%&#x394;MA = (&#x394;MA/Max) x100</li>
 </ul>
 
 </li>
 <li>Hip Extensor
 <ul>
 <li>%&#x394;ME = (&#x394;ME/Max) x100</li>
 </ul>
 
 </li>
 </ul>
 Logistic <a id="exercise-regression" data-tip="1179" target="_blank" href="/glossary-term/exercise-regression" class="glossary">regression</a> analysis and odds ratios were performed to determine if each percentage difference (%&#x394;MA or %&#x394;ME) were predictors of subsequent low back pain treatment.
 <ul>
 <li>Statistical analyses were evaluated for all participants as well as male and female subgroups</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Outcome Measures</td>
 <td>
 <ul>
 <li>Incidence of LBP</li>
 <li>Hip abductor (<a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a>) strength</li>
 <li>Hip extensor (<a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a>) strength</li>
 <li>Hip abductor side-to-side strength ratio (MA)</li>
 <li>Hip extensor side-to-side strength ratio (ME)</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Results</td>
 <td>Male college athletes
 <ul>
 <li>8 of 100 (8%) required treatment for LBP</li>
 <li>No significant difference was noted in the percentage differences in hip extension and hip abduction side-to-side strength ratios: %&#x394;ME (P=0.51) and %&#x394;MA (P=0.30)</li>
 </ul>
 Female college athletes
 <ul>
 <li>5 of 63 (7.9%) required treatment for LBP</li>
 <li>The percentage difference in the hip extensor side-to-side (right to left) strength ratio (%&#x394;ME) was predictive of LBP requiring treatment (P=0.05)</li>
 <li>No significant difference was noted in the percentage difference in the hip abductor side-to-side strength ratio (%&#x394;MA)(P=0.35)</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Our Conclusions</td>
 <td>The findings of this study reinforce the assertion that right to left asymmetry may increase the risk of dysfunction and pain, as noted in the Brookbush Institute&#x2019;s predictive model of <a href="https://brookbushinstitute.com/article/lumbo-pelvic-hip-complex-dysfunction-lphcd" target="_blank" rel="noopener">Lumbo Pelvic Hip Complex Dysfunction (LPHCD)</a>.</td>
 </tr>
 <tr>
 <td>Researchers&apos; Conclusions
 
 </td>
 <td>Hip extensor strength imbalance is associated with an increased occurrence of LBP in female college athletes. These findings support the assessment and treatment of hip muscle imbalances in persons with LBP.</td>
 </tr>
 </tbody>
</table>

Hip <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> impairment has been correlated with low back pain (LBP) (1-8), including a reduction in strength, endurance and activity of the <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> and <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> (10-14). This <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a> demonstrates that hip <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> imbalance may be causative, or at least predictive of future LBP. Specifically, imbalances between the left and right <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> strength is associated with future occurrences of pain. This <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a> provides evidence that the relationship between LBP and hip <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> impairment is not just correlated, but that impairment precedes and may be causative of LBP.

How this Study Contributes to the Body of Research

The findings of this study demonstrate that right to left imbalances in hip extensor strength are associated with low back pain, especially in female collegiate athletes. Human movement professionals should consider assessing and addressing hip extensor strength ratios as part of a preventative and rehabilitative intervention to reduce/treat the occurrence of LBP.
This study had many strengths, including:
<ol>
 <li>This was a <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a> with a one-year follow-up, aiding in determining whether impairment or pain came first. This study provides evidence that impairment may be a cause of pain and not just correlated. (Prospective studies are relatively rare).</li>
 <li>The sequence of <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> and <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> strength measurements were randomized for all participants, reducing testing bias.</li>
 <li>The <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of right to left imbalance in hip extensor strength adds an additional consideration to movement analysis that is not often addressed in studies.</li>
</ol>
Weaknesses and limitations that should be noted prior to clinical <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> of the findings include:
<ol>
 <li>A relatively small number of participants required treatment for LBP, which may imply much larger studies in the future will be necessary to confirm findings.</li>
 <li>Six of the thirteen athletes that required treatment for LBP during the study were noted as having a prior history of LBP. Other studies have noted that a history of LBP increases the risk of recurrence (1).</li>
 <li>Assessing hip <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> strength ratios in the clinic or gym setting may be challenging, and without a dynamometer the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of assessing right to left imbalances is unknown.</li>
</ol>

How the Findings Apply to Practice

This study supports several assertions made in the comprehensive <a href="https://brookbushinstitute.com/glossary/model/" target="_blank" rel="noopener">models</a> of <a href="https://brookbushinstitute.com/article/lumbo-pelvic-hip-complex-dysfunction-lphcd" target="_blank" rel="noopener">Lumbo Pelvic Hip Complex Dysfunction (LPHCD)</a> and <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction (LED)</a>. First, the assertion that right to left asymmetries may be more deleterious than symmetrical impairments. Second, that impairment precedes and is likely causative of pain and dysfunction. Finally, that these impairments may be assessed, which may be an opportunity to reduce the risk and/or prevalence of future pain and injury. This study may imply that more consideration should be given to hip extensor strength asymmetries when compared to other <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> used in a movement <a id="assessment" data-tip="1481" target="_blank" href="/glossary-term/assessment" class="glossary">evaluation</a>.

Overhead Squat Assessment: Lumbo Pelvic Hip Complex Dysfunction
<iframe src="https://player.vimeo.com/video/109548485" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Gluteus Maximus Activation
<iframe src="https://player.vimeo.com/video/82855853" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Ultimate Glute Bridge
<iframe src="https://player.vimeo.com/video/194160911" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Gluteus Maximus Reactive Activation Progressions
<iframe src="https://player.vimeo.com/video/76690880" frameborder="0" allowfullscreen="allowfullscreen"></iframe>

Bibliography

Increased Trunk Muscle Latency May Cause, Rather than Result From, Low Back Pain

Original Citation: Cholewicki, J., Silfies, S. P., Shah, R. A., Greene, H. S., Reeves, N. P., Alvi, K., &amp; Goldberg, B. (2005). Delayed trunk <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> reflex responses increase the risk of low back injuries. Spine, 30(23), 2614-2620. <a href="https://www.researchgate.net/profile/Norman_Reeves/publication/7448744_Delayed_Trunk_Muscle_Reflex_Responses_Increase_the_Risk_of_Low_Back_Injuries/links/59de58aba6fdcca0d32041fd/Delayed-Trunk-Muscle-Reflex-Responses-Increase-the-Risk-of-Low-Back-Injuries.pdf" target="_blank" rel="noopener">ARTICLE</a>
A variety of factors contribute to the onset of low back pain (LBP) and injury (1-8). Several studies have demonstrated that impaired motor control is one factor that is predictive of future injury (9 - 11). This 2005 study by U.S. researchers demonstrated that delayed trunk <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> response to sudden unloading was correlated with future low back injury. Human movement professionals should consider screening for impairments in trunk <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activation and addressing any issues with the intent of reducing the risk of injury.
<a href="https://www.datocms-assets.com/25800/1646155773-kneeling-chop.jpeg"><img src="https://www.datocms-assets.com/25800/1646155773-kneeling-chop.jpeg"></a>

<table>
 <tbody>
 <tr>
 <td width="40%">Study Design</td>
 <td>Prospective cohort study</td>
 </tr>
 <tr>
 <td>Level of Evidence</td>
 <td>III - Observational and prospective research</td>
 </tr>
 <tr>
 <td>Participant Characteristics</td>
 <td>Demographics
 <ul>
 <li>Age: average 19.4 years</li>
 <li>Height: average 1.77 meters (m)</li>
 <li>Weight: average 72.7 kilograms (kg)</li>
 <li>Gender: 148 female, 144 male</li>
 <li>Number of participants: 292
 <ul>
 <li>60 participants had a history of low back injury (LBI) lasting longer than 3 days</li>
 <li>232 participants had no history of LBI</li>
 </ul>
 
 </li>
 <li>Collegiate athletes participating in 22 different sports</li>
 </ul>
 Inclusion Criteria:
 <ul>
 <li>Collegiate athletes at Yale University</li>
 </ul>
 Exclusion Criteria:
 <ul>
 <li>N/A</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Methodology</td>
 <td>
 <ul>
 <li>Participants filled out a questionnaire with demographic data, athletic experience, varsity-level sport(s) affiliation, history and detail of LBI, and level of pain and disability while injured</li>
 <li>Baseline trunk response to sudden unloading was tested</li>
 <li>Low back injuries were tracked over a 2- to 3-year period
 <ul>
 <li>Tracked through self-report, regularly scheduled electronic mailings and athletic training room and team physician records</li>
 </ul>
 
 </li>
 <li>LBI was defined as &quot;any low back pain that caused an athlete to miss or not fully participate in at least 3 days of practice or competitions, and resulted in a visit to a sports physician or athletic trainer&quot;</li>
 <li>Athletes who sustained a LBI repeated the questionnaire and participated in a retest of trunk response to sudden unloading
 <ul>
 <li>15 athletes without a history of LBI and those who did not sustain a LBI were retested as well to verify reproducibility</li>
 </ul>
 
 </li>
 </ul>
 Trunk Response Testing
 <ul>
 <li>Testing was performed with the participant&apos;s pelvis and lower extremities stabilized in a wooden apparatus
 <ul>
 <li>Participants were semi-seated with their lumbar spine in a self-determined &quot;comfortable position,&quot; pelvic motion was then restrained leaving the upper body free to move in any direction</li>
 <li>Each participant wore a chest harness at the T9 spinal level that was connected via a pulley to an electromagnet and supplied the resistance for the isometric contraction for the trunk</li>
 <li>Resistance was &quot;30% of the maximal isometric trunk exertion for an average healthy male (108 N) or female (72 N)&quot; as determined by a pilot study</li>
 </ul>
 
 </li>
 <li>Resistance was provided from 3 different directions:
 <ul>
 <li>Flexion (cable directed <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> from harness)</li>
 <li>Extension (cable <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> from harness)</li>
 <li>Lateral bending (cable right from harness)</li>
 </ul>
 
 </li>
 <li>Each participant performed 5 trials in which:
 <ul>
 <li>The electromagnet maintained a constant resistance</li>
 <li>Participants were instructed to maintain their position and were provided with a visual of the target resistance level</li>
 <li>The electromagnet was abruptly disengaged at random</li>
 </ul>
 <ul>
 <li>EMG signals were recorded from 12 major trunk muscles for pre- and post-release
 <ul>
 <li><a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">Rectus abdominis</a>, <a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">external oblique</a>, <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal oblique</a>, <a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi</a>, <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">thoracic erector spinae, and lumbar erector spinae</a> were tested on each side of the body
 <ul>
 <li>Agonist muscles were defined as &quot;muscles that were active before the force <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> and were expected to shut off after the release&quot;</li>
 <li>Antagonist muscles were defined as &quot;muscles that were inactive before the force <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> and were expected to increase in electrical activity after the release&quot;</li>
 <li>In flexion, flexors acted as <a id="prime-mover" data-tip="1664" target="_blank" href="/glossary-term/prime-mover" class="glossary">agonists</a> (FlexOFF) and extensors as antagonists (FlexON)</li>
 <li>In extension, extensors acted as <a id="prime-mover" data-tip="1664" target="_blank" href="/glossary-term/prime-mover" class="glossary">agonists</a> (ExtOFF) and flexors as antagonists (ExtON)</li>
 <li>In <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> bending, the <a id="ipsilateral" data-tip="1550" target="_blank" href="/glossary-term/ipsilateral" class="glossary">ipsilateral</a> muscles acted as <a id="prime-mover" data-tip="1664" target="_blank" href="/glossary-term/prime-mover" class="glossary">agonists</a> (LatOFF) and <a id="contralateral" data-tip="1549" target="_blank" href="/glossary-term/contralateral" class="glossary">contralateral</a> muscles acted as antagonists (LatON)</li>
 </ul>
 </li>
 </ul>
 </li>
 </ul>
 </li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Data Collection and Analysis</td>
 <td>Data Collection
 <ul>
 <li>Onset and offset of <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity was detected when significant changes occurred in the statistical properties of the EMG signal modeled as a Gaussian random process
 <ul>
 <li>Events were marked with alarms, and the earliest alarm time between 15-150 milliseconds (ms) was used</li>
 </ul>
 
 </li>
 <li>The overall trunk muscles&apos; response to quick force <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> was quantified using the average latency and number of muscles that responded to quick <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> were calculated according to previous studies (12-13).
 <ul>
 <li>Only the muscles that responded to the force <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> were included in the average latency</li>
 <li>Censored average latency was also calculated to assign the muscles that did not respond to the force <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> a maximum latency of 150 ms</li>
 </ul>
 
 </li>
 </ul>
 Data Analysis
 <ul>
 <li>A 2-factor analysis of variance (ANOVA) identified significantly different parameters between injured and uninjured athletes and was used to determine the initial most appropriate parameters for <a id="exercise-regression" data-tip="1179" target="_blank" href="/glossary-term/exercise-regression" class="glossary">regression</a> analysis
 <ul>
 <li>Significance was set at P &lt; 0.05</li>
 <li>The 2 factors were:
 <ul>
 <li>LBI vs. no LBI during the follow-up period</li>
 <li>History of LBI vs. no history of LBI at baseline</li>
 </ul>
 </li>
 </ul>
 
 </li>
 <li>Parameters that were not normally distributed underwent logarithmic transformation for correction to a normal distribution before input into the 2-factor ANOVA</li>
 <li>A backward stepwise binary logistic <a id="exercise-regression" data-tip="1179" target="_blank" href="/glossary-term/exercise-regression" class="glossary">regression</a> <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> was used for predicting LBI
 <ul>
 <li>Experimental testing generated 18 parameters that were averaged across all trials for each athlete and served as input into the <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>
 <ul>
 <li>Parameters: 3 directions (flexion, extension, <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> bending), <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> response latencies for onsets and offsets for each direction, censored <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> response latencies for onsets and offsets, and number of muscles switching on and shutting off</li>
 </ul>
 
 </li>
 <li>At each step the parameter that contributed the least to the <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> was removed until only the parameters with P &lt; 0.1 remained</li>
 </ul>
 
 </li>
 <li>The duration of the follow-up period was added to the final <a id="exercise-regression" data-tip="1179" target="_blank" href="/glossary-term/exercise-regression" class="glossary">regression</a> <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> to determine if an effect occurred on <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> predictions</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Outcome Measures</td>
 <td>
 <ul>
 <li>History of low back pain</li>
 <li>LBI over a 2- to 3-year period</li>
 <li>EMG trunk <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> response to sudden unloading</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Results</td>
 <td>
 <ul>
 <li>During the 2-3-year follow-up period, 31 (11%) LBI occurred</li>
 <li>Reproducibility of <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> response parameters ranged from fair to very good (intraclass correlation coefficient = 0.37-0.88)</li>
 <li>The initial 2-factor ANOVA determined the following with results reported as mean (standard deviation):
 <ul>
 <li>Muscle latencies were longer in participants who sustained a LBI during the follow-up period compared to those who did not
 <ul>
 <li>77 (36) vs. 63 (31) ms for FlexOFF, (P = 0.03)</li>
 <li>63 (25) vs. 55 (20) ms for LatOFF, (P = 0.04)</li>
 </ul>
 
 </li>
 <li>A significantly smaller number of muscles were shut off in trunk flexion in participants who sustained a LBI compared to those who did not, 0.8 (1.0) vs. 1.3 (1.1), (P = 0.03)</li>
 <li>Censored <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> latency was significantly longer in participants who sustained a LBI compared to those who did not, 138 (16) vs. 129 (20) ms, (P = 0.01)</li>
 <li>A greater number of muscles were switched on in ExtON trials in participants with no history of LBI compared to those with a history of LBI 5.6 (0.5) vs. 5.5 (0.6), (P = 0.03)</li>
 <li>There was no interaction between a history of LBI and LBI during the follow-up period in any measured parameters</li>
 </ul>
 
 </li>
 <li>The final binary logistic <a id="exercise-regression" data-tip="1179" target="_blank" href="/glossary-term/exercise-regression" class="glossary">regression</a> <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> consisted of history of LBI at baseline, body weight and FlexOFF and LatOFF response latencies
 <ul>
 <li>It predicted 74% of LBI probabilities corresponding with the observed outcomes during the follow-up period</li>
 <li>The odds ratios associated with each parameter demonstrated:
 <ul>
 <li>A participant with a history of LBI was 2.8 times more likely to sustain a LBI compared to those without a history of LBI</li>
 <li>The odds of sustaining a LBI:
 <ul>
 <li>Increased by 3% for every ms delay in censored <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> response latency in FlexOFF</li>
 <li>Increased by 2% for every ms delay in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> response latency in LatOFF</li>
 <li>Increased by 3% for each kg increase in body weight</li>
 </ul>
 
 </li>
 <li>Duration of the follow-up period did not have an effect on <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> predictions (P = 0.34)</li>
 </ul>
 
 </li>
 </ul>
 </li>
 <li>The <a id="exercise-regression" data-tip="1179" target="_blank" href="/glossary-term/exercise-regression" class="glossary">regression</a> analysis was repeated with stricter definitions of injury (limited to only those referred to a sports medicine physician or those who were directed for MRI or other imaging tests) and predicted 81% and 87%, respectively, of the probability of sustaining a LBI</li>
 <li>The <a id="exercise-regression" data-tip="1179" target="_blank" href="/glossary-term/exercise-regression" class="glossary">regression</a> analysis was repeated separately for participants with and without a history of LBI and predicted 71% and 72%, respectively, of the probability of sustaining a LBI</li>
 <li>Analysis of retest data demonstrated:
 <ul>
 <li>No significant differences in pre- and post-injury <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> values for <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> response times in participants who had no history of LBI, but sustained a LBI during the follow-up period</li>
 <li>No significant changes in motor control over time following a LBI</li>
 </ul>
 </li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Our Conclusions</td>
 <td>The results of this study demonstrate that delayed trunk flexion and lateral bending muscle latencies in response to sudden trunk unloading is correlated with increased risk of future LBI. This may imply that descriptions of <a href="https://brookbushinstitute.com/article/lumbo-pelvic-hip-complex-dysfunction-lphcd" target="_blank" rel="noopener">Lumbo Pelvic Hip Complex Dysfunction (LPHCD)</a> should include re-activity of trunk musculature.</td>
 </tr>
 <tr>
 <td>Researchers&apos; Conclusions
 
 </td>
 <td>Delayed FlexOFF and LatOFF trunk muscle latencies in response to sudden trunk unloading are a significant predictor of future LBI in collegiate athletes, regardless of a history of LBI. These findings support the hypothesis that delayed muscle reflex response increases vulnerability of the spine to injury under sudden unloading conditions. Clinicians should aim to modify muscle recruitment patterns in patients with LBI.</td>
 </tr>
 </tbody>
</table>
<a href="https://www.datocms-assets.com/25800/1646155825-dynamic-quadruped.png"><img src="https://www.datocms-assets.com/25800/1646155825-dynamic-quadruped.png"></a>

The correlation between low back pain and altered trunk <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment alludes to the potential for altered recruitment as a factor contributing to low back injury (6-8, 14). Recent studies have supported the <a id="hypothesis" data-tip="1446" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypothesis</a> that impaired motor control increases the risk of low back pain (9-11). Unique to this study, the researchers demonstrated that impaired trunk <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> reactivity was correlated with future low back injury. The focus on reactivity, as opposed to EMG or strength ratios alone, may result in a better understanding of the sequelae leading to injury, and the development of more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> screening methods.

The findings of this study demonstrate a correlation between trunk <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> reactivity and increased risk of future low back injury. This implies that <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> screens for trunk <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> reactivity should be developed, and included in a comprehensive movement <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of the <a href="https://brookbushinstitute.com/article/lumbo-pelvic-hip-complex-dysfunction-lphcd" target="_blank" rel="noopener">Lumbo Pelvic Hip Complex</a>. Further, human movement professionals should have a repertoire of techniques for addressing altered trunk <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activation, recruitment, and reactivity for addressing any noted impairments.
This study had many methodological strengths, including:
<ul>
 <li>Prospective studies are relatively rare in human movement science. This study followed athletes for 2-3 years after initial testing; demonstrating that impairment may be predictive of injury.</li>
 <li>The reaction to a <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> of an isometric force was tested in multiple directions, providing additional data that may more closely resemble the variety of forces encountered by athletes during competitive play.</li>
 <li>Throughout the follow-up period, the researchers included regular electronic mailings to participants to ensure a high capture rate of reported LBI and avoid missing data.</li>
</ul>
Weaknesses that should be noted prior to clinical <a href="https://brookbushinstitute.com/glossary/integration/" target="_blank" rel="noopener">integration</a> of the findings include:
<ul>
 <li>The intraclass correlation coefficient (ICC) was fair to very good due to <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> parameters resulting in a wide range of outcomes. This may limit reproducibility in future studies, and/or result in difficulty developing <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> for clinical use.</li>
 <li>The testing methodology used in this study included a significant amount of equipment to position, load, and measure the reaction distance/time. Future research should consider a field <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> that would measure similar core strength attributes with minimal equipment.</li>
 <li>A functional athletic position was not tested. While the authors noted this was done to avoid compensation by any lower extremity muscles, this limits the generalizability of findings to the <a id="etiology" data-tip="1489" target="_blank" href="/glossary-term/etiology" class="glossary">etiology</a> of injury during functional tasks.</li>
</ul>

The Brookbush Institute (BI) has developed predictive <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a> of <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">postural</a> dysfunction, such as the <a href="https://brookbushinstitute.com/article/lumbo-pelvic-hip-complex-dysfunction-lphcd" target="_blank" rel="noopener">Lumbo Pelvic Hip Complex Dysfunction (LPHCD)</a> <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>, to aid human movement professionals in selecting <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a>, manual interventions, and exercise. This study demonstrates that delayed reactivity to forces resulting in eccentric trunk flexion or <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> flexion is correlated with an increased risk of low back injury in athletes. The findings of this study were <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> with additional prospective studies demonstrating a correlation between altered trunk <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity, <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a>, and the onset of <a href="https://brookbushinstitute.com/article/lumbo-pelvic-hip-complex-dysfunction-lphcd" target="_blank" rel="noopener">Lumbo Pelvic Hip Complex Dysfunction (LPHCD)</a>. The BI recommends the inclusion of <a href="https://brookbushinstitute.com/article/tva" target="_blank" rel="noopener">trunk/core reactive activation exercises</a> to ensure that altered recruitment and timing are addressed. The BI continues to refine an <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a>, systematic, outcomes-driven approach and looks forward to the <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> of more prospective research in the pursuit of <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> practice.

TVA and Gluteus Maximus Activation and Progressions
<iframe src="https://player.vimeo.com/video/82877282" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Quadruped Crawl
<iframe src="https://player.vimeo.com/video/133934741" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Quadruped Crawl 2
<iframe src="https://player.vimeo.com/video/263787607" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Resisted Quadruped Crawl
<iframe src="https://player.vimeo.com/video/306488004" frameborder="0" allowfullscreen="allowfullscreen"></iframe>

<ol>
 <li>Stevenson, J. M., Weber, C. L., Smith, J. T., Dumas, G. A., &amp; Albert, W. J. (2001). A longitudinal study of the development of low back pain in an industrial population. Spine, 26(12), 1370-1377.</li>
 <li>Bigos, S. J., Battie, M. C., Spengler, D. M., Fisher, L. D., Fordyce, W. E., Hansson, T. O. M. M. Y., &hellip; &amp; Zeh, J. U. D. I. T. H. (1992). A longitudinal, prospective study of industrial back injury reporting. Clinical orthopaedics and related research, (279), 21-34.</li>
 <li>Hoogendoorn, W. E., Bongers, P. M., De Vet, H. C., Houtman, I. L., Ari&euml;ns, G. A., Mechelen, W. V., &amp; Bouter, L. M. (2001). Psychosocial work characteristics and psychological strain in relation to low-back pain.</li>
 <li>Carroll, L. J., Cassidy, J. D., &amp; C&ocirc;t&eacute;, P. (2004). Depression as a risk factor for onset of an episode of troublesome neck and low back pain. Pain, 107(1-2), 134-139.</li>
 <li>Biering-S&oslash;rensen, F. I. N. (1984). Physical measurements as risk indicators for low-back trouble over a one-year period. Spine, 9(2), 106-119.</li>
 <li>Batti&eacute;, M. C., Bigos, S. J., Fisher, L. D., Spengler, D. M., Hansson, T. H., Nachemson, A. L., &amp; Wortley, M. D. (1990). Anthropometric and clinical measures as predictors of back pain complaints in industry: a prospective study. Journal of spinal disorders, 3(3), 195-204.</li>
 <li>Takala, E. P., &amp; Viikari-Juntura, E. (2000). Do functional tests predict low back pain?. Spine, 25(16), 2126-2132.</li>
 <li>Iwamoto, J., Abe, H., Tsukimura, Y., &amp; Wakano, K. (2004). Relationship between radiographic abnormalities of lumbar spine and incidence of low back pain in high school and college football players: a prospective study. The American journal of sports medicine, 32(3), 781-786.</li>
 <li>Panjabi, M. M. (1992). The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. Journal of spinal disorders, 5, 383-383.</li>
 <li>Hodges, P. W., &amp; Richardson, C. A. (1996). Inefficient muscular stabilization of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine, 21(22), 2640-2650.</li>
 <li>Magnusson, M. L., Aleksiev, A., Wilder, D. G., Pope, M. H., Spratt, K., Lee, S. H., &hellip; &amp; Weinstein, J. N. (1996). Unexpected load and asymmetric posture as etiologic factors in low back pain. European Spine Journal, 5(1), 23-35.</li>
 <li>Radebold, A., Cholewicki, J., Panjabi, M. M., &amp; Patel, T. C. (2000). Muscle response pattern to sudden trunk loading in healthy individuals and in patients with chronic low back pain. Spine, 25(8), 947-954.</li>
 <li>Cholewicki, J., Greene, H. S., Polzhofer, G. K., Galloway, M. T., Shah, R. A., &amp; Radebold, A. (2002). Neuromuscular function in athletes following recovery from a recent acute low back injury. Journal of Orthopaedic &amp; Sports Physical Therapy, 32(11), 568-575.</li>
 <li>Lee, J., Hoshino, Y., Nakamura, K., Kariya, Y., Saita, K., Ito, K. (1999). Trunk muscle weakness as a risk factor for low back pain. Spine, 24(1), 54-57.</li>
</ol>

Trunk Muscle Weakness as a Risk Factor for Low Back Pain

Original Citation: Lee, J., Hoshino, Y., Nakamura, K., Kariya, Y., Saita, K., Ito, K. (1999). Trunk <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> weakness as a risk factor for low back pain. Spine, 24(1), 54-57. <a href="https://www.ncbi.nlm.nih.gov/pubmed/9921591" target="_blank" rel="noopener">ABSTRACT</a>
Introduction: Low back pain (LBP) may affect as much as 80% of the population (1). Several studies have demonstrated a correlation between LBP and <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> imbalance and/or weakness (2-5). This 1999 Korean study investigated the isokinetic strength of trunk muscles in all planes, and the ratio between agonist and <a id="antagonists" data-tip="1705" target="_blank" href="/glossary-term/antagonists" class="glossary">antagonist</a> strength as a risk factor for LBP over a five-year period. The findings demonstrate that an imbalance between weaker extensors and stronger flexors (lower extensor/flexor ratio) of the trunk may increase the likelihood of low back pain.
<a href="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2017/06/Kneeling-Chop.jpg" target="_blank" rel="noopener"><img src="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2017/06/Kneeling-Chop.jpg" alt="Dr. Brookbush instructs model, Melissa Ruiz, on proper form during a Kneeling Chop"></a> Kneeling Chop

<table>
 <tbody>
 <tr>
 <td width="40%">Study Design</td>
 <td>Prospective study</td>
 </tr>
 <tr>
 <td>Level of Evidence</td>
 <td>III - Evidence from non-experimental descriptive studies</td>
 </tr>
 <tr>
 <td>Participant Characteristics</td>
 <td>
 Demographics
 Low Back Pain Group:
 <ul>
 <li>Number of participants: 18</li>
 <li>Gender: 8 male and 10 female</li>
 <li>Age: 17.2 +/- 2.4</li>
 <li>Experienced low back pain during the five-year follow-up period</li>
 </ul>
 Non-Low Back Pain Group:
 <ul>
 <li>Number of participants: 49</li>
 <li>Gender: 22 male, 27 female</li>
 <li>Age: 17.1 +/- 2.2</li>
 <li>No low back pain reported during the five-year follow-up period</li>
 </ul>
 Inclusion Criteria:
 <ul>
 <li>Student Volunteers</li>
 <li>13-26 years old</li>
 <li>No low back pain at the start of the <a id="assessment" data-tip="1481" target="_blank" href="/glossary-term/assessment" class="glossary">evaluation</a> period</li>
 <li>No history of low back pain</li>
 <li>Observed over a five-year period</li>
 </ul>
 Exclusion Criteria:
 <ul>
 <li>History of low back pain or prior treatment for low back pain</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Methodology</td>
 <td>
 Participants were observed prospectively for five-years
 Peak <a id="torque" data-tip="1294" target="_blank" href="/glossary-term/torque" class="glossary">torque</a> values were measured isokinetically in N &#xB7; m (ratios of peak <a id="torque" data-tip="1294" target="_blank" href="/glossary-term/torque" class="glossary">torque</a> in extension to flexion and in left to right torso rotation were calculated as E/F and L/R ratios)
 Peak Torque
 <ul>
 <li>Extension</li>
 <li>Flexion</li>
 <li>Left rotation</li>
 <li>Right rotation</li>
 </ul>
 Agonist/antagonist ratio
 <ul>
 <li>E/F ratio</li>
 <li>L/R ratio</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Data Collection and Analysis</td>
 <td>Trunk muscle strength was measured isokinetically
 <ul>
 <li>A Cybex Trunk Extension/Flexion Unit and Torso-Rotation Unit (Lumex, Ronkonkoma, NY) was used</li>
 <li>5 repetitions were performed at 60-degrees/second</li>
 <li>Range of motion was preset 0&#xB0; &#x2013; 60&#xB0; flexion and from 60&#xB0; rightward rotation to 60&#xB0; leftward rotation</li>
 <li>Maximal strength was measured as peak torque</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Outcome Measures</td>
 <td>
 <ul>
 <li>Incidence of LBP</li>
 <li>Flexion</li>
 <li>Extension</li>
 <li>Left rotation</li>
 <li>Right rotation</li>
 <li>Left rotation/right rotation ratio (L/R)</li>
 <li>Extension/flexion ratio (E/F)</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Results</td>
 <td>Peak torque &#x2013; males (LBP &amp; non-LBP groups)
 <ul>
 <li>230.2 &#xB1; 59.0 N &#xB7; m in extension</li>
 <li>203.6 &#xB1; 46.0 N &#xB7; m in flexion</li>
 <li>128.6 &#xB1; 28.0 N &#xB7; m in leftward rotation</li>
 <li>126.4 &#xB1; 25.3 N &#xB7; m in rightward rotation</li>
 </ul>
 Peak <a id="torque" data-tip="1294" target="_blank" href="/glossary-term/torque" class="glossary">torque</a> &#x2013; females (LBP &amp; non-LBP groups)
 <ul>
 <li>113.1 &#xB1; 30.5 N &#xB7; m in extension</li>
 <li>121.6 &#xB1; 24.9 N &#xB7; m in flexion</li>
 <li>60.0 &#xB1; 18.9 N &#xB7; m in leftward rotation</li>
 <li>58.4 &#xB1; 19.2 N &#xB7; m in rightward rotation</li>
 </ul>
 No significant differences in peak <a id="torque" data-tip="1294" target="_blank" href="/glossary-term/torque" class="glossary">torque</a> ratios were noted between non-LBP group and LBP group in any areas except E/F ratio
 <ul>
 <li>Men in LBP group = 0.96 &#xB1; 0.27 N &#xB7; m</li>
 <li>Women in LBP = 0.77 &#xB1; 0.19 N &#xB7; m</li>
 <li>Men in non-LBP group = 1.23 &#xB1; 0.28 N &#xB7; m</li>
 <li>Women in non-LBP group = 1.00 &#xB1; 0.16 N &#xB7; m</li>
 </ul>
 E/F ratio was the more <a id="sensitivity" data-tip="1227" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitive</a> predictor for possible LBP episodes. No statistical differences were noted in L/R ratio between the LBP and non-LBP groups.
 </td>
 </tr>
 <tr>
 <td>
 Our Conclusions
 </td>
 <td>The findings of this study support the assertion that muscle imbalance is a predictor of future low back pain, specifically between flexors and extensors.</td>
 </tr>
 <tr>
 <td>Researchers&apos; Conclusions</td>
 <td>Imbalances in trunk muscle strength may be a risk factor for increased incidence in low back pain; specifically, reduced trunk extensor muscle strength compared to flexor strength.</td>
 </tr>
 </tbody>
</table>
<a href="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2016/07/Dynamic-Quadruped.png" target="_blank" rel="noopener"><img src="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2016/07/Dynamic-Quadruped.png" alt="Dr. Brent Brookbush instructs patient/client on how to perform a dynamic quadruped"></a> Dynamic Quadruped

Several studies have demonstrated correlations between low back pain, <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> imbalance, and <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> weakness; however, prospective studies are relatively rare (2-5). This study investigated isokinetic <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> strength and antagonist/agonist ratio in a 5-year <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a> to determine what findings may be precursors to low back pain (LBP). No significant differences were found in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> strength between low back pain and asymptomatic individuals, and left to right rotation was not significantly different. This study did show a strong correlation between the occurrence of future low back pain and reduced trunk extensor <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> strength when compared to flexor strength.

Human movement professionals should consider assessing trunk extensor/flexor strength ratios for those exhibiting symptoms of low back pain. More important, assessing this ratio and designing interventions to correct noted imbalance may be preventative of future episodes of LBP. Ideally, interventions would aim to correct dysfunction and not simply increase extensor strength (6-7)
This study had many methodological strengths, including:
<ol>
 <li>Prospective studies are relatively rare, much less prospective studies with a 5 year follow-up period.</li>
 <li>The study investigated strength in multiple directions and ratios between agonists/antagonists allowing for direct comparison between all findings. This resulted in demonstrating that only flexor/extensor strength ratios were significantly different and that other findings may be unreliable predictors of future low back pain.</li>
 <li>Participants had no history of low back pain prior to this study, reducing the affect recurrence may have had on episodes of LBP.</li>
</ol>
Weaknesses that should be noted prior to the clinical <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> of the findings include:
<ol>
 <li>Participants were all students (with an average age of 17) without a history of LBP, reducing generalizability.</li>
 <li>It can be difficult to reliably determine trunk <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> strength in practice, making practical application difficult.</li>
 <li>Researchers had little control over participants&#x2019; actions over the five-year period, and 9 became involved in occupations other than academic study, changing their daily habits.</li>
</ol>

This study supports several assertions made in the comprehensive <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a> of <a href="https://brookbushinstitute.com/article/lumbo-pelvic-hip-complex-dysfunction-lphcd" target="_blank" rel="noopener">Lumbo Pelvic Hip Complex Dysfunction (LPHCD)</a> and <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction (LED)</a>. First, the assertion that <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> imbalance, and not simply <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> strength are correlated with dysfunction. This study also demonstrates that dysfunction precedes pain and injury (imbalance increased the risk of LBP). Last, the imbalance between flexors and extensors may be explained by altered <a id="osteokinematic-motion" data-tip="1797" target="_blank" href="/glossary-term/osteokinematic-motion" class="glossary">osteokinematics</a>, <a id="lengthtension-relationship" data-tip="1685" target="_blank" href="/glossary-term/lengthtension-relationship" class="glossary">length/tension</a> relationships, and perhaps <a id="arthrokinematic-inhibition" data-tip="1700" target="_blank" href="/glossary-term/arthrokinematic-inhibition" class="glossary">arthrokinematic inhibition</a> as a result of facet joint <a id="hypermobility" data-tip="1677" target="_blank" href="/glossary-term/hypermobility" class="glossary">hypermobility</a> or excessive stiffness.

How Does this Relate to Brookbush Institute Content

Overhead Squat Assessment: Lumbo Pelvic Hip Complex Dysfunction
<iframe src="https://player.vimeo.com/video/109548485" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Dynamic Glute Bridge with Trunk Rotation
<iframe src="https://player.vimeo.com/video/76685014" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Ultimate Glute Bridge
<iframe src="https://player.vimeo.com/video/194160911" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Standing Chop Pattern

<ol>
 <li>Biering-S&oslash;rensen, F. (1983). A prospective study of low back pain in a general population. I. Occurrence, recurrence and aetiology. Scandinavian journal of rehabilitation medicine, 15(2), 71-79.</li>
 <li>Cho, K., Beom, J., Lee, T., Lim, J., Lee, T., Yuk, J. (2014). Trunk muscles strength as a risk factor for nonspecific low back pain: a pilot study. Annals of Rehabilitation Medicine, 38(2), 234-240,</li>
 <li>Kendall, K., Schmidt, C., Ferber, R. (2010). The relationship between hip-abductor strength and the magnitude of pelvic drop in patients with low back pain. Journal of Sport Rehabilitation, 19(4), 422-435.</li>
 <li>Bayramoglu, M., Akman, M., Kilnic, S., Cetin, N., Yavuz, N., Ozker, R. (2001). Isokinetic measurement of trunk muscle strength in women with chronic low-back pain. American Journal of Physical Medicine &amp; Rehabilitation, 80(9), 650-655.</li>
 <li>Yahia, A., Jribi, S., Ghroubi, S., Elleuch, M., Baklouti, S., Habib Elleuch, M. (2011). Evaluation of the posture and muscular strength of the trunk and inferior members of patients with chronic lumbar pain. Joint, Bone, and Spine, 78(3), 291-297.</li>
 <li>Hides, J., Stanton, W., McMahon, S., Sims, K., &amp; Richardson, C. (2008). Effect of stabilization training on multifidus <a href="https://brookbushinstitute.com/glossary/muscle-cell/" target="_blank" rel="noopener">muscle</a> cross-sectional area among young elite cricketers with low back pain. journal of orthopaedic &amp; sports physical therapy, 38(3), 101-108.</li>
 <li>Danneels, L. A., Vanderstraeten, G. G., Cambier, D. C., Witvrouw, E. E., Bourgois, J. D. W. D. C. H. J., Dankaerts, W., &amp; De Cuyper, H. J. (2001). Effects of three different training modalities on the cross sectional area of the lumbar multifidus <a href="https://brookbushinstitute.com/glossary/muscle-cell/" target="_blank" rel="noopener">muscle</a> in patients with chronic low back pain. British journal of sports medicine, 35(3), 186-191.</li>
</ol>

Low Back Pain in College Athletes: A Prospective Study Correlating Lower Extremity Overuse or Acquired Ligamentous Laxity With Low Back Pain

Original Citation: Nadler, S. F., Wu, K. D., Galski, T., &amp; Feinberg, J. H. (1998). Low back pain in college athletes: a <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a> correlating lower extremity overuse or acquired ligamentous laxity with low back pain. Spine, 23(7), 828-833. <a href="https://www.ncbi.nlm.nih.gov/pubmed/9563115" target="_blank" rel="noopener">ABSTRACT</a>
Research suggests that approximately 25% of collegiate athletes have experienced low back pain (LBP) (1- 2). Biomechanical faults, lower extremity (LE) overuse, ligament laxity, and gender differences have been identified as potential causes (3-8). This 1998 <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a> by U.S. researchers demonstrates that collegiate athletes (especially females) with acquired LE ligamentous and overuse injuries are more likely to develop LBP. Human movement professionals should consider assessing and addressing LE impairments prior to activity with the intent of reducing the occurrence of LBP.
<a href="https://www.datocms-assets.com/25800/1646155502-screen-shot-2016-09-09-at-11-11-44-am.png"><img src="https://www.datocms-assets.com/25800/1646155502-screen-shot-2016-09-09-at-11-11-44-am.png"></a>
The Modified Thomas <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a>, as performed by the Brookbush Institute. (Image: Courtesy of www.BrentBrookbush.com)

<table>
 <tbody>
 <tr>
 <td width="40%">Study Design</td>
 <td>Prospective 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: 257</li>
 <li>Gender: 170 males, 87 females</li>
 <li>7 varsity male sports
 <ul>
 <li>Football, soccer, baseball, track, tennis, basketball, swimming</li>
 </ul>
 </li>
 <li>7 varsity female sports
 <ul>
 <li>Volleyball, soccer, softball, track, tennis, basketball, swimming</li>
 </ul>
 </li>
 </ul>
 Inclusion Criteria:
 <ul>
 <li>Varsity sport level collegiate athletes</li>
 <li>Undergoing pre-participation sports physical</li>
 </ul>
 Exclusion Criteria:
 <ul>
 <li>Direct trauma to the low back region</li>
 <li>History of low back surgery</li>
 <li>History of trauma, discomfort or previous surgery without positive physical findings on examination</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Methodology</td>
 <td>A detailed evaluation of the back and lower extremities was performed with intensive screening for the presence of: muscle inflexibility, leg length discrepancy, knee joint line tenderness, acquired ligamentous laxity, musculotendinous overuse and any residual post-surgical deficits in the lower extremities. Tests included:
 <ul>
 <li>Wilson-Barstow Maneuver &#x2013; <a id="assessment" data-tip="1486" target="_blank" href="/glossary-term/assessment" class="glossary">assess</a> functional leg length discrepancy</li>
 <li><a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">Thomas test</a> &#x2013; <a id="assessment" data-tip="1486" target="_blank" href="/glossary-term/assessment" class="glossary">assess</a> <a href="https://brookbushinstitute.com/article/hip-flexors-anterior-thigh-muscles" target="_blank" rel="noopener">hip flexor</a> tightness</li>
 <li>Tenderness on palpation:
 <ul>
 <li>All four quadrants of the patella</li>
 <li>Achilles tendon</li>
 <li><a href="https://brookbushinstitute.com/article/tibialis-posterior" target="_blank" rel="noopener">Tibialis posterior</a> tendon</li>
 <li>Plantar fascia</li>
 <li>Joint line tenderness of the knee</li>
 </ul>
 
 </li>
 <li>Ligament laxity:
 <ul>
 <li><a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">Knee</a>
 <ul>
 <li><a href="https://brookbushinstitute.com/video/valgus-and-varus-stress-test" target="_blank" rel="noopener">Valgus/varus stress test</a> for <a id="medial" data-tip="1568" target="_blank" href="/glossary-term/medial" class="glossary">medial</a> and <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> collateral ligaments (MCL/LCL)</li>
 <li><a href="https://brookbushinstitute.com/video/lachmans-and-anterior-draw" target="_blank" rel="noopener">Lachman&apos;s test</a> for <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> cruciate ligament (ACL)</li>
 <li>Godfrey Maneuver for the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> cruciate ligament (PCL)</li>
 </ul>
 </li>
 <li><a href="https://brookbushinstitute.com/article/ankle-joint-talocrural-subtalor-tibiofibular-joints" target="_blank" rel="noopener">Foot/ankle</a>
 <ul>
 <li>Anterior drawer <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> for <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> talofibular ligament laxity</li>
 </ul>
 
 </li>
 </ul>
 </li>
 </ul>
 Participants were questioned for a history of trauma, discomfort, or previous surgery of the lower extremities.
 All <a id="assessment" data-tip="1483" target="_blank" href="/glossary-term/assessment" class="glossary">evaluations</a> were performed by residents in physical medicine and rehabilitation and a sports medicine fellow, under the direction of the sports medicine director.
 Participants were observed prospectively over one year for occurrence of LBP, which was tracked by the team athletic trainer and determined as any athlete requiring treatment by the athletic trainer.
 </td>
 </tr>
 <tr>
 <td>Data Collection and Analysis</td>
 <td>Data Analysis
 <ul>
 <li>Chi-square analysis was performed to evaluate differences between groups</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Outcome Measures</td>
 <td>
 <ul>
 <li>Incidence of low back pain</li>
 <li>Lower extremity impairment:
 <ul>
 <li>Patellar tendonitis, patellofemoral pain syndrome, knee <a id="stability" data-tip="1193" target="_blank" href="/glossary-term/stability" class="glossary">instability</a>, ankle instability</li>
 </ul>
 </li>
 <li>Leg length discrepancy</li>
 <li>Hip flexor tightness</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Results</td>
 <td>Lower extremity impairment
 <ul>
 <li>57 athletes (22%) were found with lower extremity impairment
 <ul>
 <li>Patellar tendonitis (23%) and <a href="https://brookbushinstitute.com/article/frontal-plane-biomechanics-female-male-participants-with-without-patellofemoral-pain-syndrome" target="_blank" rel="noopener">patellofemoral pain syndrome</a> (16%) were the most common overuse injuries</li>
 <li>Non-painful <a href="https://brookbushinstitute.com/article/overactivity-ankle-evertors-chronic-ankle-instability" target="_blank" rel="noopener">ankle instability</a> (21%) was the most common ligamentous laxity</li>
 </ul>
 </li>
 <li>14 of the 57 athletes (24%) with lower extremity impairment experienced LBP (P&lt; 0.001)
 <ul>
 <li><a href="https://brookbushinstitute.com/article/overactivity-ankle-evertors-chronic-ankle-instability" target="_blank" rel="noopener">Chronic ankle instability</a> and <a href="https://brookbushinstitute.com/article/frontal-plane-biomechanics-female-male-participants-with-without-patellofemoral-pain-syndrome" target="_blank" rel="noopener">patellofemoral syndrome</a> were the most common conditions associated with LBP</li>
 </ul>
 
 </li>
 </ul>
 24 of the 257 athletes (9.3%) required treatment for LBP during the prospective year
 <ul>
 <li>13 out of 87 women (15%) required treatment for LBP</li>
 <li>11 out of 170 men (6%) required treatment for LBP</li>
 <li>The difference in LBP occurrence between the sexes was statistically significant (P= 0.0048)</li>
 </ul>
 No correlation between a reported history of LBP (P = 0.19) and the athletes that required treatment for LBP
 No correlation with leg length discrepancy (P= 0.22) or <a href="https://brookbushinstitute.com/article/hip-flexors-anterior-thigh-muscles" target="_blank" rel="noopener">hip flexor</a> tightness (P= 0.52) and incidence of LBP
 </td>
 </tr>
 <tr>
 <td>Our Conclusions</td>
 <td>The results of this study support the correlation between lower extremity impairment and LBP as described in the Brookbush Institute&#x2019;s (BI) predictive model of <a href="https://brookbushinstitute.com/article/lumbo-pelvic-hip-complex-dysfunction-lphcd" target="_blank" rel="noopener">Lumbo Pelvic Hip Complex Dysfunction (LPHCD)</a>. Further, this correlation demonstrates the importance of a transitional postural assessment, such as the <a href="https://brookbushinstitute.com/article/sign-clusters-compensation-patterns-overhead-squat-assessment" target="_blank" rel="noopener">overhead squat assessment</a>, in determining lower extremity symmetry in individuals with LBP.</td>
 </tr>
 <tr>
 <td>Researchers&apos; Conclusions
 
 </td>
 <td>Collegiate athletes with acquired lower extremity overuse injuries or ligamentous laxity were more likely to require treatment for LBP, particularly impacting female athletes. Neither leg length discrepancy nor impaired <a href="https://brookbushinstitute.com/article/hip-flexors-anterior-thigh-muscles" target="_blank" rel="noopener">hip flexor</a> flexibility were associated with future incidence of LBP.</td>
 </tr>
 </tbody>
</table>
<a href="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2018/09/LAchmans-Test.jpg" target="_blank" rel="noopener"><img src="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2018/09/LAchmans-Test-1024x532.jpg" alt="Lachman&apos;s &lt;a id=" assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a> - Commonly peformed special <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a> for ACL Integrity&quot;&gt; Lachman&apos;s <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a> - Commonly performed special <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a> for ACL Integrity. (Image: Courtesy of www.BrentBrookbush.com)

Several studies have demonstrated a correlation between low back pain (LBP) and lower extremity (LE) impairment, including joint <a id="hypomobility" data-tip="1673" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobility</a>, <a id="stability" data-tip="1193" target="_blank" href="/glossary-term/stability" class="glossary">instability</a>, muscular tightness, and overuse injury (4-8). However, prospective studies are relatively rare (9-10). In this study, researchers demonstrated that LE ligamentous and overuse injuries were correlated with future incidence of LBP in female collegiate athletes. Prospective studies like this suggest that impairment is not only correlated but perhaps a contributing factor or cause of low back pain.

The findings of this study suggest that college athletes with LE <a id="stability" data-tip="1193" target="_blank" href="/glossary-term/stability" class="glossary">instability</a>, particularly females, are at increased risk of developing LBP. Human movement professionals should consider the implementation of a comprehensive examination for the LE prior to physical activity. Further, considerations should be given to developing prevention and/or rehabilitation programs to address assessed issues with the intent of reducing the occurrence of LBP.
This study had many methodological strengths, including:
<ul>
 <li>Prospective studies are relatively rare in human movement science. This study followed participants for 1 year after initial testing; demonstrating that impairment may be predictive of injury.</li>
 <li>A single examiner assessed all participants for leg length discrepancy in order to minimize error and improve <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of the results.</li>
 <li>A variety of tests and <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> were performed, allowing for a more nuanced understanding of which impairments were correlated with LBP.</li>
 <li>A fairly large participant pool (257 athletes) allowed for a variety of statistical relationships to be investigated, including the difference between male and female athletes, as well as the predictive <a id="power" data-tip="1399" target="_blank" href="/glossary-term/power" class="glossary">power</a> of individual tests.</li>
</ul>
Weaknesses that should be noted prior to clinical <a href="https://brookbushinstitute.com/glossary/integration/" target="_blank" rel="noopener">integration</a> of the findings include:
<ul>
 <li>Incidence of LBP was recorded when an athlete required treatment from the school athletic trainer; the use of regularly scheduled follow-up sessions may have improved reporting and enhance the <a id="validity" data-tip="1511" target="_blank" href="/glossary-term/validity" class="glossary">validity</a> of the results by capturing more unreported pain and injury.</li>
 <li>The <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> used in this study rely on the examiner&apos;s skills and are subject to error; limiting <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>.</li>
 <li>The researchers studied a young population that participated in collegiate sport activities. Findings may not be generalizable to an older or more sedentary populations.</li>
</ul>

The Brookbush Institute (BI) has developed predictive <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a> of <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">postural</a> dysfunction, such as the <a href="https://brookbushinstitute.com/article/lumbo-pelvic-hip-complex-dysfunction-lphcd" target="_blank" rel="noopener">Lumbo Pelvic Hip Complex Dysfunction (LPHCD)</a> <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>, to aid human movement professionals in selecting <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a>, manual interventions, and exercise. This study demonstrates that collegiate athletes (especially females) with acquired LE ligamentous and overuse injuries are more likely to develop LBP. The findings of this study were <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> with additional prospective studies demonstrating a correlation between LBP, <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction (LED)</a>, and the onset of <a href="https://brookbushinstitute.com/article/lumbo-pelvic-hip-complex-dysfunction-lphcd" target="_blank" rel="noopener">LPHCD</a>. Further, this study demonstrates the importance of <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>, and the potential of <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> to identify impairments that could increase the risk of future injury. The BI continues to refine an <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a>, systematic, outcomes-driven approach and looks forward to the <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> of more prospective research in the pursuit of <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> practice.

Overhead Squat Assessment: Lumbo Pelvic Hip Complex Dysfunction
<iframe src="https://player.vimeo.com/video/109548485" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Overhead Squat Assessment: Sign Clusters - Lower Extremity Dysfunction
<iframe src="https://player.vimeo.com/video/109546175" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Modified Thomas Test
<iframe src="https://player.vimeo.com/video/82866022" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Knee Valgus and Varus Tests
<iframe src="https://player.vimeo.com/video/270102538" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Lachman&apos;s Test
<iframe src="https://player.vimeo.com/video/270096891" frameborder="0" allowfullscreen="allowfullscreen"></iframe>
Ankle <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> Drawer Test
<iframe src="https://player.vimeo.com/video/291586786" frameborder="0" allowfullscreen="allowfullscreen"></iframe>

<ol>
 <li>Lively, M. (2002). Prevalence of pre-existing recurrent low back pain in college athletes. WV Medical Journal, 98(5), 202-205</li>
 <li>Semon, R., Spengler, D. (1981). Significance of lumbar spondylosis in college football players. Spine, 6(2), 172-174</li>
 <li><a href="https://brookbushinstitute.com/article/trunk-muscle-weakness-risk-factor-low-back-pain" target="_blank" rel="noopener">Lee, J. H., Hoshino, Y., Nakamura, K., Kariya, Y., Saita, K., &amp; Ito, K. (1999). Trunk muscle weakness as a risk factor for low back pain: a 5-year prospective study. Spine, 24(1), 54-57.</a></li>
 <li><a href="https://brookbushinstitute.com/article/core-stability-measures-as-risk-factors-lower-extremity-injury-athletes" target="_blank" rel="noopener">Leetun, D., Ireland, M., Willson, J., Ballantyne, B., Davis, I. (2004). Core stability measures as risk factors for lower extremity injury in athletes. Medicine and Science in Sports and Exercise, 36(6), 926-934.</a></li>
 <li>Nadler, S., Malanga, G., DePrince, M., Stitik, T., Feinberg, J. (2000). The relationship between lower extremity injury, low back pain, hip muscle strength in male and female collegiate athletes. Clinical Journal of Sport Medicine, 10(2), 89-97</li>
 <li>Cummings, G., Scholz, J. P., &amp; Barnes, K. (1993). The effect of imposed leg length difference on pelvic bone symmetry. Spine, (18),368-368</li>
 <li>Mellin, G. (1988). Correlations of hip mobility with degree of back pain and lumbar spinal mobility in chronic low-back pain patients. Spine, 13(6), 668-670.</li>
 <li>Chesworth, B. M., Padfield, B. J., Helewa, A., et al. (1994). A comparison of hip mobility in patients with low back pain and matched healthy subjects. Physiother Can, 46, 267-274.</li>
 <li>Fairbank, J. C., Pynsent, P. B., Van, J. P., &amp; Phillips, H. (1984). Influence of anthropometric factors and joint laxity in the incidence of adolescent back pain. Spine, 9(5), 461-464.</li>
 <li>Nadler, S. F., Shumko, J., Galski, T., &amp; Feinberg, J. H. (1995). Low back pain in college athletes: true incidence and proper screening. Proc North Am Spine Soc, 10, 62.</li>
</ol>

&copy; 2018 Brent Brookbush
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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