Introduction

Additional Research

Research Summary

Summary of Research Findings

Trapezius, Rhomboids and Pectoralis Minor

Infraspinatus & Subscapularis

Pectoralis Major & Posterior Deltoid

Paraspinals & Quadratus Lumborum

Rectus Femoris, Sartorius, Quadriceps

Gastrocnemius, Solues, Fibularis Muscles, EHL and EDL

Trigger Point Assessment (and Palpation)

PACE

AOTA

CPTA

TPTA

AUSPHYSIO

NYPT

NCBTMB

In this course, we cover a topic that has only recently become controversial. <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">Trigger point</a> therapy has a relatively long history in medicine, including publications referencing <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">Trigger point</a> injection for <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> pain in the early 1900s. Additional papers referencing the treatment of pain by addressing a <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">Trigger point</a>, <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> knot, <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> spasm, or pressure point, start to increase in number in the 1960s. Travell and Simons published the 1st edition of their classic 2 volume set, &quot;Myofascial Pain and Dysfunction&quot;, in the early 1990s, including definitions of the terms <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">Trigger point</a>, <a id="latent-trigger-point" data-tip="1132" target="_blank" href="/glossary-term/latent-trigger-point" class="glossary">latent trigger point</a>, active <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">Trigger point</a> (painful <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">Trigger point</a>), <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">Trigger point</a> pain, and a detailed description of how <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> may develop in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> fibers and how they may affect normal movement. In the 1990s and early 2000s, EMG research correlated <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> with an increase in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity and <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> spasm. In the early 2000s, microdialysis was introduced, providing a more detailed account of the chemical environment of <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a>. Finally, more recent advances in imaging technology have provided the first images of active <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> within a contracting <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a>.&#xA0;
Additionally, in the last 3 decades, <a id="randomized-control-trial" data-tip="1406" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">randomized controlled</a> trials (RCTs) have compared the efficacy of conventional treatment methods to a <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> therapy session, <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> massage, pressure point massage, <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> acupressure, and <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> injections. As well as, research investigating therapies that may affect <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> such as massage therapy and <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> therapeutic exercise. The <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> efficacy of adding <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> therapy sessions to conventional treatment methods has been demonstrated for the treatment of neck pain, <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> headache, whiplash syndrome, chronic pain of the low back, knee pain, general leg pain, pain management for <a id="fibromyalgia" data-tip="1135" target="_blank" href="/glossary-term/fibromyalgia" class="glossary">fibromyalgia</a>, sports injuries, <a id="connective-tissue-cell" data-tip="1368" target="_blank" href="/glossary-term/connective-tissue-cell" class="glossary">connective tissue</a> disorders, and <a id="nerve-cell" data-tip="1361" target="_blank" href="/glossary-term/nerve-cell" class="glossary">nerve</a> pain.
It is rather unnerving to witness a young, under-educated group of new therapists, condemn nearly 100 years of scientific inquiry, research, and refinement. <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">Trigger point</a> therapy (including self-administered, manual, and needling techniques) is one of the most effective techniques available for addressing <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> and <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> spasm that often accompanies an increase in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity, with the presence of <a id="latent-trigger-point" data-tip="1133" target="_blank" href="/glossary-term/latent-trigger-point" class="glossary">latent trigger points</a> and active <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a>. Further, the research is clear, that locating a <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">Trigger point</a> in an affected <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> via palpation is <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a>, with a relatively small amount of training.&#xA0;
We hope this course aids in providing clarity around a topic that has been confounded by a recent proliferation of misinformation. Further, this course is pre-approved for credits toward the <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">Integrated</a> Manual Therapist (IMT) Certification, and pre-approved for continuing education credits for sports medicine professionals and health care providers (physical therapists, athletic trainers, massage therapists, chiropractors, occupational therapists, etc.).
<h3>Brookbush Institute&apos;s Position Stand: Trigger Point Assessment</h3>
The majority of research investigating the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> demonstrates moderate to excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (1- 3, 5 -8, 10- 26, 33 - 37), with only a few studies demonstrating less than moderate, or variable <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (4, 9, 27, 32). A review of all published original research has highlighted several modifications that may improve <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> in practice. The one systematic review that could be located by Myburgh et al. (1) makes similar suggestions as below; however, ads that more high-level <a id="randomized-control-trial" data-tip="1410" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">randomized control trials</a> (RCTs) should be a focus of future research on this topic. Muscle-specific recommendations based on all <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> research lean heavily toward moderate to excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and are also discussed below.
Brookbush Institute <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">Evidence-based</a> <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">Trigger Point</a> Assessment
<ol>
 <li>Identify muscles to be treated via movement <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>.</li>
 <li>Palpate muscles to be treated and strum fascicles perpendicular to fiber direction to identify taut bands.</li>
 <li>Search the <a id="taut-band" data-tip="1148" target="_blank" href="/glossary-term/taut-band" class="glossary">taut band</a> for a tender spot, nodule, or area of increased tissue density.
 <ul>
 <li>Note: Based on the current studies, <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> may use &quot;taut bands&quot; for direction, and <a id="referred-trigger-point-pain" data-tip="1709" target="_blank" href="/glossary-term/referred-trigger-point-pain" class="glossary">referral pain</a> patterns as confirmation, but should rely on point tenderness for identification.</li>
 </ul>
 </li>
</ol>
For a review of <a id="muscle-fiber-dysfunction" data-tip="1126" target="_blank" href="/glossary-term/muscle-fiber-dysfunction" class="glossary">muscle fiber dysfunction</a> and <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> etiology:
<ul>
 <li><a href="https://brookbushinstitute.com/article/muscle-fiber-dysfunction-trigger-points" target="_blank" rel="noopener">Muscle Fiber Dysfunction and Trigger Points</a></li>
</ul>

Course Description: Trigger Point Assessment and Palpation

Review of <a id="muscle-fiber-dysfunction" data-tip="1126" target="_blank" href="/glossary-term/muscle-fiber-dysfunction" class="glossary">muscle fiber dysfunction</a> and <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> etiology:
<ul>
 <li><a href="https://brookbushinstitute.com/article/muscle-fiber-dysfunction-trigger-points" target="_blank" rel="noopener">Muscle Fiber Dysfunction and Trigger Point</a></li>
</ul>
<h3>Definition:</h3>
<ul>
 <li><a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">Trigger Point</a> - &quot;A hyper-irritable spot in skeletal <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> that is associated with a hypersensitive palpable nodule in a <a id="taut-band" data-tip="1148" target="_blank" href="/glossary-term/taut-band" class="glossary">taut band</a>. The spot is painful on <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> and can give rise to characteristic <a id="referred-trigger-point-pain" data-tip="1710" target="_blank" href="/glossary-term/referred-trigger-point-pain" class="glossary">referred pain</a>, referred tenderness, motor dysfunction, and autonomic phenomena (38).&quot;</li>
</ul>
<h3>Travell and Simons Assessment Criteria (38):</h3>
<ul>
 <li>Taut band</li>
 <li>Exquisite spot tenderness</li>
 <li>Patient&apos;s recognition of pain induced by pressure on tender nodule</li>
 <li>Painful limit to full stretch range of motion</li>
</ul>
<h4>Other signs mentioned</h4>
<ul>
 <li><a id="referred-trigger-point-pain" data-tip="1709" target="_blank" href="/glossary-term/referred-trigger-point-pain" class="glossary">Referral pain</a> pattern</li>
 <li>Palpable band</li>
 <li>Local twitch response</li>
 <li>Jump sign (patient cringes or pulls away)</li>
</ul>
<h3>Brookbush Institute (research refined) Guidelines for Trigger Point Assessment</h3>
<ol>
 <li>Identify muscles to be treated via movement <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>.</li>
 <li>Palpate muscles to be treated and strum fascicles perpendicular to fiber direction to identify taut bands.</li>
 <li>Search <a id="taut-band" data-tip="1148" target="_blank" href="/glossary-term/taut-band" class="glossary">taut band</a> for a tender spot, nodule, or area of increased tissue density.
 <ul>
 <li>Note: Based on the current studies, <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> may use &quot;taut bands&quot; for direction, <a id="referred-trigger-point-pain" data-tip="1709" target="_blank" href="/glossary-term/referred-trigger-point-pain" class="glossary">referral pain</a> patterns as confirmation, but should rely on point tenderness for identification.</li>
 </ul>
 </li>
</ol>
<a href="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2016/04/FHL-and-FDL-2.png" target="_blank" rel="noopener"><img src="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2016/04/FHL-and-FDL-2.png" alt="Dr. Brookbush explains palpation and release of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) including common trigger point referral sites."></a>
Flexor Hallucis Longus (FHL) and Flexor Digitorum Longus (FDL) Manual Release

Definitions and Recommendations

Research Corner

<ul>
 <li>Studies lean heavily toward moderate to excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>.</li>
 <li>Studies <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a> the <a id="validity" data-tip="1511" target="_blank" href="/glossary-term/validity" class="glossary">validity</a> of manual palpation for <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>.</li>
 <li>Training or expertise <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> to <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> is necessary to achieve excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>.</li>
 <li><a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">Reliability</a> of <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> is higher when pain pressure threshold is lower (symptoms are more intense).</li>
 <li>Location of the <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> may affect <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (deeper muscles may be hard to <a id="assessment" data-tip="1486" target="_blank" href="/glossary-term/assessment" class="glossary">assess</a>).</li>
 <li>Repeated measures in a short period of time reduce the <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> of <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> and decrease the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>.</li>
 <li>Manual palpation is more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than algometry.</li>
 <li><a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">Trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> may use &quot;taut bands&quot; for direction, <a id="referred-trigger-point-pain" data-tip="1709" target="_blank" href="/glossary-term/referred-trigger-point-pain" class="glossary">referral pain</a> patterns as confirmation, but should rely on point tenderness for identification.</li>
 <li>Muscles assessed and treated for <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> should be identified via functional <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>.</li>
</ul>
<a href="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2019/07/Trapezius-Manual-Release.jpg" target="_blank" rel="noopener"><img src="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2019/07/Trapezius-Manual-Release.jpg" alt></a>

Muscle Specific Research Findings

<h3>Trapezius muscle</h3>
The <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius</a> has been the focus in numerous studies on <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> and <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>. Most studies demonstrate that <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of the <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius</a> is reliable; however, training and/or experience may be a pre-requisite. The study by Gerwin et al. included the <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius</a> and demonstrated that <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of palpating <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> was initially poor; however, a brief training period resulted in good inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (2). Additional studies have demonstrated good inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> between experienced clinicians (3-6). Research has demonstrated lower <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> in asymptomatic individuals (7), which may be due at least in part to lower <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> of <a id="latent-trigger-point" data-tip="1133" target="_blank" href="/glossary-term/latent-trigger-point" class="glossary">latent trigger points</a> (8). One study by Levoska et al. demonstrated variable <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, which may imply that either the methodology of repeated manual <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> and <a id="algometery" data-tip="1123" target="_blank" href="/glossary-term/algometery" class="glossary">dolorimetery</a> in a single day resulted in diminishing <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>, or that the examiners would have benefited from <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> training (9). An additional factor that may aid in improving the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of palpating <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> is locating the <a id="neuromuscular-junction" data-tip="1304" target="_blank" href="/glossary-term/neuromuscular-junction" class="glossary">neuromuscular junction</a> with EMG; <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> are correlated with the site of the <a id="neuromuscular-junction" data-tip="1304" target="_blank" href="/glossary-term/neuromuscular-junction" class="glossary">neuromuscular junction</a> (10). In summary, there is sufficient evidence to suggest that <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> may be reliably palpated.
<h3>Rhomboids</h3>
Jones et al. demonstrated good inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for manual <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of <a href="https://brookbushinstitute.com/article/rhomboids" target="_blank" rel="noopener">rhomboid</a> trigger points; however, the study suggests that repeated <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> in a short period of time may decrease <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> and <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (11).
<h3>Pectoralis Minor</h3>
Two studies by Hong et al. (12, 13) demonstrated that algometry for the pectoral region is <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a>. Further, a study by Nascimento et al. demonstrated moderate to perfect inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for manual <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of <a href="https://brookbushinstitute.com/article/pectoralis-minor" target="_blank" rel="noopener">pectoralis minor</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> (14).

Trapezius, Rhomboids, & Pectoralis Minor

<h3>Infraspinatus</h3>
Research has demonstrated <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> has good to excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (2, 15-19). A study by Bron et al. demonstrated <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> was more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than assessing <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">anterior deltoid</a> and biceps brachii <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> (16). The study by Gerwin et al. (mentioned above) demonstrated that clinicians achieved good <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> in multiple muscles (including the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a>) after a 3-hour training course (2). A study by Mayoral del Moral et al. demonstrated excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> between expert clinicians (17). Last, <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a>, re-test <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was demonstrated for treatment of <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> correlated with <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> tendonitis (18), and breast cancer surgery (19). These studies imply that manual <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> has demonstrated good <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> in various studies and patient groups.
<h3>Subscapularis</h3>
The few studies including <a href="https://brookbushinstitute.com/article/subscapularis" target="_blank" rel="noopener">subscapularis</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> suggest that <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> is at least moderately <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> (19 - 21). The study by DeGroef et al. (mentioned above) demonstrated good inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of upper extremity <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> in breast cancer survivors, and Al-Shenqiti et al. demonstrated good <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a>, re-test <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> in cases of rotator cuff tendinitis (19, 20). An interesting study by Hollingworth et al. suggests that treating shoulder pain using <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> (including the <a href="https://brookbushinstitute.com/article/subscapularis" target="_blank" rel="noopener">subscapularis</a>) was more effective when functional <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>, rather than palpation alone, was used to determine the <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> addressed (21). Note, in this study functional <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> included pain during resisted motion, and/or restrictions in range of motion. Although only a few studies include <a href="https://brookbushinstitute.com/article/subscapularis" target="_blank" rel="noopener">subscapularis</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a>, all studies demonstrate good <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and the study by Hollingworth et al. adds a wonderful means of refining <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> in practice.
<a href="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2019/01/Pectoralis-Major-Release.png" target="_blank" rel="noopener"><img src="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2019/01/Pectoralis-Major-Release.png" alt></a>

<h3>Pectoralis Major</h3>
Several studies mentioned above, have included <a href="https://brookbushinstitute.com/article/pectoralis-major" target="_blank" rel="noopener">pectoralis major</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> and have demonstrated good or better <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of manual <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> and algometry. Mayoral del Moral et al. demonstrated <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and some external <a id="validity" data-tip="1511" target="_blank" href="/glossary-term/validity" class="glossary">validity</a> for the <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of <a href="https://brookbushinstitute.com/article/pectoralis-major" target="_blank" rel="noopener">pectoralis major</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a>, comparing both symptomatic and asymptomatic sides and between symptomatic and asymptomatic individuals (shoulder pain) using blinded assessors (17). A study by Fischer et al. demonstrated excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> using algometry in nine muscles, including the <a href="https://brookbushinstitute.com/article/pectoralis-major" target="_blank" rel="noopener">pectoralis major</a> (15). Further, the study by DeGreof et al. demonstrated good interrater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of upper limb <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> in breast cancer survivors (19). Although more research is needed, the demonstration of <a id="validity" data-tip="1511" target="_blank" href="/glossary-term/validity" class="glossary">validity</a> and good or better <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> in all published studies, suggests that the palpation of <a href="https://brookbushinstitute.com/article/pectoralis-major" target="_blank" rel="noopener">pectoralis major</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> is initially supported.
<h3>Posterior Deltoid</h3>
Jones et al. demonstrated good test-retest <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for pain pressure threshold measurements for several muscles including the <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">posterior deltoid</a> (11).

<h3>Paraspinals</h3>
Research investigating <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>, palpation, and algometry of <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> and <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> have demonstrated good inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (22-26). Fryer et al. demonstrated that <a id="medial" data-tip="1568" target="_blank" href="/glossary-term/medial" class="glossary">medial</a> paraspinal sites identified as having abnormal tissue texture via palpation were correlated with sites identified using algometry to be significantly more tender than sites immediately above, below, and on the opposite side of the abnormal region (22). Binderup et al. demonstrated good intra-examiner <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> between patients evaluating dozens of lumbar and cervicothoracic points using algometry, and further that there was no difference between lumbar and <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">trapezius</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> in asymptomatic individuals (23). Potter et al. demonstrated the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of algometry both within-session and between-sessions for the measurement of paraspinal tissue sensitivity/pain (24). Further, a study by Koo et al. demonstrated manual algometry was as <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> as machine (computerized) algometry (25). In an interesting study by Nice et al. that may allude to the importance of appropriate training, large variations in <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> were demonstrated when the protocol outlined by Travel and Simmon&apos;s was used alone (26). These studies <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a> not only <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> but the <a id="validity" data-tip="1511" target="_blank" href="/glossary-term/validity" class="glossary">validity</a> of <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> and <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>. This includes a demonstration that palpated points may be confirmed by algometry, that <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> exhibit a lower pain pressure threshold than surrounding tissue, that lumbar <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> exhibit a lower pain threshold than the same point in asymptomatic individuals, and further, that asymptomatic individuals demonstrate no difference in pain pressure threshold between the <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> and <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius</a>.
<h3>Quadratus Lumborum (QL)</h3>
Several studies have included <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">QL</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> when investigating the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>. A study by Hau et al. demonstrated good <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> when localized tenderness and patient&apos;s recognition of <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> were used as criteria; however, <a id="referred-trigger-point-pain" data-tip="1710" target="_blank" href="/glossary-term/referred-trigger-point-pain" class="glossary">referred pain</a> was not a <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> sign (27). A study Hsieh et al. demonstrated poor <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> between physicians, physiatrists, and chiropractors when finding taut bands was used as the criteria (4). However, some consideration should be given to the depth of the <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">QL</a> and how that may affect the ability to &quot;feel&quot; individual taut bands. The study by Gerwin et al. included <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">QL</a> <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> and found that the initial inter-tester <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was poor, but after a 3-hour training course covering the <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of several muscles, inter-tester <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was good to excellent (2). The depth of the <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">QL</a> likely makes this a challenging palpation, but research suggests that training and reliance on point tenderness may result in adequate <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>.

<h3>Rectus Femoris and Sartorius</h3>
Two studies mention <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of <a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">rectus femoris</a> and/or <a href="https://brookbushinstitute.com/article/sartorius" target="_blank" rel="noopener">sartorius</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> with conflicting results. Again the study by Hsieh et al. demonstrated that inter-examiner <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of trunk and lower limb muscles was poor among untrained, licensed professionals (4). However, Rozenfeld et al. demonstrated that inter-examiner <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of hip and thigh <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> was good to substantial (28). The difference in these studies may relate to the participants chosen to be assessed, the muscles selected for <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>, or the experience of the assessors in the study. Both studies highlight that <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> is inconsistent when trigger point-specific training is not used as an inclusion criterion, i.e. expert assessors, or training is not included as part of the studies methodology, as used in Gerwin et al. (2).
<h3>Quadriceps</h3>
<a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> of <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> in the <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a> has demonstrated moderate to excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (29, 30). Considering that these muscles are large and superficial, it is not surprising that <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is relatively high, despite these studies not including a training period.

<h3>Gastrocnemius and Soleus:</h3>
The study by Hseih et al. (4) included the <a href="https://brookbushinstitute.com/article/gastrocnemius-plantaris" target="_blank" rel="noopener">gastrocnemius</a> and <a href="https://brookbushinstitute.com/article/soleus" target="_blank" rel="noopener">soleus</a>, demonstrating that <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> was unreliable among untrained, licensed professionals (4). However, Zuil-Escobar et al. demonstrated excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for assessing lower extremity <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> among trained professionals (31). Some consideration should also be given to the relatively large number of studies demonstrating the efficacy of <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> techniques for <a href="https://brookbushinstitute.com/article/gastrocnemius-plantaris" target="_blank" rel="noopener">gastrocnemius</a> and <a href="https://brookbushinstitute.com/article/soleus" target="_blank" rel="noopener">soleus</a> trigger points; a thorough review can be found in the article <a href="https://brookbushinstitute.com/article/static-manual-release-lower-leg-muscles" target="_blank" rel="noopener">Static Manual Release: Lower Leg Muscles</a>. Although more research is needed, it seems unlikely that <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> from trained professionals could be unreliable, and still result in a large number of studies demonstrating the efficacy of <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a>.
<h3>Fibularis Muscles</h3>
Studies have demonstrated good inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> when assessing <a href="https://brookbushinstitute.com/article/fibularis-muscles" target="_blank" rel="noopener">fibularis muscle</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a>. Zuil-Escobar et al. reported the relatively high prevalence of <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> in various lower extremity muscles and excellent inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for lower extremity <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> (31). Further, a study by Sanz et al. demonstrated that <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of the <a href="https://brookbushinstitute.com/article/fibularis-muscles" target="_blank" rel="noopener">fibularis brevis</a> resulted in a wide range of agreement values, but could reach 82% agreement between professionals (32). More research is needed to understand the variance in <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>.
<h3>Extensor Hallucis Longus (EHL) and Extensor Digitorum Longus (EDL)</h3>
A few studies have investigated <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> and treatment of the <a href="https://brookbushinstitute.com/article/flexor-hallucis-longus-and-flexor-digitorum-longus" target="_blank" rel="noopener">long toe flexors</a> and <a href="https://brookbushinstitute.com/article/extensor-hallucis-longus-and-extensor-digitorum-longus-fibularis-tertius" target="_blank" rel="noopener">extensors</a>. The study mentioned above by Sanz et al. demonstrated that manual <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of <a href="https://brookbushinstitute.com/article/extensor-hallucis-longus-and-extensor-digitorum-longus-fibularis-tertius" target="_blank" rel="noopener">EDL</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> was <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> (32). Further, a study by Zale et al. was able to show a correlation between diagnosis, manual palpation, and points assessed using sonography (including the <a href="https://brookbushinstitute.com/article/extensor-hallucis-longus-and-extensor-digitorum-longus-fibularis-tertius" target="_blank" rel="noopener">EHL and EDL</a>) implying a level of external <a id="validity" data-tip="1511" target="_blank" href="/glossary-term/validity" class="glossary">validity</a>, and that ultrasound may be a useful tool for <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> (33).

Additional studies have investigated the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of manual palpation for various issues. A study by Ohrbach et al. demonstrated that temporomandibular <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> had a significantly lower pain pressure threshold (PPT) when compared to the same site in the <a id="contralateral" data-tip="1549" target="_blank" href="/glossary-term/contralateral" class="glossary">contralateral</a> muscle; further, PPT was significantly lower at sites producing <a id="referred-trigger-point-pain" data-tip="1710" target="_blank" href="/glossary-term/referred-trigger-point-pain" class="glossary">referred pain</a> compared to sites producing localized pain on palpation, and adequate <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> was demonstrated in all patient groups (34). Rasmussen et al. demonstrated that the use of pressure-algometry may be useful for research, but in the daily clinical routine, palpatory examination for <a id="latent-trigger-point" data-tip="1134" target="_blank" href="/glossary-term/latent-trigger-point" class="glossary">tender points</a> may be more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> (35). Wolfe et al. demonstrated that palpation of <a id="latent-trigger-point" data-tip="1134" target="_blank" href="/glossary-term/latent-trigger-point" class="glossary">tender points</a> in <a id="fibromyalgia" data-tip="1135" target="_blank" href="/glossary-term/fibromyalgia" class="glossary">fibromyalgia</a> patients was reliable; however, <a id="referred-trigger-point-pain" data-tip="1709" target="_blank" href="/glossary-term/referred-trigger-point-pain" class="glossary">referral pain</a> pattern and <a id="twitch-response" data-tip="1142" target="_blank" href="/glossary-term/twitch-response" class="glossary">twitch response</a> were not <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> signs (36). Tunks et al. demonstrated that manual palpation of <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> in <a id="fibromyalgia" data-tip="1135" target="_blank" href="/glossary-term/fibromyalgia" class="glossary">fibromyalgia</a> patients was actually more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than algometry (37). The studies above demonstrate that <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> is <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> in a variety of patient populations, and that manual palpation is likely more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than algometry.

<ol>
 <li>Myburgh, C., Larsen, A. H., &amp; Hartvigsen, J. (2008). A systematic, critical review of manual palpation for identifying myofascial trigger points: evidence and clinical significance. Archives of physical medicine and rehabilitation, 89(6), 1169-1176.</li>
 <li>Gerwin, R. D., Shannon, S., Hong, C. Z., Hubbard, D., &amp; Gevirtz, R. (1997). Interrater reliability in myofascial trigger point examination. Pain, 69(1-2), 65-73.</li>
 <li>Sciotti, V. M., Mittak, V. L., DiMarco, L., Ford, L. M., Plezbert, J., Santipadri, E., … &amp; Ball, K. (2001). Clinical precision of myofascial trigger point location in the trapezius muscle. Pain, 93(3), 259-266.</li>
 <li>Hsieh, C. Y. J., Hong, C. Z., Adams, A. H., Platt, K. J., Danielson, C. D., Hoehler, F. K., &amp; Tobis, J. S. (2000). Interexaminer reliability of the palpation of trigger points in the trunk and lower limb muscles. Archives of physical medicine and rehabilitation, 81(3), 258-264.</li>
 <li>Myburgh, C., Lauridsen, H. H., Larsen, A. H., &amp; Hartvigsen, J. (2011). Standardized manual palpation of myofascial trigger points in relation to neck/shoulder pain; the influence of clinical experience on inter-examiner reproducibility. Manual therapy, 16(2), 136-140.</li>
 <li>Persson, A., Brogardh, C., &amp; Sjolund, B. H. (2004). Tender or not tender: test-retest repeatability of pressure pain thresholds in the trapezius and deltoid muscles of healthy women. Journal of Rehabilitation Medicine, 36(1), 17-27.</li>
 <li>Lew, P. C., Lewis, J., &amp; Story, I. (1997). Inter-therapist reliability in locating latent myofascial trigger points using palpation. Manual therapy, 2(2), 87-90.</li>
 <li>Hong, C. Z., Chen, Y. N., Twehous, D., &amp; Hong, D. H. (1996). Pressure threshold for referred pain by compression on the trigger point and adjacent areas. Journal of Musculoskeletal Pain, 4(3), 61-79.</li>
 <li>Levoska, S., Keinänen-Kiukaanniemi, S. I. R. K. K. A., &amp; Bloigu, R. (1993). Repeatability of measurement of tenderness in the neck-shoulder region by a dolorimeter and manual palpation. The Clinical journal of pain, 9(4), 229-235.</li>
 <li>Barbero, M., Cescon, C., Tettamanti, A., Leggero, V., Macmillan, F., Coutts, F., &amp; Gatti, R. (2013). Myofascial <a href="https://brookbushinstitute.com/glossary/trigger-point/" target="_blank">trigger points</a> and innervation zone locations in upper trapezius muscles. BMC musculoskeletal disorders, 14(1), 179.</li>
 <li>Jones, D. H., Kilgour, R. D., &amp; Comtois, A. S. (2007). Test-retest reliability of pressure pain threshold measurements of the upper limb and torso in young healthy women. The Journal of Pain, 8(8), 650-656.</li>
 <li>Hong, C. Z., Kuan, T. S., Chen, J. T., &amp; Chen, S. M. (1997). Referred pain elicited by palpation and by needling of myofascial trigger points: a comparison. Archives of physical medicine and rehabilitation, 78(9), 957-960.</li>
 <li>Hong, C. Z. (1998). Algometry in evaluation of trigger points and referred pain. Journal of Musculoskeletal Pain, 6(1), 47-59.</li>
 <li>do Nascimento, J. D. S., Alburquerque-Sendín, F., Vigolvino, L. P., de Oliveira, W. F., &amp; de Oliveira Sousa, C. (2018). Inter-and intraexaminer reliability in identifying and classifying myofascial trigger points in shoulder muscles. Archives of physical medicine and rehabilitation, 99(1), 49-56.</li>
 <li>Fischer, A. A. (1987). Pressure algometry over normal muscles. Standard values, validity and reproducibility of pressure threshold. Pain, 30(1), 115-126.</li>
 <li>Bron, Carel, Jo Franssen, Michel Wensing, and Rob AB Oostendorp. "Interrater reliability of palpation of myofascial trigger points in three shoulder muscles." Journal of Manual &amp; Manipulative Therapy 15, no. 4 (2007): 203-215.</li>
 <li>Mayoral del Moral, O., Torres Lacomba, M., Russell, I. J., Sánchez Méndez, Ó., &amp; Sánchez Sánchez, B. (2017). Validity and reliability of clinical examination in the diagnosis of myofascial pain syndrome and myofascial trigger points in upper quarter muscles. Pain medicine, 19(10), 2039-2050.</li>
 <li>Al-Shenqiti, A. M., &amp; Oldham, J. A. (2005). Test-retest reliability of myofascial trigger point detection in patients with rotator cuff tendonitis. Clinical rehabilitation, 19(5), 482-487.</li>
 <li>De Groef, A., Van Kampen, M., Dieltjens, E., De Geyter, S., Vos, L., De Vrieze, T., … &amp; Devoogdt, N. (2017). Identification of myofascial trigger points in breast cancer survivors with upper limb pain: interrater reliability. Pain Medicine, 19(8), 1650-1656.</li>
 <li>Jalil, N. A., Prateepavanich, P., &amp; Chaudakshetrin, P. (2010). Atypical chest pain from myofascial pain syndrome of subscapularis muscle. Journal of Musculoskeletal Pain, 18(2), 173-179.</li>
 <li>Hollingworth, G. R., Ellis, R. M., &amp; Hattersley, T. S. (1983). Comparison of injection techniques for shoulder pain: results of a double blind, randomised study. Br Med J (Clin Res Ed), 287(6402), 1339-1341.</li>
 <li>Fryer, G., Gibbons, P., &amp; Morris, T. (2004). The relation between thoracic paraspinal tissues and pressure sensitivity measured by a digital algometer. Journal of osteopathic medicine, 7(2), 64-69.</li>
 <li>Binderup, A. T., Arendt-Nielsen, L., &amp; Madeleine, P. (2010). Pressure pain sensitivity maps of the neck-shoulder and the low back regions in men and women. BMC musculoskeletal disorders, 11(1), 234.</li>
 <li>Potter, L., McCarthy, C., &amp; Oldham, J. (2006). Algometer reliability in measuring pain pressure threshold over normal spinal muscles to allow quantification of anti-nociceptive treatment effects. International journal of osteopathic medicine, 9(4), 113-119.</li>
 <li>Koo, T. K., Guo, J. Y., &amp; Brown, C. M. (2013). Test-retest reliability, repeatability, and sensitivity of an automated deformation-controlled indentation on pressure pain threshold measurement. Journal of manipulative and physiological therapeutics, 36(2), 84-90.</li>
 <li>Nice, D. A., Riddle, D. L., Lamb, R. L., Mayhew, T. P., &amp; Rucker, K. (1992). Intertester reliability of judgments of the presence of trigger points in patients with low back pain. Archives of physical medicine and rehabilitation, 73(10), 893-898.</li>
 <li>Hua, N. K., &amp; Van der Does, E. (1994). The occurrence and inter-rater reliability of myofascial trigger points in the quadratus lumborum and gluteus medius: a prospective study in non-specific low back pain patients and controls in general practice. Pain, 58(3), 317-323.</li>
 <li>Rozenfeld, E., Finestone, A. S., Moran, U., Damri, E., &amp; Kalichman, L. (2017). Test-retest reliability of myofascial trigger point detection in hip and thigh areas. Journal of bodywork and movement therapies, 21(4), 914-919.</li>
 <li>Walsh, R., Kinsella, S., &amp; McEvoy, J. (2017). The intra-rater reliability of locating and measuring the severity of latent trigger points in the quadriceps. Journal of bodywork and movement therapies, 21(4), 926-932.</li>
 <li>Botter, A., Oprandi, G., Lanfranco, F., Allasia, S., Maffiuletti, N. A., &amp; Minetto, M. A. (2011). Atlas of the muscle motor points for the lower limb: implications for electrical stimulation procedures and electrode positioning. European journal of applied physiology, 111(10), 2461.</li>
 <li>Zuil-Escobar, J. C., Martínez-Cepa, C. B., Martín-Urrialde, J. A., &amp; Gómez-Conesa, A. (2016). The prevalence of latent trigger points in lower limb muscles in asymptomatic subjects. PM&amp;R, 8(11), 1055-1064.</li>
 <li>Sanz, D. R., Lobo, C. C., López, D. L., Morales, C. R., Marín, C. S., &amp; Corbalán, I. S. (2016). Interrater reliability in the clinical evaluation of myofascial trigger points in three ankle muscles. Journal of manipulative and physiological therapeutics, 39(9), 623-634.</li>
 <li>Zale, K. E., Klatt, M., Volz, K. R., Kanner, C., &amp; Evans, K. D. (2015). A mixed-method approach to evaluating the association between myofascial trigger points and ankle/foot pain using handheld sonography equipment: a pilot study. Journal of Diagnostic Medical Sonography, 31(4), 210-220.</li>
 <li>Ohrbach, R., &amp; Gale, E. N. (1989). Pressure pain thresholds, clinical assessment, and differential diagnosis: reliability and validity in patients with myogenic pain. Pain, 39(2), 157-169.</li>
 <li>Rasmussen, J. O., Smidth, M., &amp; Hansen, T. M. (1990). Examination of tender points in soft tissue. Palpation versus pressure-algometer. Ugeskrift for laeger, 152(21), 1522-1526.</li>
 <li>Wolfe, F., Simons, D. G., Fricton, J., Bennett, R. M., Goldenberg, D. L., Gerwin, R., … &amp; Sanders, H. O. (1992). The fibromyalgia and myofascial pain syndromes: a preliminary study of tender points and trigger points in persons with fibromyalgia, myofascial pain syndrome and no disease. The Journal of rheumatology, 19(6), 944-951.</li>
 <li>Tunks, E. L. D. O. N., McCain, G. A., Hart, L. E., Teasell, R. W., Goldsmith, C. H., Rollman, G. B., … &amp; DeShane, P. J. (1995). The reliability of examination for tenderness in patients with myofascial pain, chronic fibromyalgia and controls. J Rheumatol, 22(5), 944-52.</li>
 <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>

Bibliography

© 2019 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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Please contact us through the
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