The Body as One Upper Extremity Movement Mechanics Scapulothroacic Region = Stable Thoracic Spine = Mobile The Body as One Upper Extremity Movement Mechanics By: Fabio Comana, MA., MS. NASM CPT, CES, PES; NSCA CSCS; ACS< HFS: ACE CPT, HC; CISSN NASM Faculty Instructor April 24, 2014

What Do You Want to Learn? Learning Outcomes: Describe the overall function of the human body in movement. Explain primary components of human movement science. Administer and interpret an upper extremity movement screen. Implement a simple UE corrective exercise program. Instruct proper mechanics for UE movements.

Movement Fundamental trait we all share – improve movement efficiency. Requires appropriate levels of simultaneous stability and mobility. Stability Ability to maintain or control joint movement or position Mobility Possessing uninhibited 3-D ROM around a joint or body segment Must Never Compromise Each Other Movement Efficiency Arthrokinetics Muscle Properties (hardware) Neural Control (software) What happens when the Software or Hardware becomes faulty? Analogy of computer software and hardware

Movement Examining the Body as One Glenohumeral = Mobile Foot = Stable Knee = Stable Lumbar Spine = Stable Scapulo-thoracic Region = Stable Ankle = Mobile Hips = Mobile Thoracic Spine = Mobile Glenohumeral = Mobile Define Stability: Ability to control joint position or movement Define Mobility: Functional ROM needed at a joint Demonstrate LE relationship with gait Demonstrate UE relationship with overhead reach

What Happens if the Body Loses / Lacks this Relationship? Movement What Happens if the Body Loses / Lacks this Relationship? Step One: Law of Facilitation = ‘Dyskinesis’ Compensation: Compromised stability to facilitate mobility. Compensation: Movement into other planes. Example: Bird-dog Why? Step One: Law of Facilitation = “Dyskinesis” Compensation: Stable joints give up some stability to help provide mobility. Example: Increased lumbar lordosis when trying to extend the thoracic spine. Compensation: Moving joint will incorporate movement into another plane Example: Hip extension (sagittal) involving transverse plane rotation. Step Two: Loss of stability = injury potential. Chronic overuse injuries versus acute injuries. Coincidence? Low back – stable ! 80 – 90 % of all adults,60% of work-related injuries involve LB = 9 missed work days / event Knees – stable ! 200,000 ACL injuries/year. 70 – 75 % non-contact. Osteoarthritis = 10x increase with ACL injuries Shoulder girdle – stable ! 21 % of population with 40% persisting < 1 year

Movement and Injuries What Happens if the Body Loses / Lacks this Relationship? Step Two: Loss of stability = injury potential. Chronic overuse injuries versus acute injuries. Low back – stable ! Knees – stable ! Shoulder girdle – stable ! 80 – 90 % of all adults 200,000 ACL injuries/year. 70 – 75 % non-contact. 21 % of population with 40% persisting < 1 year $100 billion annually $650 million (surgery + rehabilitation) $39 billion annually   Sport & Exercise-related Injuries Injuries in Recreational & Sports Facilities Sprain/Strain-type Injuries 1997 13.4% of all injuries 11.6% of all injuries 26.4% of all injuries 2007 17.9% of all injuries 15.0% of all injuries 30.7% of all injuries Step One: Law of Facilitation = “Dyskinesis” Compensation: Stable joints give up some stability to help provide mobility. Example: Increased lumbar lordosis when trying to extend the thoracic spine. Compensation: Moving joint will incorporate movement into another plane Example: Hip extension (sagittal) involving transverse plane rotation. Step Two: Loss of stability = injury potential. Chronic overuse injuries versus acute injuries. Coincidence? Low back – stable ! 80 – 90 % of all adults,60% of work-related injuries involve LB = 9 missed work days / event Knees – stable ! 200,000 ACL injuries/year. 70 – 75 % non-contact. Osteoarthritis = 10x increase with ACL injuries Shoulder girdle – stable ! 21 % of population with 40% persisting < 1 year Look at popular programs since 2004 – What will happen to injuries between 2007 and 2017?

Specifics: Shoulder Abduction Movement Mechanics Specifics: Shoulder Abduction Frontal Plane Action Application: Internally rotate the arms and abduct as high as possible – notice end ROM. Externally rotate the arms and abduct as high as possible – notice end ROM. Difference? Impingement of greater tuberosity (humerus) against coracoid process (scapula) - space is generally small (~ 5-10 mm). Implications for Movement: Caution against excess shoulder abduction with internal rotation = bursitis and tendonitis (supraspinatus and biceps long head). Example: Upright rows, front and lateral raises.

Specifics: Shoulder Abduction Movement Mechanics Specifics: Shoulder Abduction Scaption Plane Action Application: Perform a lateral raise movement with the arms in the frontal plane – notice any resistance to movement? Perform a lateral raise movement with the arms 30° forward in the frontal plane – notice any resistance to movement? Difference? With arms 30° forward to frontal plane, greater tuberosity falls in line with highest point of coraco-acromial arch - experiencing least amount of resistance. Implications for Movement: Perform lateral raises with slight external rotation or forward 30° in frontal plane. Example: Moving from 3 / 9 o’clock position to 4 / 8 o’clock position for shoulder flexion exercises (press, lat pull-down, lateral raises).

Specifics: Overhead Press Movement Mechanics Specifics: Overhead Press Frontal Plane Action Application: Three heads offer anterior, middle and posterior containment of shoulder (lowered position). Place index finger and thumb over origin and insertion points of anterior deltoid - perform overhead raise movement. Difference? Observe external rotation of humerus - changes muscle’s orientation. Arm lowering - no anterior stabilizer to prevent anterior humeral displacement (exacerbated with behind the head presses). Implications for Movement: Overhead positions – External humeral rotation creates no anterior containment beyond passive structures – need to engage lats as stabilizers.

Scapulohumeral Rhythm Force-Coupling Vectors Direction, Magnitude and Timing Movement application? 180° abduction - scapular and glenohumeral (GH) joint movement ratio = ~ 2-to-1. 2° of GH motion for every 1° of scapular motion (120°-to-60° ratio). True scapulae movement = 45 – 60° upward rotation coupled with: 20 – 40° posterior tilt. 15 – 35° external rotation. All designed to reduce encroachment into sub-acromial space.

Scapulohumeral Rhythm Scaption Plane Action Glenoid fossa (GF) is ⅓ size of the gleno-humeral head (GH) Golf ball & tee analogy - labrum increases socket depth by 50 %. Due to GF-GH shape, rotator cuffs (RC) collectively coordinate GF-GH movement: Compress, depress, stabilize and steer the humeral head within socket - constrained within 1-2 mm of center of glenoid fossa (creates ICR). Also function to clear humerus from acromion process. RC muscles play important role in initiating movement and facilitating humeral inferior glide. Muscle Function Supraspinatus Abduction + compression/depression during arm elevation + slight external rotation (ER). Infraspinatus + Teres Minor ER + compression/depression during arm elevation. Subscapularis Internal rotation (IR) + compression/depression during arm elevation

Scapulohumeral Rhythm Movement: 0 – 15° Supraspinatus = inward / upward pull Infraspinatus + Teres Minor + Subscapularis = inward / downward pull Glide Movement: ~ 15° + Deltoids = primary agonist RC Group = stabilizers Abduction

Programming Pre-Requisites/Screens Wall Screen: Overhead Reach Contact Points: Heels, butt, shoulder blades. Shoulder Flexion to OH position. Approx. 170 - 180° movement Increased lumbar lordosis Overhead Squat Arms elevated overhead: Stresses musculature @ shoulder complex. Increases core stabilizing muscle-demand.

Programming Pre-Requisites/Screens LPHC Low Back Arch Overactive Muscles Hip Flexor Complex Erector Spinae Latissimus Dorsi Ideal LPHC Low Back Arch Underactive Muscles Abdominal Complex Gluteus Maximus Hamstrings Compensation

Programming Pre-Requisites/Screens Arms Fall Forward Overactive Muscles Ideal Pectoralis Major Pectoralis Minor Latissimus Dorsi Arms Fall Forward Underactive Muscles Compensation Middle/Lower Trapezius Rhomboids

Corrective Exercise-Movement Quality Identify desired planes of movement Identify regions of stability and mobility throughout kinetic chain Explain – demonstrate – practice trials Observe movement efficiency and limitations Where to start? Segmental Corrective Exercise Desired Movement? Observe Educate Validate Identify locations and movement breakdown Identify possible reasons Inhibit Lengthen Strengthen (type I fibers) Integrate Myofascial release Static Stretching PNF Positional Isometrics Isolated dynamic strengthening Integration (Mobility) (Stability) (Integration)

Corrective Exercise-Movement Quality Scapula dyskinesis: Represents imbalance in stability-mobility relationship. Ineffective joint positioning; general lack of neuromuscular control of scapulae (altered muscle activation patterns). Causes - Examples Inappropriate or deficient training Repetitive trauma (overuse) Improper posture / poor positioning Structural / congenital issues Degenerative changes Shoulder Program Overall Goal Improve parascapular stability – promote T-spine mobility & movement efficiency Pre-requisite: Lumbar Stability Phase One: Promote Thoracic Mobility Phase Two: Promote Scapulo-thoracic Stability Phase Three Promote Integrated Function

Corrective Exercise-Movement Quality Phase One: Promote Thoracic Mobility Address planes sequentially: Sagittal Plane 1st Frontal Plane 2nd Transverse Plane 3rd – most problematic. Never compromise lumbar stability !! – demonstration Thoracic Spine: Supine foam-roller. Supine arm movement – short-to-long lever (progress to prone – short lever). Examples: Alphabets – “I”, “Y” Spinal twists with rib-grab. Thoracic matrix (Gary Gray).

Corrective Exercise-Movement Quality Phase Two: Promote ST Stability Focus: ST position & control (stability), not GH movement Parascapular muscles best stabilized with CKC exercises (joint compression – muscles function as stabilizers). Too challenging initially? Start with OKC exercises Use supported surfaces (e.g., floor, wall) + kinesthetic feedback ‘feel’ Shoulder Packing (reduce scapular elevation) Reverse Codman’s – short lever (alphabets) Supine Letters – short lever (“I-Y-T-W”, “Wipers”) Depress Retract

Corrective Exercise-Movement Quality Phase Two: Promote ST Stability Progress to CKC: Example: Packed Quadruped Loading – progressions Loading and 3-D weight shifts Off-set hand position Elbow extension Lengthen moment arm Unstable Surfaces Scapular Clocks - hand fixed, change scapular loading positions. 12 o’clock (depression). 6 o’clock (elevation) 3 o’clock (retraction) 9 o’clock (protraction)

Corrective Exercise-Movement Quality Integrated 3-D Shoulder Press Pattern Follow M.O.V.E. MOVEMENT   OBSERVE VALIDATE EDUCATE

References … American Council on Exercise (2010). ACE Personal Trainer Manual (4th edition). San Diego, CA, ACE. Bell, DR, and Padua, DA, (2007). Influence of ankle dorsiflexion range of motion and lower leg muscle activation on knee valgus during a double-legged squat. Journal of Athletic Training, 42:S84. Centers for Disease Control and Prevention (2009). Injury episodes and circumstances: National Health Interview Survey, 1997-2007, Vital and Health Statistics, 10 (241). Retrieved 06/15/13. Clark, MA, Lucett, SC, and Sutton, BG, (editors) (2012). NASM Essentials of Personal Fitness Training (4th edition). Baltimore, MD: Lippincott, Williams and Wilkins. Cook, G (2003). Athletic Body in Balance. Champaign, IL., Human Kinetics Gray, G and Tiberio, D (2007). Chain Reaction Function. Gray Institute, Adrian, MI. Gray, G (2008). The Thoracic Spine. Gray Institute Newsletter, Gray Institute, Adrian, MI. Kendall, FP, McCreary EK, Provance, PG, Rodgers, MM, Romani, WA (2005). Muscles Testing and Function with Posture and Pain (5th edition). Baltimore, MD., Lippincott, Williams and Wilkins Sahrmann S, (2002). Diagnosis and Treatment of Movement Impairment Syndromes, St Louis, MO: Mosby.

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Contact Information Fabio Comana Fabio.comana@nasm.org

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