Introduction

Lesson Plan Development

Addition of Force Recording Instruments

Effect of Force Recording Instruments on Accuracy, Variability, and Reliability

Retention and Limitations

Joint Mobilizations and Manipulations: Evidenced-based Teaching and Learning

NASM

ACSM

AFAA

NCBTMB

CanFitPro

PTAGlobal

ISSA

REPSI

PACE

WITS

CIMSPA

TPTA

NYPT

AOTA

Joint Mobilizations and Manipulations: Evidence-based Teaching and Learning

This course discusses the research investigating various strategies for delivering manual therapy education, with the intent of improving the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and efficacy of a clinician&apos;s manual therapy technique. These findings could be applied to college and university programs, continuing education courses, and manual therapy technique certifications, as well as used by clinical educators working to improve clinical practice at their clinics (e.g. with staff physical therapists, physical therapy students during clinical affiliations, etc.). This course does not cover the construction of a quality written exam or multiple-choice question test; however, the information in this course likely has significant implications for practical examination, and perhaps patient education.&#xA0;
Although this course does not cover material that would be considered part of a &quot;conventional&quot; manual therapy course or manual technique certification, it is recommended that all sports medicine professionals and health care providers (physical therapists, athletic trainers, massage therapists, chiropractors, occupational therapists, etc.) take this course with the intent of improving the profession, and our ability to teach manual techniques for the treatment of pain. It is time the industry went beyond teaching anatomy, body mechanics, musculoskeletal dysfunction, and manual therapy techniques, and started thinking about how better teaching could improve the delivery, retention, and application of all coursework.&#xA0;
<h3>Brookbush Institute Position Statement:</h3>
<ul>
 <li>Research implies that ideal lesson plan development would include video instruction and step-by-step demonstration prior to live instruction. Live instruction would prioritize lab and blocked-practice sessions taught by the most experienced instructors. Feedback should be concurrent, student-paced, qualitative, and quantitative, and students should have opportunities to teach the techniques back to instructors and/or peers. Random-variable practice with progressively less feedback may be used to optimize retention.</li>
</ul>
<h3>Research Summary:</h3>
<ul>
 <li>More Lab:&#xA0;Studies suggest that students are generally dissatisfied with the proportion of lecture time dedicated to lab and practicing techniques.</li>
 <li>Lesson Plan Construction: Step-by-step instruction may be beneficial during the initial demonstration; however, whole technique practice is as effective during labs. Further, it may be beneficial to have students attempt to instruct a teacher and/or peer as part of proficiency development.</li>
 <li>Integrating Didactic and Lab Instruction: Research suggests that ideal lesson plans might begin with video instruction prior to live instruction and live instruction would focus on practical application with concurrent feedback.</li>
 <li>Types of Feedback: Staff instructors are most beneficial during lab instruction and should provide both qualitative and quantitative feedback.</li>
 <li>Feedback Timing: Feedback should be concurrent and student-paced, blocked practice should be used for skill acquisition, and random-variable practice with progressively less feedback may be ideal for optimizing retention.</li>
 <li>Validity of Feedback: Few studies are available to refine the <a id="validity" data-tip="1511" target="_blank" href="/glossary-term/validity" class="glossary">Validity</a> of feedback; however, these studies should inspire more research comparing various instruction sets, cues, and alignment between student, instructor, and patient perception.&#xA0;</li>
 <li>Additional Findings: Lectures may have important effects on practice beyond the recall of testable information (e.g. prevalence of use, confidence, etc.), and an exercise program may be beneficial for new students learning joint manipulation techniques.</li>
</ul>

Course Description: Joint Mobilizations and Manipulations: Evidenced-based Teaching and Learning

<h2>Lesson Plan Development:</h2>
<h3>Brookbush Institute Position Statement:</h3>
<ul>
 <li>Research implies that ideal lesson plan development would include video instruction and step-by-step demonstration prior to live instruction. Live instruction would prioritize lab and blocked-practice sessions taught by the most experienced instructors. Feedback should be concurrent, student-paced, qualitative, and quantitative, and students should have opportunities to teach the techniques back to instructors and/or peers. Random-variable practice with progressively less feedback may be used to optimize retention.</li>
</ul>
<h3>Research Summary:</h3>
<ul>
 <li>More Lab:&#xA0;Studies suggest that students are generally dissatisfied with the proportion of lecture time dedicated to lab and practicing techniques.</li>
 <li>Lesson Plan Construction: Step-by-step instruction may be beneficial during the initial demonstration; however, whole technique practice is as effective during labs. Further, it may be beneficial to have students attempt to instruct a teacher and/or peer as part of proficiency development.</li>
 <li>Integrating Didactic and Lab Instruction: Research suggests that ideal lesson plans might begin with video instruction prior to live instruction, and live instruction would focus on practical application with concurrent feedback.</li>
 <li>Types of Feedback: Staff instructors are most beneficial during lab instruction and should provide both qualitative and quantitative feedback.</li>
 <li>Feedback Timing: Feedback should be concurrent and student-paced, blocked-practice should be used for skill acquisition, and random-variable practice with progressively less feedback may be ideal for optimizing retention.</li>
 <li>Validity of Feedback: Few studies are available to refine the <a id="validity" data-tip="1511" target="_blank" href="/glossary-term/validity" class="glossary">Validity</a> of feedback; however, these studies should inspire more research comparing various instructions sets, cues, and alignment between student, instructor, and patient perception.&#xA0;</li>
 <li>Additional Findings: Lectures may have important effects on practice beyond the recall of testable information (e.g. prevalence of use, confidence, etc.), and an exercise program may be beneficial for new students learning joint manipulation techniques.</li>
</ul>
<h3>The Addition of Force Recording Instruments (Instrumented Manakins, Tables and Gauges)</h3>
<h3>Brookbush Institute Position Statement:</h3>
<ul>
 <li>The addition of real-time feedback from instrumented tables, manakins, inertial sensors, or the Dynadjust&#x2122; may be beneficial for improving <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> force characteristics, as well as reducing variability, improving <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a>, improving <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and potentially improving clinical outcomes. However, without multiple and continued practice sessions, these improvements degrade quickly, potentially resulting in a return to baseline within a month. It is recommended these tools should only be adopted if an affordable, portable, and convenient technology is developed that can be reasonably expected to be acquired by every school, facility, and/or professional. For example, a wearable inertial sensor and <a id="mobility" data-tip="1457" target="_blank" href="/glossary-term/mobility" class="glossary">mobile</a> application that uses a smartphone for hardware.&#xA0;</li>
</ul>
<h3>Research Summary:</h3>
<h4>Force Recording Instruments:&#xA0;</h4>
<ul>
 <li>Tables and Manakins: Instrumented tables and manakins may improve joint mobilization and manipulation <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a>, peak force variability, and preload force, but may not improve the rate of force or thrust duration (which improves with experience).&#xA0;</li>
 <li>Inertial Sensors: The addition of inertial sensors to joint mobilization and manipulation instruction may improve the rate of force, the magnitude of peak force, and length of thrust duration; interestingly, the force characteristics that were not improved by instrumented tables and manakins. Further, a study by Gonz&#xE1;lez-S&#xE1;nchez et al. demonstrated that use of inertial sensors may improve clinical outcomes.</li>
 <li>Dynadjust&#x2122;: Adding the Dynadjust&#x2122; to instruction on spine manipulation may improve certain force characteristics, but only when sufficient time is allocated to technique practice.&#xA0;</li>
</ul>
<h4>Accuracy, Variability, and Reliability</h4>
<ul>
 <li>Accuracy and Variability: Joint mobilization and manipulation instruction with the addition of pre-set target forces, force recording instruments, and real-time feedback, may improve <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">Accuracy</a> and decrease variability; however, follow-up sessions are needed to maintain improvements.</li>
 <li>Reliability: Four weeks or more of joint mobilization instruction with the addition of force recording instruments may increase inter-therapist and intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of force characteristics.</li>
</ul>
<h4>Retention and Additional Limitations</h4>
<ul>
 <li>Retention: The addition of force recording instruments to joint mobilization and manipulation instruction may improve <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> performance characteristics; however, without additional and continued practice sessions, improvements degrade quickly, potentially resulting in a return to baseline within a month.</li>
 <li>Additional Limitations: Additional limitations worth further consideration include no effect on the perception of error, effect on a narrow range of kinematic measures, and no effect on parameters related to technique, including those that would be commonly assessed during the practical examination of manual therapy students.</li>
</ul>

Introduction: Research Review

<h4>More Lab</h4>
Publication on research investigating the ideal construction of courses and lectures has been increasing over the past 2 decades. Yamamoto et al. used qualitative research methods to analyze the education process of four mentors (Orthopedic Manual Physical Therapists) and five mentees learning cervical spine manipulations. The results showed that education was primarily focused on the mitigation of risk, with the next largest emphasis on clinical decision making, and the development of practical skills was taught separately with less emphasis. Mentees wanted more emphasis on the development of practical skills (1). Noteboom et al. used survey research to demonstrate that 99% of physical therapy programs include manipulations in their curricula; however, students were dissatisfied with the amount of time spent practicing the techniques during labs and clinical affiliations (2). These studies suggest that students are generally dissatisfied with the proportion of lecture time dedicated to lab and practicing techniques.
<h4>Lesson Plan Construction:</h4>
Studies have investigated a variety of lesson plan designs. Wise et al. demonstrated that instructing chiropractic students on the performance of lumbar spine manipulations using a sequential partial-task practice <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> improved confidence in the safety, efficacy, and proficiency of technique performance (3). Washmuth et al. compared a lab designed to practice the full technique to a lab designed to practice sequential steps of high-velocity low-amplitude thrust manipulations (HVLAT), demonstrating that both designs resulted in similar student confidence and outcomes when students were asked to teach the techniques back to classmates (4). And, Gradl-Dietsch demonstrated that a &quot;Peyton&apos;s four-step teaching approach&quot; (demonstrate, talk the student through it, student talks instructor through it, and the student does it) was more effective than conventional instruction (5). These studies likely suggest that step-by-step instruction may be beneficial during the demonstration portion of lectures; however, whole technique practice is as effective during labs. Further, it may be beneficial to have students attempt to instruct a teacher and/or peer as part of proficiency development.
<h4>Integrating Didactic and Lab Instruction:&#xA0;</h4>
Additional studies have investigated the value of lectures and experience prior to lab practice. Triano et al. compared students with little or no prior knowledge of manipulations to students with prior knowledge of manipulations, demonstrating that individuals with prior knowledge developed <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> skills following a single session of instruction on a new manipulative technique (6). Watson et al. compared skill development and retention of a spinal manipulation technique following video instruction, instructor training with delayed feedback, and instructor training with concurrent feedback. The findings demonstrated that the 3 groups exhibited similar skill acquisition; however, there were significant differences in retention (8-days later) favoring the students who received instructor training with concurrent feedback (7). Harvey et al. investigated the use of a conventional teaching methodology in which didactic information was taught first, followed by instruction on <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> and clinical decision making, followed by the dictation of technique instructions, and last performing the technique, compared to an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> teaching methodology that introduced practice early and throughout all lessons. The results revealed that students exposed to an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> methodology exhibited <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> peak force, time to peak force, and rate of force development (8). These studies suggest prior learning may improve new skill acquisition, initial skill acquisition is similar when it follows videos or live didactic instruction; and further, live didactic instruction should attempt to <a id="integration" data-tip="1476" target="_blank" href="/glossary-term/integration" class="glossary">integrate</a> practice with concurrent feedback early and throughout all lessons. These findings suggest that ideal lesson plans might begin with video instruction prior to live instruction and live instruction would focus on practical application with concurrent feedback.
<h4>Types of Feedback</h4>
Several studies have compared various types of feedback during the instruction of joint mobilizations and manipulations. Scaringe et al. demonstrated that during instruction of chiropractic manipulations, both qualitative and quantitative feedback improved <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> and reduced the variability of force characteristics (9). Petty et al. compared the <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> and <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of feedback from a force plate, a fellow student, and an experienced therapist on a student&apos;s performance of a grade III spine mobilization. The findings demonstrated that the feedback from the student lacked <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> and <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (10). An RCT by Knobe et al. compared the efficacy of staff teachers, student-teachers, and peer-assisted learning, demonstrating that staff teachers were <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> for lab/technique instruction, but student- and staff-teachers were similarly effective for didactic instruction (11). It is common practice for staff instructors to prioritize quantitative feedback over qualitative feedback, and prioritize teaching didactic lessons while delegating lab/technique practice to adjunct professors or student teachers. These studies imply that staff instructors should provide both qualitative and quantitative feedback, and are most beneficial during lab instruction.
<h4>Feedback Timing</h4>
Additional studies have investigated the timing of feedback during lessons on joint mobilizations and manipulations. As mentioned above, Watson et al. demonstrated that retention was better for students receiving instructor training with concurrent feedback when compared to instructor training with delayed feedback (7). Sheaves et al. demonstrated that students learning the appropriate force for lumbar mobilizations benefited more from student-controlled feedback (feedback when the student asked for it) when compared to constant feedback (instructor-dictated feedback) (12). Lardon et al. compared force during manipulations following continuous feedback over 10-sessions or progressively less feedback over 10 sessions, demonstrating no difference between the groups (13). In another study mentioned above, Scaringe et al. demonstrated that increasing the time between practice sessions reduced <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> more than <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (9). Last, Enebo et al. compared manipulation technique <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> and variability following blocked practice, random/variable practice, visual feedback of force (using force gauges), and/or post-performance feedback from an instructor. Findings demonstrated that blocked practice had the largest impact on accuracy; however, random variable practice with visual feedback had the largest impact on <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> over multiple sessions (retention) (14). These studies may suggest that feedback should be concurrent and student-paced, blocked-practice should be used for skill acquisition, and random-variable practice with progressively less feedback may be ideal for optimizing retention.
<h4>Validity of Feedback</h4>
Research has started investigating which aspects of manipulations and mobilizations should be prioritized during lessons. O&apos;Donnell et al. used survey data to identify the most important aspects of a side-lying lumbar manipulation. A consensus was reached for patient comfort, table height, localizing the target segment, log-rolling the patient towards the operator, moving up and over the patient, close contact between the operator and patient, maintaining contact using forearms, maintenance of localization during the manipulation phase, high-velocity and low-amplitude thrust by generating force through the body and legs, and dropping the body downwards. Although this may appear to be a long list of details, this list may be used to construct a set of instructions based on input from experienced practitioners (15). Pasquier et al. compared objective and subjective measures during a thoracic manipulation performed on a student by another student. Findings demonstrated that subjective ratings of comfort were strongly correlated with objective measures of preload force and thrust duration, but were not correlated with peak force during thrust, and <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of comfort by an experienced instructor was weakly correlated with a momentary decrease in preload force (16). Although few studies are available to refine the <a id="validity" data-tip="1511" target="_blank" href="/glossary-term/validity" class="glossary">validity</a> of feedback, these studies should inspire more research comparing various instructions sets, cues, and alignment between student, instructor, and patient perception.&#xA0;
<table style="border-collapse: collapse;" border="1">
 <tbody>
 <tr>
 <td>
 <h4>Additional Studies:</h4>
 The following two studies highlight additional considerations, and/or potential topics for additional research. Karas et al. demonstrated that conventional lectures on the evidence supporting the use of thoracic manipulation for cervical dysfunction patients increased the student&apos;s use of thoracic manipulation with cervical patients despite the lectures having little effect on the student&apos;s ability to recall research details (testable knowledge) (17). And, Lardon et al. investigated whether 1st-year chiropractic students would benefit from the addition of an exercise program including push-ups, core stabilization, and speed board exercises, 3x&apos;s/week for 8-weeks. Findings demonstrated that the exercise group exhibited similar thrust duration but larger improvements in preload force when compared to students who did not participate in the exercise program (18). These studies suggest that lectures may have important effects on practice beyond the recall of testable information (e.g. prevalence of use, confidence, etc.), and an exercise program may be beneficial for new students learning joint manipulation techniques.
 </td>
 </tr>
 </tbody>
</table>

<h4>Addition of Force Recording Instruments</h4>
Research has investigated the potential benefits of adding force recording instruments and real-time feedback to instruction on joint mobilizations and manipulations.
<h4>Instrumented Tables and Manikins</h4>
Several studies have investigated the efficacy of teaching with instrumented tables and manikins. A single-blind RCT by Triano et al. compared chiropractic students learning an L4 mammillary push technique following conventional instruction with and without the addition of real-time visual feedback from instrumented tables. Following 10-minutes of a distracting activity (practice exam questions), students who received feedback from manikins were significantly closer to target forces (more accurate) (19). An RCT by Descarreaux et al. compared conventional teaching methods to the addition of instrumented manikins during 5-weeks of spinal manipulation training for chiropractic students, demonstrating that the addition of manikins reduced peak force variability and increased preload force (20). Pasquier et al. compared the force parameters of a simulated thoracic manipulation by 103 chiropractic students of various levels of experience (1st year, 3rd year, or 5th year) following augmented learning including instruction from a video and practice on a force recording table. The findings demonstrated that the augmented training improved the magnitude of preload force and reduced drops in preload force for all experience levels; however, the rate of force application and thrust duration were not influenced by augmented learning and only improved with experience (21). These studies suggest that instrumented tables and manikins may improve joint mobilization and manipulation <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a>, peak force variability, and preload force, but may not improve the rate of force or thrust duration (which improved with experience).&#xA0;
<h4>Inertial Sensors</h4>
Two studies have investigated the efficacy of adding inertial sensors and real-time feedback to joint mobilization and manipulation instruction. An RCT by Cuesta-Vargas et al. compared conventional learning of thoracic manipulations to learning manipulations with real-time feedback from inertial sensors, demonstrating that the sensor group exhibited significantly larger improvements in peak force, time to peak force, and thrust duration (22). A double-blind RCT by Gonz&#xE1;lez-S&#xE1;nchez et al. compared a 90-minute lesson on two directions of ankle mobilization with conventional teaching methods or conventional teaching with the addition of real-time kinematic data via inertial sensors and a laptop. The findings suggest the addition of real-time kinematic feedback via a laptop improved velocity, runtime, and post-intervention outcomes for dorsiflexion ROM and <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> (23). These studies imply that the addition of inertial sensors to joint mobilization and manipulation instruction may improve the rate of force, the magnitude of peak force, and length of thrust duration; interestingly, the force characteristics that were not improved by instrumented tables and manikins. Further, a study by Gonz&#xE1;lez-S&#xE1;nchez et al. demonstrated that the use of inertial sensors may improve clinical outcomes.
<h4>Dynadjust</h4>
Three studies performed by Triano et. al. investigated the efficacy of adding the Dynadjust&#x2122; electromechanical training aid to conventional instruction of joint manipulations. An RCT by Triano et al. (2002) compared a full semester chiropractic manipulation course with and without the addition of the Dynadjust&#x2122;, demonstrating that the addition of the Dynadjust&#x2122; improved lumbar manipulation performance based on several kinematic measures (24). Another study by Triano et al., performed the following year (2003), compared conventional instruction of cervical spine and thoracic spine manipulations, with and without the Dynadjust&#x2122;, demonstrating the Dynadjust&#x2122; resulted in similar improvements in kinematic measures for the cervical and thoracic spine (25). And, Triano et al. (2014) compared 6-weeks of conventional instruction of manual therapy, with and without the Dynadjust&#x2122;, for 2nd and 4th-year chiropractic students. Findings suggest that the addition of the Dynadjust&#x2122; did not benefit 2nd-year students; however, 4th-year students exhibited <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> improvements in the rate and rise of peak force. Some consideration should be given to a larger proportion of didactic learning, and a smaller proportion of lab/technique practice, in the courses for 2nd-year students (26). These studies likely suggest that the addition of the Dynadjust&#x2122; to instruction on spine manipulation may improve certain force characteristics, but only when sufficient time is allocated to technique practice.&#xA0;

Force Recording Instruments (Instrumented Manikins, Tables and Gauges)

<h4>Effect of Force Recording Instruments on Accuracy and Variability</h4>
Research has investigated the potential of force recording instruments to reduce force variability during joint mobilizations and manipulations. As mentioned above, Descarreaux et al. demonstrated that the addition of an instrumented manikin to spinal manipulation instruction significantly reduced variability of peak forces following 5-weeks of training (20). Lee et al. compared 2nd-year physiotherapy students who had previously been instructed on peripheral mobilizations, based on the <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> and variability of forces during spinal mobilizations, following a single session of conventional instruction with and without the addition of force plates. The students were asked to match the average force administered by the instructor. Findings demonstrated that students who used force plates exhibited greater <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> and less variability following the practice session, and continued to demonstrate <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> and less variability 1-week later (27). Shannon et al. compared the variability of peak forces and durations of force administered by chiropractors and student chiropractors following practice for 6 sessions of 30 minutes over 4 weeks of thoracic region manipulations on a <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> instrumented manikin with real-time feedback. Immediately following the training mean variability improved from 107 N to 0.2 N for the high target (550N), and 63 N to &#x2212;6 N for the light target (350N). Variability then increased during each of the 8 weekly follow-ups; however, the variability was still much less at the final 8-week follow-up than noted prior to training (28). These studies suggest that joint mobilization and manipulation instruction with the addition of pre-set target forces, force recording instruments, and real-time feedback, may improve <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> and decrease variability; however, follow-up sessions are needed to maintain improvements.
<h4>Effect of Force Recording Instruments on Reliability</h4>
Additional studies demonstrate that force recording instruments may improve <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>. Petersen et al. used a cross-over design to compare force parameters during grade III lumbar mobilizations performed by a 1st-year doctor of physical therapy students, following 4-weeks of conventional instruction with and without force pads and real-time feedback. The findings demonstrated that the addition of force pads improved inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (when compared to an expert&apos;s force) for determining R2 (end of accessory range resistance) and peak-to-peak amplitude (29). Gautam et al. compared the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of forces applied during grade III central PA mobilizations of L4 performed by two physiotherapists on more than 200 volunteers, before and after 4 weeks of practice with the addition of a pressure <a id="algometery" data-tip="1125" target="_blank" href="/glossary-term/algometery" class="glossary">algometer</a>. The findings demonstrated that the addition of the <a id="algometery" data-tip="1125" target="_blank" href="/glossary-term/algometery" class="glossary">algometer</a> improved inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> to good and intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> to excellent (30). These studies imply that 4 weeks or more of joint mobilization instruction with the addition of force recording instruments may increase inter-therapist and intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of force characteristics.

<h4>Retention</h4>
Several studies have investigated whether improvements were retained following the addition of force recording devices. Chang et al. compared peak displacement following a 45-minute practice session on a shoulder joint simulator with no feedback, concurrent feedback, or post-practice feedback, demonstrating that both feedback groups exhibited similar improvements in variability and similar retention during <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> 10-minutes and 5-days later (31). Marchand et al. demonstrated that practicing 45 manipulations, with variable or constant force goals, on a thoracic joint simulator, significantly increased peak force and reduced variability; however, variability increased during follow-up 48 hours later, suggesting retention requires additional practice sessions (32). Snodgrass et al. compared the force imparted by physiotherapy students following a session of cervical mobilization practice, with and without the addition of a table fitted with force plates, and a goal to match the average force from an experienced clinician. The findings demonstrated that practice with the instrumented table resulted in a reduction in mean variation following practice and during follow-up 8-days later; however, the variation was larger during follow-up (33). As mentioned above, Shannon et al. demonstrated a significant reduction in chiropractic student force variability following six 30-minute practice sessions over 4 weeks on an instrumented manikin, and although variability increased with each weekly follow-up it was still less than controls at week 8 (28). Another study by Snodgrass et al. compared physiotherapy students to expert force characteristics for mean peak force, force amplitude, and oscillation frequency following 3 sessions of lumbar mobilization practice, with and without the addition of a table fitted with force plates. The findings demonstrated that <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> and variability improved with each of the 3 practice sessions; however, force parameters returned to baseline during a follow-up 1 month later, implying retention was poor (34). These studies imply that the addition of force recording instruments to joint mobilization and manipulation instruction may improve <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> performance characteristics; however, without additional and continued practice sessions, improvements degrade quickly, potentially resulting in a return to baseline within a month.
<h4>Additional Limitations</h4>
Although many studies have demonstrated that the addition of force recording instruments to conventional instruction may improve several kinematic measures associated with joint mobilization and manipulation performance, several studies demonstrate limitations worthy of considerations before adoption by instructors. Latimer et al. demonstrated that 75 practice trials assessing L3 stiffness using a force recording instrument did not improve the <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> of a student&apos;s perception of force applied (35). In a study mentioned above by Pasquier et al., 1-week of augmented training including instrumented manikins improved preload force and drop in preload force; however, the augmented training did not improve the rate of force and thrust duration, which only improved with experience (1st year, 3rd year, or 5th year) (21). A study mentioned above by Triano et al. demonstrated that the addition of the Dynadjust&#x2122; to 6-weeks of manual therapy instruction was not effective for 2nd-year students who were taking courses with a high proportion of didactic content; and further, was only effective for increasing the rate and rise of peak force for 4th years students who were taking courses with a high proportion of lab and technique practice (26). A study by Cuesta-Vargas et al. demonstrated that learning cervical manipulations with feedback from inertial sensors had no effect on pre-manipulation position, thrust displacement, or side-bending velocity; however, significant improvements were noted in angular velocity for rotation (36). Last, Young et al. compared teaching the diversified cervical manipulation technique with conventional hands-on learning to the addition of instrumented manikins, demonstrating that both sets of chiropractic students attained similar <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> scores during practical examination (37). In summary, the addition of force recording instruments to joint mobilization and manipulation instruction has potential benefits, but there are several limitations worth considering. These limitations include the need for multiple practice sessions (3+), regular and continued follow-up to maintain improvements, no effect on the perception of error, effect on a narrow range of kinematic measures, and no effect on parameters related to technique, including those that would be commonly assessed during the practical examination of manual therapy students.
<table style="border-collapse: collapse;" border="1">
 <tbody>
 <tr>
 <td>
 <h4>Addition of Ultrasound</h4>
 A study by Markowski et al. compared conventional joint mobilization and manipulation instruction to instruction with the addition of real-time ultrasound to aid students in achieving appropriate joint space during knee joint mobilizations. Although no significant difference was found between groups for joint space, students who used ultrasound felt more confident in their mobilization technique (38). Further research is recommended.
 </td>
 </tr>
 </tbody>
</table>

More Lab
<ol>
 <li>Yamamoto, K., Condotta, L., Haldane, C., Jaffrani, S., Johnstone, V., Jachyra, P., ... &amp; Yeung, E. (2018). Exploring the teaching and learning of clinical reasoning, risks, and benefits of cervical spine manipulation.&nbsp;Physiotherapy theory and practice,&nbsp;34(2), 91-100.</li>
 <li>Noteboom, J. T., Little, C., &amp; Boissonnault, W. (2015). Thrust joint manipulation curricula in first-professional physical therapy education: 2012 update.&nbsp;journal of orthopaedic &amp; sports physical therapy,&nbsp;45(6), 471-476.
 <ul>
 <li>Lesson Plan Construction</li>
 </ul>
 </li>
 <li>Wise, C. H., Schenk, R. J., &amp; Lattanzi, J. B. (2016). A model for teaching and learning spinal thrust manipulation and its effect on participant confidence in technique performance.&nbsp;Journal of Manual &amp; Manipulative Therapy,&nbsp;24(3), 141-150.</li>
 <li>Washmuth, N. B., Ross, S., &amp; Bowens, A. N. (2019). Effect of motor learning theory-assisted instruction versus traditional demonstration on student learning of spinal joint manipulation.&nbsp;Health Professions Education.</li>
 <li>Gradl-Dietsch, G., L&uuml;bke, C., Horst, K., Simon, M., Modabber, A., S&ouml;nmez, T. T., ... &amp; Knobe, M. (2016). Peyton&rsquo;s four-step approach for teaching complex spinal manipulation techniques&ndash;a prospective randomized trial.&nbsp;BMC medical education,&nbsp;16(1), 284.
 <ul>
 <li>Integrating Didactic and Lab Instruction:</li>
 </ul>
 </li>
 <li>Triano, J. J., Bougie, J., Rogers, C., Scaringe, J., Sorrels, K., Skogsbergh, D., &amp; Mior, S. (2004). Procedural skills in spinal manipulation: do prerequisites matter?. The Spine Journal, 4(5), 557-563.</li>
 <li>Watson, T. A., &amp; Radwan, H. (2001). Comparison of three teaching methods for learning spinal manipulation skill: A pilot study.&nbsp;Journal of Manual &amp; Manipulative Therapy,&nbsp;9(1), 48-52.</li>
 <li>Harvey, M. P., Wynd, S., Richardson, L., Dugas, C., &amp; Descarreaux, M. (2011). Learning spinal manipulation: a comparison of two teaching models. Journal of Chiropractic Education, 25(2), 125-131.
 <ul>
 <li>Types of Feedback</li>
 </ul>
 </li>
 <li>Scaringe, J. G., Chen, D., &amp; Ross, D. (2002). The effects of augmented sensory feedback precision on the acquisition and retention of a simulated chiropractic task.&nbsp;Journal of manipulative and physiological therapeutics,&nbsp;25(1), 34-41.</li>
 <li>Petty, N. J., Bach, T. M., &amp; Cheek, L. (2001). Accuracy of feedback during training of passive accessory intervertebral movements. Journal of Manual &amp; Manipulative Therapy, 9(2), 99-108.</li>
 <li>Knobe, M., Holschen, M., Mooij, S. C., Sellei, R. M., M&uuml;nker, R., Antony, P., ... &amp; Pape, H. C. (2012). Knowledge transfer of spinal manipulation skills by student-teachers: a randomised controlled trial.&nbsp;European Spine Journal,&nbsp;21(5), 992-998.
 <ul>
 <li>Feedback Timing</li>
 </ul>
 </li>
 <li>Sheaves, E. G., Snodgrass, S. J., &amp; Rivett, D. A. (2012). Learning lumbar spine mobilization: the effects of frequency and self-control of feedback.&nbsp;journal of orthopaedic &amp; sports physical therapy,&nbsp;42(2), 114-124.</li>
 <li>Lardon, A., Cheron, C., Pag&eacute;, I., Dugas, C., &amp; Descarreaux, M. (2016). Systematic augmented feedback and dependency in spinal manipulation learning: a randomized comparative study.&nbsp;Journal of manipulative and physiological therapeutics,&nbsp;39(3), 185-191.</li>
 <li>Enebo, B., &amp; Sherwood, D. (2005). Experience and practice organization in learning a simulated high-velocity low-amplitude task.&nbsp;Journal of manipulative and physiological therapeutics,&nbsp;28(1), 33-43
 <ul>
 <li>Validity of Feedback</li>
 </ul>
 </li>
 <li>O'Donnell, M., Smith, J. A., Abzug, A., &amp; Kulig, K. (2016). How should we teach lumbar manipulation? A consensus study.&nbsp;Manual therapy,&nbsp;25, 1-10.</li>
 <li>Pasquier, M., Ch&eacute;ron, C., Barbier, G., Dugas, C., Lardon, A., &amp; Descarreaux, M. (2020). Learning Spinal Manipulation: Objective and Subjective Assessment of Performance. Journal of Manipulative and Physiological Therapeutics, 43(3), 189-196.
 <ul>
 <li>Additional Studies</li>
 </ul>
 </li>
 <li>Karas, S., Westerheide, A., &amp; Daniel, L. (2016). A knowledge translation programme to increase the utilization of thoracic spine mobilization and manipulation for patients with neck pain.&nbsp;Musculoskeletal care,&nbsp;14(2), 98-109.</li>
 <li>Lardon, A., Pasquier, M., Audo, Y., Barbier-Cazorla, F., &amp; Descarreaux, M. (2019). Effects of an 8-week physical exercise program on spinal manipulation biomechanical parameters in a group of 1st-year chiropractic students. Journal of Chiropractic Education, 33(2), 118-124.
 <ul>
 <li>Addition of Instrumented Tables and Manakins</li>
 </ul>
 </li>
 <li>Triano, J. J., Scaringe, J., Bougie, J., &amp; Rogers, C. (2006). Effects of visual feedback on manipulation performance and patient ratings. Journal of manipulative and physiological therapeutics, 29(5), 378-385.</li>
 <li>Descarreaux, M., Dugas, C., Lalanne, K., Vincelette, M., &amp; Normand, M. C. (2006). Learning spinal manipulation: the importance of augmented feedback relating to various kinetic parameters.&nbsp;The Spine Journal,&nbsp;6(2), 138-145.</li>
 <li>Pasquier, M., Cheron, C., Dugas, C., Lardon, A., &amp; Descarreaux, M. (2017). The effect of augmented feedback and expertise on spinal manipulation skills: an experimental study. Journal of Manipulative and Physiological Therapeutics, 40(6), 404-410.
 <ul>
 <li>Inertial Sensors</li>
 </ul>
 </li>
 <li>Cuesta-Vargas, A. I., Gonz&aacute;lez-S&aacute;nchez, M., &amp; Lenfant, Y. (2015). Inertial sensors as real-time feedback improve learning posterior-anterior thoracic manipulation: a randomized controlled trial. Journal of manipulative and physiological therapeutics, 38(6), 425-433.</li>
 <li>Gonz&aacute;lez-S&aacute;nchez, M., Ruiz-Mu&ntilde;oz, M., &Aacute;vila-Bol&iacute;var, A. B., &amp; Cuesta-Vargas, A. I. (2016). Kinematic real-time feedback is more effective than traditional teaching method in learning ankle joint mobilisation: a randomised controlled trial. BMC medical education, 16(1), 261.
 <ul>
 <li>Dynajust</li>
 </ul>
 </li>
 <li>Triano, J. J., Rogers, C. M., Combs, S., Potts, D., &amp; Sorrels, K. (2002). Developing skilled performance of lumbar spine manipulation.&nbsp;Journal of manipulative and physiological therapeutics,&nbsp;25(6), 353-361</li>
 <li>Triano, J. J., Rogers, C. M., Combs, S., Potts, D., &amp; Sorrels, K. (2003). Quantitative feedback versus standard training for cervical and thoracic manipulation.&nbsp;Journal of manipulative and physiological therapeutics,&nbsp;26(3), 131-138.</li>
 <li>Triano, J. J., McGregor, M., Dinulos, M., &amp; Tran, S. (2014). Staging the use of teaching aids in the development of manipulation skill. Manual Therapy, 19(3), 184-189.
 <ul>
 <li>Effect on Variability and Accuracy</li>
 </ul>
 </li>
 <li>Lee, M., Moseley, A., &amp; Refshauge, K. (1990). Effect of feedback on learning a vertebral joint mobilization skill.&nbsp;Physical therapy,&nbsp;70(2), 97-102.</li>
 <li>Shannon, Z. K., Vining, R. D., Gudavalli, M. R., &amp; Boesch, R. J. (2019). High-velocity, low-amplitude spinal manipulation training of prescribed forces and thrust duration: A pilot study. Journal of Chiropractic Education.
 <ul>
 <li>Effects on Reliability</li>
 </ul>
 </li>
 <li>Petersen, E. J., Thurmond, S. M., Buchanan, S. I., Chun, D. H., Richey, A. M., &amp; Nealon, L. P. (2019). The effect of real-time feedback on learning lumbar spine joint mobilization by entry-level doctor of physical therapy students: a randomized, controlled, crossover trial. Journal of Manual &amp; Manipulative Therapy, 1-11.</li>
 <li>Gautam, N., &amp; Sharma, S. (2011). Effect of concurrent quantitative feedback training on intra-rater and inter-rater reliability of grade III mobilization over fourth lumbar spinous process.&nbsp;Physiotherapy and Occupational Therapy,&nbsp;5(1).
 <ul>
 <li>Retention</li>
 </ul>
 </li>
 <li>Chang, J. Y., Chang, G. L., Chien, C. J. C., Chung, K. C., &amp; Hsu, A. T. (2007). Effectiveness of two forms of feedback on training of a joint mobilization skill by using a joint translation simulator.&nbsp;Physical therapy,&nbsp;87(4), 418-430.</li>
 <li>Marchand, A. A., Mendoza, L., Dugas, C., Descarreaux, M., &amp; Pag&eacute;, I. (2017). Effects of practice variability on spinal manipulation learning. Journal of Chiropractic Education, 31(2), 90-95.</li>
 <li>Snodgrass, S. J., Rivett, D. A., Robertson, V. J., &amp; Stojanovski, E. (2010). Real-time feedback improves accuracy of manually applied forces during cervical spine mobilisation. Manual therapy, 15(1), 19-25.</li>
 <li>Snodgrass, S. J., &amp; Odelli, R. A. (2012). Objective concurrent feedback on force parameters improves performance of lumbar mobilisation, but skill retention declines rapidly. Physiotherapy, 98(1), 47-56.
 <ul>
 <li>Additional Limitations</li>
 </ul>
 </li>
 <li>Latimer, J., Lee, M., &amp; Adams, R. (1996). The effect of training with feedback on physiotherapy students' ability to judge lumbar stiffness.&nbsp;Manual Therapy,&nbsp;1(5), 266-270.</li>
 <li>Cuesta-Vargas, A. I., &amp; Williams, J. (2014). Inertial sensor real-time feedback enhances the learning of cervical spine manipulation: a prospective study. BMC Medical Education, 14(1), 1-5.</li>
 <li>Young, T. J., Hayek, R., &amp; Philipson, S. A. (1998). A cervical manikin procedure for chiropractic skills development. Journal of manipulative and physiological therapeutics, 21(4), 241-245.
 <ul>
 <li>Ultrasound</li>
 </ul>
 </li>
 <li>Markowski, A., Watkins, M. K., Burnett, T., Ho, M., &amp; Ling, M. (2018). Using real-time ultrasound imaging as adjunct teaching tools to enhance physical therapist students' ability and confidence to perform traction of the knee joint.&nbsp;Musculoskeletal Science and Practice,&nbsp;34, 83-88.</li>
</ol>

Bibliography

&copy; 2021 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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