تمرینات اصلاح کننده لوردوز (Advanced Corrective Exercises Hyper Lordosis)

تمرینات اصلاح کننده لوردوز (Advanced Corrective Exercises Hyper Lordosis)

اسلاید 1: 1

اسلاید 2: Hyper LordosisYousef yarahmadiAdvanced Corrective Exercises2

اسلاید 3: IntroductionNormal lordosisHyperlordosisRelated musclesPrevalence of lordosisComplications of lordosisLordosis relationship with age, gender and sportsCommon cuasesAssessment and DiagnosisHistoryStatic postrual assessmentMovement assessmentGoniometric AssessmentStrength AssessmentCorrective exercise programInhibitionLengtheningActivationIntegrationContent:3

اسلاید 4: Normal lumbar lordosisLordosis: Anterior curves in the cervical and lumbar regions. Lordosis is a term also used to denote an anterior curve, although some sources reserve the term lordosis to denote abnormal conditions (Kisner, 2007).Gelb et al. reported normal lordosis in middle and older aged volunteer as 64°,1995). 4

اسلاید 5: Normal lumbosacral angle is 140°Normal lumbar lordotic curve is about the 50° normal sacral angle is 30Pelvic angle is 30°(Magee, 2006).Picture from mageeThe mean angle of lordosis was and 29.07 ±9.71 in women group and 24.00±10.50 in men (Kargarfard et al, 2010).Lumbar lordosis were measured 49 degree in young 100 adults without spinal abnormalities (22 -79 degree) (Lee, 1999).. Women (mean, 49.5 degrees +/-10.7 degrees ) Men (mean, 43.0 degrees +/-10.7 degrees (Youdas, 2006).Normal lumbar lordosis5

اسلاید 6: کمالی میانگین لوردوز کامل کمر را در افراد 20 تا 70 سال شهرستان بابل 11.5±54.5 گزارش کرده است (1382).Normal lumbar lordosis6

اسلاید 7: مرکزشرقغربشمالجنوب15.30±43.2212.79±46.1412.24±55.1014.56±48.7914.40±42.32زن11.40±36.9412.8±43.9112.23±35.929.71±37.6810.54±38.65مردکل ایرانکل ایران14.65±46.99زن11.71±38.60مردتعيين نورم كايفوز و لوردوز جامعه ايران.پژوهشكده تربيت بدني1387,(رضا رجبی (مسئول طرح Normal lumbar lordosis7

اسلاید 8: Low back arches forward, creating an in-creased forward curve in the low back.(Cailliet, R, 1988; as cited in Therapeutic Exercise)Lordosis is an excessive anterior curvature of the spine (Fahrni, 1976; Finneson, 1981; Kendall, 1983; McKenzie, 1981; Wiles, P., and R. Sweetnam,1965(افزایش بیش از حد گودی کمر را گود پشتی می نامند (دانشمندی، علیزاده و قراخانلو، 1387)Hyper lordosis افزایش گودی کمر به نحوی که از حد طبیعی بیشتر باشد را گودی کمر مینامند (دانشمندی، جزوه).8

اسلاید 9: Lordotic posture:Is characterized by an increase in the lumbosacral angle, an increase in lumbar lordosis, and an increase in the anterior pelvic tilt and hip flexion ) Cailliet, R . Cited in Kisner,2007).Hyperextension of the lumbar spine, with the pelvis in anterior tilt (Patel, 2005 ). A high correlation was noted between LLA and SIA (r = 0.883, p = 0.0001).(Lin, Jou , 1992; Mac-thiong et al. 2003; Vaille et al, 2005). Hyper lordosis9

اسلاید 10: musclesSome muscles around the hip and spine become tight and some become weak and stretched, causing an imbalance.10

اسلاید 11: Hip flexorsHip flexors (in particular the iliopsoas muscle). Tight muscles:Trunk extensors (erector spinae and quadratus lumborum) 11

اسلاید 12: Underactivity and inability of the gluteus maximus to maintain an upright trunk position, the latissimus dorsi may become synergistically dominant (overactive or tight) to provide stability through the trunk, core, and pelvis (Sahrmann, 2002, as cited in NASM).. The latissimus dorsi attaches to the pelvis and will anteriorly rotate the pelvis, which causes extension of the lumbar spine (Sahrmann, 2002; Neumann, 2002, as cited in NASM).Tight muscles:12

اسلاید 13: weak muscles:13

اسلاید 14: Vladimir Janda categorizes thebody’s muscles: postural or phasic muscles(janda, 1968; as cited Chaitow, 2007)When overused and fatigued, posturalmuscles tend to become hypertonic, while phasic muscles tend to become weak and inhibited. The phasic muscles are antagonists to postural muscles.Because postural muscles tend toward hypertonicity, they create a functional weakness in the phasic muscles through the process of reciprocal inhibition(Chaitow, 2007)Lower crossed syndrome14

اسلاید 15: Specific postural changes in LCS: anterior pelvic tilt, increased lumbar lordosis, lateral lumbar shift, lateral leg rotation, and knee hyperextension.lower crossed syndrome15

اسلاید 16: Prevalence of hyperlordosis(32%) of School children in the Czech Republic (KRATEˇNOVA´ ,ZˇEJGLICOVA´, MALY´, FILIPOVA´, 2007).No sports activities were reported by 20% of children, and these children had significantly higher probability of poor posture than children performing sports. (KRATEˇNOVA´ et al., 2007).فراوانی ناهنجاری لوردوز در سه رده سنی نوجوان، جوان و میان سال 25.8% گزارش شده ، است (نظریان، دانشجو، قربانی و قایدی، 1388).22.99% of pupils aged 11-13 years in Karaj (Lasjouri and Mirzaei, 2005)83.7% of lifting load workers of Behshahr industrial factory (Gharahgouzlou, 2000).سیمرغ و همکاران شیوع هایپر لوردوز را در دانشجویان دختر 19-34 سال 25.49 گزارش کردند (1338).16

اسلاید 17: Prevalence of hyperlordosis 9.75% of teenagers boy and 6.89% of teenager girl between 11-15 year-old of Lorestan province (Bahrami and Farhadi, 2006).65% of individuals with Schuerman disease, 27.8% of postural kyphotic individuals (Vanzi, Chih , Meves , Caffaro, and Pellegrini , 2007).17

اسلاید 18: Mobility impairment in the hip flexor muscles and lumbar extensor musclesImpaired muscle performance due to stretched and weak abdominal musclesWatson reported that 67% of players with lordosis suf-fered muscular injuries, while in the group without postural changes, only 36% suffered the same injury (1995). Complications of hyperlordosisResearch has shown low-back pain to be predominant among people who have altered lumbar lordosis (curve in the lumbar spine) (NASM).18

اسلاید 19: Stress to the anterior longitudinal ligament (Kisner, 2007).Narrowing of the posterior disk space and narrowing of the intervertebral foramen by Increased lumbar extension, leading to spinal nerve root compression (Kisner, 2007).Approximation of the articular facets.(Kisner, 2007; Gross, 2009).Increased weight on posterior vertebral arch structuresLBP and myofascial trigger points from hypertonicity in these muscles and exaggerate the lordosis.(Chaitow, 2009)spinal pathology such as facet joint dysfunction, disc herniation, spondylolysis, or spondylolisthesis can result. .(Chaitow, 2009)Complications of hyperlordosis19

اسلاید 20: The lumbar spine in the child has an exaggerated lumbar curve, or excessive lordosis. caused by the presence of large abdominal contents, weakness of the abdominal musculature (Magee, 2006).Beginning at approximately 9 years of age, there seems to be a tendency for increased forward curve or lordosis of the low back. The deviations should become less pronounced as the child grows older (19,22).Lordosis relationship with age, gender and sportIn children in age-groups between 8 and 16 years of age, there is a slow continuous increase in lumbar lordosis (Willner and Johnson, 1983).Kyphosis and lordosis increased and mobility decreased in the 90 children who were examined both at age 5-6 and 15-16 years. The relationship between kyphosis and lordosis decreased in girls but not in boys (Widhe, 2001).20

اسلاید 21: Lordosis relationship with age, gender and sport تعيين نورم كايفوز و لوردوز جامعه ايران (رجبی، 1387) تعيين نورم كايفوز و لوردوز جامعه ايران (رجبی، 1387) تعيين نورم كايفوز و لوردوز جامعه ايران (رجبی، 1387)مردزنسن34.45±11.2440.26±12.19-1439.20±11.8046.92±12.0115-2441.46±12.5650.34±14.0425-4440.52±10.3551.22±15.2945-6437.37±11.2145.96±16.54+6421

اسلاید 22: Lordosis relationship with age, gender and sportFarhadi and Bahrami reported the prevalence of lordosis: 6.89% in girl and 9.75% boy (2006).Zuluaga et al. reported that lumbar lordosis reaches its highest degree(55°) in adolscence (13-19) and decreases by aging (1995).The average of lumbar lordosis in men and women decreases by aging (Nissinen, 2008; Kamali, 2003; Gelb et al, 1995).. Lordosis was absent in an increasingly large proportion of men and women as age rose above 60 years.(Milne, Lauder, 1974).22

اسلاید 23: Lordotic curve in female 20-65 years old is greater than their male counterpart(Nourbakhsh, Moussavi, Salavati, 2002).Lordosis and hyperlordosis were the most prevalent among the young (38.8%) and adult (48.7%) females respectively (Nazarian et al. 2009).Women (mean, 49.5 degrees +/-10.7 degrees ) demonstrated about 6.5 degrees more LLC than their male (mean, 43.0 degrees +/-10.7 degrees ) counterparts. Youdas, Hollman, and Krause, 2006).Lordosis relationship with age, gender and sport23

اسلاید 24: Female volleyball players have rounded shoulders and excessive arch of the lower back (Performance Conditioning Volleyball, 2006). Volleyball players were predominantly kyphotic, their lumbar lordosis was flattened and head protruded, especially in those having longer training experience (Grabara, 2009).. In the lumbar spine there was no difference as to either posture or sagittal motion between former female elite gymanasts in comparison with matched control subjects (Tsai and Wredmark, 2002). Lordosis relationship with age, gender and sport24

اسلاید 25: There was a significantly higher incidence of lordosis in the soccer and football players when compared to the other sportsmen (Young, 2001)Futsal players show changes on the body alignment. The most common changes seen were in ankle and knee in both groups. The changes of the alignment in lumbar spine was more common in group 1(suffered injuries related to Futsal) (Ribeiro, 2003).Lordosis relationship with age, gender and sport25

اسلاید 26: Watson observed that only 26.5% of soccer, rugby andAmerican football players investigated had their lumbarspine alignment preserved. He also found an incidence of 51.9% soccer players with enhanced lumbar lordosis (1995).subjects participating in Gaelic football and soccer were monitored over a period of 21 months. It was found that subjects participating in these two sports showed a significant increase in lordosis (Young, 2001).Comparison between soccer players and the volunteer with no sports activities: In athletes, spinal alignment was achieved by a less pronounced thoracic kyphosis and a more pronounced angle, sacral tilt and lumbar lordosis (Wodecki, Guigui, Hanotel, Cardinne, and Deburge, 2002).Lordosis relationship with age, gender and sport26

اسلاید 27: Lordosis angle was also greater in SC versus RC and climbers back was characterized by an increased thoracic kyphosis, increased lumbar lordosis. The climbing ability level was strongly correlated to the postural adaptations.(Förster, Penka, Bösl, Schöffl, 2009).Chronic lower back injuries are also common in windsurfers and may be related to prolonged lordosis (lumbar extension) of the spine while pumping the sail (Neville V, Folland JP, 2009).Lordosis relationship with age, gender and sport27

اسلاید 28: In young athletes between 8 and 18 years showed that larger angles of thoracic kyphosis and lumbar lordosis were associated with greater cumulative training time. Gymnasts showed the largest curves. Lack of sports participation, on the other hand, was associated with the smallest curves. Age and sex did not appear to affect the degree of curvature.(Wojtys EM, Ashton-Miller JA, Huston LJ, Moga PJ. , 2000).Distance runners and sprinters had a greater degree of thoracic kyphosis and greater degree of lumbar lordosis. Swimmers, bodybuilders, rugby and soccer players had partial lordosis. Uetake T, Ohtsuki F. , 1993).Lordosis relationship with age, gender and sport28

اسلاید 29: 29Common Causes

اسلاید 30: Sustained faulty posture and repetitive movement Repetitive movement also affects everyday people Waiters and waitresses, much the same as a mother carries her child.Muscle that is repeatedly placed in a shortened position, such as the iliopsoas complex during sitting, will eventually adapt and tend to remain short (10,14).30

اسلاید 31: Sustained faulty posture and repetitive movement Repetitive movements can cause imbalances by placing demands on certain muscle groups more predominantly. This is evident when looking at many athletes such as football players.31

اسلاید 32: weak abdominal muscles with tight muscles, especially hip flexors or lumbar extensorsA tight psoas decreases the neural drive and therefore optimal recruitment of the gluteus maximus. This altered recruitment and force production of the gluteus maximus (prime mover for hip extension), leads to compensation and substitution by the synergists (hamstrings) and stabilizers (erector spinae).32

اسلاید 33: Heavy abdomen: Pregnancy or ObesityAs the pregnancy progresses,both forward rotation and hyperlordosis increase as the sacroiliac ligaments become lax. These factors contribute to increasing mechanical strain on the low back, sacroiliac, and pelvis (Ritchie, 2003).The degree of lumbar lordosis was positively related with the number of pregnancies, age and height and negatively related with weight of the subjects. (Nourbakhsh 2002).Lumbar lordosis increases during pregnancy, but physical exercises reduces lordosis increasment and low back pain (Kashanian, Akbari, and Alizadeh, 2009). 33

اسلاید 34: Heavy abdomen: Pregnancy or obesityKamali et al. reporetd Lumbar curve is greater in over-weight women (2004).Lumbar lordosis happens due to increase in anterior mass by increasement in mother’s wieght, fetus and breast (Hainline, 1994).34

اسلاید 35: Compensatory mechanism that result from deformity, such as kyphosisLumbar lordosis had significant correlation with thoracic kyphosis(Lee, 1999).65% of individuals with Schuerman disease, 27.8% of postural kyphotic individuals (Vanzi, Chih , Meves , Caffaro, and Pellegrini , 2007).Kyphosis and lordosis increased and mobility decreased in the 90 children who were examined both at age 5-6 and 15-16 years. The relationship between kyphosis and lordosis decreased in girls but not in boys (Widhe, 2001).A definite correlation exists between the presence of idiopathic lumbar scoliosis and hyperlordosis of the lumbar spine. (Pelker and Gage, 1982).A positive correlation was also observed between the ranges of the kyphosis and lordosis in most of the age-groups (Willner and Johnson,1983).35

اسلاید 36: wearing high-heeled shoes!!Although other effects, such as decreased gait speed and step length, and increased knee flexion at heel strike have been found in more than one study, no increase in lumbar lordosis has been found. The results indicate that the greatest compensation is at the ankle and knee. Where a significant effect occurred in the lumbar spine (males, dynamic study), high heels decreased the lumbar lordosis(de Lateur, Giaconi, Questad, Ko, Lehmann, 1991).By one-hour adaptation to a corresponding shoe type. With increasing heel height, the lumbar lordosis and the pelvis inclination were decreased. The back and abdominal muscles did not alter their activities. (BENDIX, SØRENSEN, and KLAUSEN, 1984).36

اسلاید 37: In sagittal plane kinematics during gait, the lumbar lordosis did not increase in high-heeled gait. The knee flexion and ankle plantarflexion increased in high-heeled gait(Song SH, Yoo JY, Ha SB. 1997).Intrasubject comparison of barefoot and high-heeled stance showed that the wearing of high heels caused lumbar flattening, a backward tilting pelvis (OPILA, WAGNER, SCHIOWITZ, CHEN, 1988).Snow et al. did not observe changes in the positioning of the pelvis and the lumbar spine while walking in high heels even though they noted at the same time a forward shifting of the COM (1994).Wearing high-heeled shoes!!37

اسلاید 38: Positive heel inclination of subjects brought about significantly lower anterior pelvic tilt, lumbar lordosis, and sacral base angles when compared with zero heel inclination. Clinically, patients with low back pain may be affected by high heel usage because of the reduction of the normal lumbar lordosis (Franklin, Chenier, Brauninger, Cook, Harris, 1995).STS from a chair while wearing high-heeled shoes demands significant ES and RF muscle contractions. The sustained and repeated wearing of heels with excessive heights can induce inappropriate neuromuscular behaviors due to muscle imbalance (Kim et al. 2011).Wearing high-heeled shoes!!38

اسلاید 39: There are many Internet sites that support the belief that high-heeled shoes cause increased lordosis. However, published research for this topic mostly does not support this belief; but some mixed results, small subject groups, and questionable methods have left the issue unclear (Russell, 2010).Significant increase in erector spine activity was observed in Trunk Flexion and during Flexion-Relaxation Position when wearing high hell shoes. The prolonged wearing of shoes with stiletto type low and high heels by individuals without back pain is not safe for their spine and may lead to chronic paraspinal muscle fatigue. (Mika, Oleksy , Mikołajczyk, Marchewka, 2009).Wearing high-heeled shoes!!39

اسلاید 40: A corrective exercise program is only as good as the assessment process (NASM).Assessment:40

اسلاید 41: Health risk appraisal1. physical readiness for activity:Gathering personal background information about an individual can be very valuable in gaining an understanding of the individual’s physical condition and can also provide insights into what types of imbalances they may exhibit.History:41

اسلاید 42: 2. general life-style information Occupation provide the health and fitness professional with insight into what his or her movement capacity is and what kinds of movement patterns are performed throughout the day. History:42

اسلاید 43: if an individual is sitting a large portion of the day, his or her hips are flexed for prolonged periods of time. This, in turn, can lead to tight hip flexors that can cause postural imbalances within the kinetic chain.History:43

اسلاید 44: MENTAL STRESS Mental stress or anxiety can lead to a dysfunctional breathing pattern that can further lead to postural distortion and kinetic chain dysfunction. History:44

اسلاید 45: REPETITIVE MOVEMENTSRepetitive movements can create a pattern overload to muscles and joints that may lead to tissue trauma and eventually kinetic chain dysfunction (2). History:45

اسلاید 46: RECREATIONRefers to an individual’s physical activities outside of the work environment. . For example, many people like to golf, ski, play tennis, or engage in a variety of other sporting activities in their spare timeBetter designing of a program to fit these needs. Provides insight on the types of stresses being placed on one’s structure that can lead to muscle imbalances.History:46

اسلاید 47: HOBBIES Hobbies, refer to activities that an individual may partake in regularly, but are not necessarily athletic in nature:gardening, working on cars, reading, watching television, and playing video games. In many of these cases, the individual must maintain a particular posture for an extended period of time.History:47

اسلاید 48: MEDICAL HISTORYThe medical history (Figure 4-4) is absolutely crucial. Not only does it provide information about any life-threatening chronic diseases (such as coronary heart disease, high blood pressure, and diabetes).information about the structure and function of the individual by uncovering important information such as past injuries, surgeries.History:48

اسلاید 49: Past Injuries There is a vast array of research that has demonstrated past injuries affect the functioning of the human movement system (5–46). Low-back injuries can cause decreased neural control to stabilizing muscles of the core, resulting in poor stabilization of the spine. (26).History:49

اسلاید 50: Past Surgeries Surgical procedures create trauma for the body and may have similar effects to those of an injury• • Cesarean section for birth (cutting through the abdominal wall to deliver a • baby) Appendectomy (cutting through the abdominal wall to remove the • appendix)Even the best of surgeries results in scar tissue. Scar mobility is often an overlooked aspect of the rehabilitation paradigmHistory:50

اسلاید 51: Static postural assessment: “Size up” of client. Giving a “big picture”Consider the body as a road map. The kinetic chain checkpoints: 1. Foot and ankle 2. Knee 3. Lumbo-pelvic-hip complex (LPHC)4. Shoulders5. Head/Cervical spine (NASM)51

اسلاید 52: LATERAL VIEW Foot/ankle: neutral position, leg vertical at right angle to sole of foot.Knees: neutral position, not fl exed or hyperextended• LPHC: pelvis in neutral position, not anteriorly (lumbar extension) or posteriorly rotated • (lumbar fl exion)Shoulders: normal kyphotic curve, not excessively rounded• Head: neutral position, not in excessive extension (“jutting” forward) (NASM).Static postural assessment52

اسلاید 53: Movement assessmentTHE SCIENTIFIC RATIONALE FOR MOVEMENT ASSESSMENTS Movement represents the integrated functioning of many systems within the human body, primarily the muscular, skeletal, and nervous systems (1–3). When HMS impairments exist, there are muscles that are overactive and muscles that are underactive around a joint (Table 6-1) (1–3,6,9,10). The terms “overactive” and “underactive” are used in this text to refer to the activity level of a muscle relative to another muscle or muscle group, not necessarily to its own normal functional capacity. Any muscle, whether in a shortened or lengthened state, can be underactive or weak because of altered length-tension relationships or altered reciprocal inhibition (chapter three) (10). This results in an altered recruitment strategy and ultimately an altered movement pattern (1,2,6,7,10,11). Thorough understanding of human movement science and the use of the kinetic chain checkpoints to systematically detect compensation in joint motion, inferences as to HMS impairments can be made (1–3,9,10). 53

اسلاید 54: Movement assessment:A. Transitional movement assessment:B. Dynamic movement assessment:1. Gait assessmentOverhead squatPressingPushing54

اسلاید 55: Reaching downward to pick up something (spinalflexion), then reaching overhead to place it on a high shelf(spinal extension). In sports activities the activity may require moving quickly from a forward-bent position to anextended position with arms overhead (such as dribbling abasketball, then shooting). Set up drills that replicate the(kisner).Transitional movement assessments are assessments that involve movement without a change in one’s base of support (NASM).Transitional Movements Assessment 55

اسلاید 56: 1. OVERHEAD SQUAT ASSESSMENTPROCEDURE 1.Feet shoulder-width apart and pointed straight ahead. 2. Elbows fully extended. The upper arm should bisect the torso.Transitional Movements Assessment56

اسلاید 57: Movement 1.Instruct the individual to squat to roughly the height of a chair seat and return to the starting position. 2. Repeat the movement for 5 repetitions.Transitional Movements Assessment57

اسلاید 58: MODIFICATIONS TO THE OVERHEAD SQUAT ASSESSMENT Places the foot and ankle complex in plantarflexion, which decreases the stretch (or extensibility) required from the plantarflexor muscles (gastrocnemius and soleus). This is important because deviation through the foot and ankle complex can cause many of the deviations to the kinetic chain, especially the feet, knees, and LPHC. Transitional Movements Assessment58

اسلاید 59: removes the stretch placed on the latissimus dorsi, pectoralis major and minor, and coracobrachialis and requires less demand from the intrinsic core stabilizers. If an individual’s low back arches during the overhead squat assessment, but the compensation is then corrected when performing the squat with the hands on the hips, then the primary regions that most likely need to be addressed are the latissimus dorsi and pectoral muscles. If the compensation still exists, then the primary regions that most likely need to be stretched include the hip flexors and the regions that need to be strengthened are the hips and intrinsic core stabilizers. MODIFICATIONS TO THE OVERHEAD SQUAT ASSESSMENT Transitional Movements Assessment59

اسلاید 60: PROCEDURE1. A prone position with hands roughly shoulder-width apart and knees fully extended. Pushing against the floor, displacing the thorax backward until the scapulae are in a position of protraction.2. The individual should move slowly and consistently. A 2-0-2 speed per repetition is recommended (two seconds up, zero-second hold, two seconds down).3. Perform 10 repetitions. Pushing assessment: push-upTransitional Movements Assessment60

اسلاید 61: PULLING ASSESSMENT: STANDING ROWS PROCEDUREStand in a staggered stance with the toes pointing forward.Pull handles toward the body and return to the starting position.Perform 10 repetitions in a controlled fashion using a 2-0-2 tempo.Transitional Movements Assessment61

اسلاید 62: PRESSING ASSESSMENT: STANDING OVERHEAD DUMBBELL PRESSPROCEDURE 1. stand with feet shoulder-width apart and toes pointing forward. 2. Choose a dumbbell weight at which the individual can perform 10 repetitions comfortably. Transitional Movements Assessment62

اسلاید 63: PRESSING ASSESSMENT: STANDING OVERHEAD DUMBBELL PRESS Movementpress the dumbbells overhead and return to the starting position. The lumbar and cervical spines should remain neutral while the shoulders stay level and the arms bisect the ears.2. Perform 10 repetitions in a controlled fashion using a 2-0-2 tempo.Transitional Movements Assessment63

اسلاید 64: shoulder flexion test PROCEDURE touch the thumbs against the wall with no compensatory movements such as increasing lumbar lordosis.elbows extended with thumbs upTransitional Movements Assessment64

اسلاید 65:   DYNAMIC MOVEMENT ASSESSMENTS: Gait assessment . Dynamic movement assessments are assessments that involve movement with a change in one’s base of support, such as walking and jumping.Because posture is a dynamic quality, these observations can show postural distortions and potential overactive and underactive muscles in a naturally dynamic setting.  Dynamic Movement Assessment65

اسلاید 66: PURPOSE: To assess one’s dynamic posture during ambulation. PROCEDUREWalking on a treadmill at a comfortable pace at a 0-degree incline. From a lateral view, observe the low back, shoulders, and head. The low back should maintain a neutral lordotic curve. The shoulders and head should also be in neutral alignment.  Dynamic Movement Assessment66

اسلاید 67: Assessment Implementation OptionsAll of these assessments can become one’s first workoutDepending on one’s physical capabilities, choose assessments that the individual can perform safely.Offering 30- to 45-minute “assessment sessions” that take individuals through these assessments and a customized corrective exercise program based on the assessment findings can be a way to help generate revenue as well as to potentially have individuals working with you long term.67

اسلاید 68: 68GONIOMETRIC ASSESSMENTSTRENGTH ASSESSMENTcontinuum

اسلاید 69: GONIOMETRIC ASSESSMENTIf one joint lacks proper ROM, then adjacent joints and tissues (above and/or below) must move more to compensate for the dysfunctional joint ROM.some muscles will become overactive, shortened, and restrict joint motion whereas other muscles will become underactive, lengthened, and not promote joint motion (1,2,4,7,11,12). A noted decrease in the ROM of a joint may signify overactive muscles, underactive mus-cles, and/or altered arthrokinematics (3).69

اسلاید 70: Passive range of motion is the amount obtained by the examiner without any assistance by the client. In most normal subjects, passive ROM is slightly greater than active ROM. Passive ROM provides information regarding joint-play motion and physiologic end-feel to the movement. This helps create an objective look at the articular surfaces of the joint as well as tissue extensibility of both contractile and noncontractile tissues.Active range of motion refers to the amount of motion obtained solely through voluntary contraction from the client. Active ROM can be determined through the use of movement assessments such as the overhead squat assess-ment. Information provided here includes muscular strength, neuromuscular control, painful arcs, and overall functional abilities. Comparisons of passive and active ROM provide a complete objective assessment of the articulations and the soft tissue that envelops and moves iGoniometric Assessment70

اسلاید 71: HIP EXTENSION1. Joint motion:a. Extension of iliofemoral joint2. Muscles and tissues: Psoas, iliacus, rectus femoris, TFL, sartoriusb. Adductor complex, anterior hip capsule3. Antagonists potentially underactive if ROM is limited:Gluteus maximus, gluteus medius (posterior fi bers)b. Hamstring complex, adductor magnus4. Normal Value (22): 0–10 degreesGoniometric Assessment71

اسلاید 72: pelvis off the tableopposite hip is flexed to assist in flattening the low back against the table knee of the test leg should be flexed to almost 90 degreespassively allow the hip to extend until first restriction or compensation (anterior tilting of the pelvis or low back arching off the table).Goniometric Assessment72

اسلاید 73: :If the psoas is the primary restriction the pelvis rotates anteriorly (low back begins to arch), the thigh stays in a neutral position, and the knee remains flexed..If the rectus femoris is the primary restriction, the pelvis rotates anteriorly, the thigh remains neutral, and the knee extends.If the tensor fascia latae is the primary restriction, the pelvis rotates anteriorly, the thigh abducts and internally rotates, and the knee extends via tension through the iliotibial band.If the sartorius is the primary restriction, the pelvis rotates anteriorly, the thigh abducts and externally rotates, and the knee remains flexed.If the adductor complex is the primary restriction, the pelvis rotates anteriorly, the thigh adducts, and the knee remains flexed.Goniometric Assessment73

اسلاید 74: SHOULDER FLEXION1. Joint motion: a. Flexion of shoulder complex2. Muscles: a. Latissimus dorsi, teres major, teres minor, infraspinatus, subscapularis, pectoralis major (lower fi bers), triceps (long head)3. Antagonists potentially underactive if ROM is limited:a. Anterior deltoid, pectoralis major (upper fibers, clavicular fibers), middle deltoidb. Lower and middle trapezius, rhomboids4. Normal Value (22): 160 degreesGoniometric Assessment74

اسلاید 75: Holding the client’s arm in external rotation, place the thumb on the lateral border of the scapula and passively flex the shoulder until excessive scapular movement is felt or the first resistance barrier is noted.Goniometric assessment75

اسلاید 76: Strength assessmentOveractivity of a shortened muscle will reciprocally inhibit its functional antagonist (2,3,8). This inhibition can lead to a false reading that a muscle is weak when in fact the strength impression is purely a factor of joint position. If the muscle tests normal (strong) in the midrange, then there is either a muscle length issue on the opposing side of the joint or possibly a joint restriction (15). 76

اسلاید 77: Strength Assessment77

اسلاید 78: MEDIAL HAMSTRING COMPLEX: SEMITENDONSUS, AND SEMIMEMBRANOSUS1. Joint position being tested:a. Knee flexionb. Tibial internal rotation2. Muscles being assessed:a. Semimembranosus, semitendinosusb. Gastrocnemius, popliteus, gracilis, sartorius, plantaris3. Potentially overactive muscles if strength is limited:a. Quadriceps complex (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius)b. Biceps femorisStrength Assessment78

اسلاید 79: knee flexed approximately 50 to 70 degrees. Place thigh in slight internal rotation and internally rotate the tibia.• Stabilize the upper leg just below the knee joint.Instruct client to “hold” the position.• Apply gradual and increasing pressure to the posterior lower leg in the direction of knee extension and tibial external rotation.Look for compensations of ankle dorsiflexion, hip adduction, hip flexion, or spinal extension.Strength Assessment79

اسلاید 80: BICEPS FEMORIS1. Joint position: a. Knee flexionb. Tibial external rotation2. Muscles: a. Biceps femorisb. Gastrocnemius, plantaris3. Potentially overactive muscles if strength is limited:a. Quadriceps complex (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius)b. Medial hamstring complex, popliteus, gracilis, sartoriuStrength Assessment80

اسلاید 81: knee flexed approximately 50 to 70 degrees. Place thigh in slight external rotation and externally rotate the tibia. Stabilize the upper leg anteriorly just below the knee joint.• Apply gradual and increasing pressure to the foot in the direction of knee extension and tibial internal rotation.Look for compensations of ankle dorsifl exion, hip abduction, hip flexion, and/or spinal • extension.Grade client’s strength:81

اسلاید 82: GLUTEUS MAXIMUS1. Joint position: a. Hip extension, external rotation, and abduction2. Muscles: a. Gluteus maximus, b. Adductor magnus, hamstring complex, gluteus medius (posterior fi bers)3. Potentially overactive muscles if strength is limited:a. Iliopsoas, rectus femoris, adductor longus, adductor brevis, pectineusb. TFL, sartorius, gluteus minimusClient is prone with hip in extension and knee flexed. Place thigh into slight external rotation and abduction.•Support the opposite hip.• Apply gradual and increasing pressure to the upper leg just above the knee in the • direction of hip fl exion, adduction, and internal rotation.Look for compensations of knee flexion, hip internal rotation, and/or spinal extension.82

اسلاید 83: RECTUS ABDOMINIS1. Joint:a. Spinal (trunk) flexion2. Muscles:a. Rectus abdominis b. External obliques, internal obliques3. Potentially overactive muscles if strength is limited:a. Erector spinaeb. Latissimus dorsi, iliopsoas, rectus femoris, TFL, sartorius, quadratus lumborumClient is supine with trunk in flexion.•.• Apply gradual and increasing pressure to the upper torso in the direction of spinal extension.Look for compensations of hip fl exion or trunk rotation.83

اسلاید 84: OBLIQUE ABDOMINALS: EXTERNAL AND INTERNAL OBLIQUE1. Joint position:a. Spinal (trunk) flexion and rotation2. Muscles: a. External obliques, internal obliques b. Rectus abdominis3. Potentially overactive muscles if strength is limited:a. Erector spinaeb. Latissimus dorsi, iliopsoas, rectus femoris, TFL, sartorius, quadratus lumborum, adductor longus, adductor brevis, adductor magnus, pectineus, gracilis Apply gradual and increasing pressure to the upper torso in the direction of opposite spinal rotation and extension. Look for compensations of hip flexion and/or hip adduction.84

اسلاید 85: LATISSIMUS DORSI1. Joint position:a. Shoulder extension, adduction, and internal rotation2. Muscles being assessed:a. Latissimus dorsib. Posterior deltoid, teres major, triceps brachii (long head), lower trapezius, rhom-boids, mid-trapezius3. Potentially overactive muscles if strength is limited:a. Anterior deltoid, upper trapezius, pectoralis major, pectoralis minor, biceps brachii (long head), infraspinatus, teres minorb. Biceps femoris, medial hamstrings, adductor magnus, rectus abdominis, oblique abdominal complex. Shoulder complex in extension, adduction, and internal rotation. Apply gradual and increasing pressure to the forearm in the direction of shoulder flexion and abduction.85

اسلاید 86: GLUTEUS MEDIUS1. Joint position: a. Hip extension, external rotation, and abduction2. Muscles being assessed:a. Gluteus mediusb. Gluteus minimus, gluteus maximus (upper fi bers), TFL3. Potentially overactive muscles if strength is limited:a. Adductor brevis, adductor longus, pectineus, gracilisb. TFL, gluteus minimus, rectus femoris, iliopsoas. Place thigh in slight external rotation and abduction.• Apply gradual and increasing pressure to the lateral aspect of the lower leg just above the ankle joint in the direction of hip flexion and adduction.86

اسلاید 87: 87

اسلاید 88: CORRECTIVE EXERCISE CONTINUUM (NASM)program88

اسلاید 89: InhibitionSelf-myofascial release: a flexibility technique used to inhibit overactive muscle fibers.SMR can be used for two primary reasons: 1. To alleviate the side effects of active or latent trigger points by holding pressure on the tender areas of tissue (trigger points) for a sustained period, trigger point activity can be diminished. This will then allow the application of a stretching (or lengthening) technique such as static stretching to increase muscle extensibility of the shortened muscles and provides for optimal length-tension relationships. 89

اسلاید 90: 2. To influence the autonomic nervous systemThe importance of the effect neuromyofascial release or pressure and tension has on the autonomic nervous system is that it influences (6): 1. The fluid properties of tissue that affects the viscosity (resistance to flow or motion). 2. The hypothalamus, which increases vagal tone and decreases global muscle tonus. 3. Smooth muscle cells in fascia that may be related to regulation of fascial pretension.Inhibition90

اسلاید 91: ActivationIsolated strengthening:To isolate particular muscles to increase the force production capabilities through concentric and eccentric muscle actions. Isolated strengthening is a technique used to increase intramuscular coordination of specific muscles. Activation refers to the stimulation (or reeducation) of underactive myofascial tissue. 91

اسلاید 92: Positional isometrics: incorporates isometric contractions performed at the end ROM of a joint. It is a static technique meaning that there is no active motion. This technique would be more appropriate for a person with adequate core strength and neuromuscular control as it will involve higher intensity contractions or force. Like isolated strengthening techniques, the purpose of this technique is to increase the intramuscular coordination of specifi c muscles necessary to heighten the activation levels before integrating them back into their functional synergies.92

اسلاید 93: IntegrationIntegration techniques are used to reeducate the human movement system back into a functional synergistic movement pattern. The use of multiple joint actions and multiple muscle synergies helps to reestablish neuromuscular control, promoting coordinated movement among the involved muscles. to reestablish postural control and decrease the risk of injury93

اسلاید 94: urthermore, it is known that multijoint motions promote and require greater intermuscular coordination to achieve the desired outcome and is often the reason for their use (1). 1. Enoka RM. Neuromechanics of Human Movement. 3rd ed. Champaign, IL: Human Kinetics; 2002Intermuscular coordination: the ability of the neuromuscular system to allow all muscles to work together with proper activation and timing between them.94

اسلاید 95: CORRECTIVE EXERCISES FOR HYPERLORDOSISKEY APPLICATION POINTS FOR SELF-MYOFASCIAL RELEASE :1. Maintains proper postural alignment while performing SMR.2. Maintain the drawing-in maneuver at all times to provide stability to the lumbo-pelvic-hip complex.3. The client may use his or her extremities to alter the amount of weight on the treatment area. 4.Roll the device slowly over the treatment area to decrease the risk of further tissue excitation.5. Relax and not tighten up while working on an area. Tension in the tissue being treated will prevent the roller from penetrating into the deeper layers of soft tissue.6. Pause the rolling action over painful areas until a “release” is felt in the area or the pain subsides and the tissue softens (roughly 30 seconds with maximal pain tolerance and 90 seconds for lower pain tolerance) (2).95

اسلاید 96: Corrective Exercises for HyperlordosisStep 1: InhibitKey regions to inhibit via foam rolling include the hip flexor complex (rectus femoris) and latissimus dorsi.96

اسلاید 97: Step 2: LengthenKey lengthening exercises via static and/or neuromuscular stretches include the hip flexor complex, erector spinae, and latissimus dorsi.97

اسلاید 98: Static stretchesStep 2: Lengthen98

اسلاید 99: Step 2: Lengthen99

اسلاید 100: Step 3: ActivationKey activation exercises via isolated strengthening exercises and/or positional isometrics include the gluteus maximus and abdominal complex.100

اسلاید 101: Isolated strengtheningStep 3: Activation101

اسلاید 102: Step 3: Activation102

اسلاید 103: Step 3: Activation103

اسلاید 104: Step 4: IntegrationAn integration exercise that could be implemented for this compensation could be a ball squat to overhead press.Step 4: Integration104

اسلاید 105: This exercise will help teach proper hip hinging while maintaining proper lumbo-pelvic control. Adding the overhead press component will place an additional challenge to the core. The individual can then progress to step-ups to overhead presses (sagittal, frontal, and transverse planes), then to lunges to overhead presses (sagit-tal, frontal, and transverse planes), and then to single-leg squats to overhead presses.Step 4: Integration105

اسلاید 106: CONCLUSION106There is high prevalence of hyperlordosis and there are lot of related complications, so the importance of addressing this abnormality is cleared.There is a relationship between lordosis and age, gender and sports, which must be considered while developing a corrective exercise program.Common causes should be addressed in order to achieve a effective and persistent goal.A corrective exercise program is only as good as the assessment process.

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اسلاید 117: 117کاشانیان، اکبری و علیزاده. تاثیر ورزش بر میزان کمر درد و قوس کمری زنان حامله. دانشگاه علوم پزشکی ایران، 1388؛ 16(69): 40-45.دانشمندی، علیزاده و قراخانلو،حرکات اصلاحی، سمت: 1387دانشمندی، حسن. جزوه منتشر نشده.ن.کمالی، م. حاجی احمدی، م. کشانی و ا. محبوبی. تاثیر جنس و چاقی روی دانشگاه علوم پزشکی بابل، 1382؛ 5(3): 18-23..اندازه لوردوز کمر

اسلاید 118: 118هشیار سری بود ز سودای تو مستخوش آنکه ز روی تو دلش رفت ز دستبی‌تو همه هیچ نیست در ملک وجودور هیچ نباشد چو تو هستی همه هستسعدی