آناتومی و فیزیولوژی • بیماری‌ها • پزشکی و سلامت

تمرینات اصلاح کننده لوردوز (Advanced Corrective Exercises Hyper Lordosis)

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درد زر ‎LORDOSIS‏ Yousef yarahmadi

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Introduction © Normal lordosis ۳۲۱۷۵۵۲۱۵۲۵ icy Related muscles ۴۲۵۷۵۱۵86۵ 0۲ ۱0۲۵05 Complications of lordosis Lordosis relationship with age, gender and sports Common cuases 220515 300 روت ۱ ۷ 9 o Static postrual assessment 6 ‏غمع ممع ناوالا‎ 255655104 3 3 و و و هو و هو ل كا ‎Strength Assessment‏ ۵6۲656 60۲۲۵61۷ ‎Inhibition‏ © ‎Lengthening‏ © ‎leon)‏ كن ‎Integration‏ ©

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ها مس مس م۱۱ ام وی ما۱۳ ‎ca‏ ایا ‎a‏ متا متا ما ۰ e0o0?). Columna vertebral Lordosis de la normal columna vertebral Curvatura, Oe ae econ eco tee 1 lumbar = aol exagerada w O° (O98).

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1 ako 10 oe Set Tau ۱ ا ‎CRUE ogee eet‏ ‎FOO (ORO RR Conan nn‏ ا ل ا ‎OS‏ ON ae Ec ‏واستمصصاه‎ ‎aC slele)e‏ ل عا ‎a een eee Soh ee eS ‏صصبط‎ ( ‎0 ‏ا‎ ‎۱ eee) ‎ ‎ ‎ ‎ ‎

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گقالی میانگین لوردوز کامل کر را در افراد 20 تا 70 ‎Here) ole‏ ۳ .است (1382)

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>« سسسس«<-«۳ MUNA ner) eS) 12.24+55 14.56448 14.40+42 79 32 12.23435 9.71237 48 68 65 15.30 43. 6 22 14 11.40+36. ۰ 94 91 كل ايران

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* ee ed ee oe eee eet eed ore MS re Ce Use (CC MCS ‏ا‎ ‎۱ AC slelele افزايش بيش از حد كودى كمر را كود يشتقى مى نامند افزايش كودى كمر به نحوى ‎ed‏ ا كودى كمر مينامند Image: Kapandyi: Physiology of the Joints

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* Hyper lordosis 9 ۱ ‏و‎ ‎] ‏هت‎ Rt ea ne a ae ce ek Owe! oo lumbar lordosis# ASIS: pubis symphsis: anterior tilt Sacral Angle, Lateral View ene NIC eee Ne ‏مت سس‎ 0 as ‏يي‎ ‎۱ ed Ce ad 0.899, p = 0.000). (ant 6: etd. ‏ال‎ et ol, ‏ری‎

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MUSCLES °Some muscles around the hip and spine become tight and some become weak and stretched, causing an Tight imbalance. balance Weak, i ww Tight ‏اتير‎ Weak

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۰۳۷۱۳ FLEXORSHIP FLEXORS (IN PARTICULAR 0 THE ILIOPSOAS * MUSCLE). * Trunk extensors (erector spinae and quadratus Seem lumborum)

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pore, ond ‏رممممم )راوج‎ OOOO, we ried is DOGO). +. Dhe hatsskous dorsi otaches the pebis ord wall coteriony rotate the pelts, whick couse ‏مس‎ oF he heobor spice (Schram, 6009 ‏جه ,9000 رسد‎ ced 1 DOGO). =

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Weak aodominals Weak gluteus maximus Tight iiopsoas عط دمعتدهوماهه مفصه[ عنسنقه۷1 ‎toate Rena Ca‏ 1۱ ‎muscles(janda, 1968; as cited Chaitow, 2007)‏ When overused and fatigued, postural muscles 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)

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5 Specific postural changes in LCS: anterior pelvic tilt, increased lumbar lordosis, lateral lumbar shift, lateral leg rotation, and knee hyperextension.

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Prevalence of hyperlordosis © (32%) of School children in the Czech Republic (KRATE”NOVA ’ ,Z°EJGLICOVA’, MALY’, FILIPOVA’, 2007). ۶ No sports activities were reported by 20% of children, and these children had significantly higher probability of poor posture than children performing sports. (KRATE* NOVA’ et al., 2007). فراوانى ناهتجارى لوردوز در سه رده سنى نوجوان, جوان و ميان سال 9625.8 ‎CW UI OPT‏ اا 0 ‎of pupils aged 11-13 years in Karaj (Lasjouri and‏ 22.99% © ‎Mirzaei, 2005)‏ © 83.7% of lifting load workers of Behshahr industrial factory (Gharahgouzlou, 2000). سیمرغ و همکاران شیوع هایپر لوردوز را در دانشجویان دختر 34-19 سال 25,49 ‎rc oben‏ 1 » 6

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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).

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Complications of hyperlordosis * Research has shown low-back pain to be predominant among people who have altered lumbar lordosis (curve in the lumbar spine) © NAGMimpairment in the hip flexor muscles and lumbar extensor muscles © Impaired muscle performance due to stretched and weak abdominal muscles © Watson 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). » 06

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Complications of hyperlordosis © 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 structures © LBP 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) » 06

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Lordosis relationship with age, gender and sport 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 the low back. The deviations should becom: pronounced as the child grows older (19,22) ل ا تفت 000 تا مر تس ‎ee Oe (Ole ©00000(.‏ و تا

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Lordosis relationship with age, gender and sport (Sores) Wes hor er Sh mE Ce Si ret) زن 40.26412.19 21 46.92 4 50.342 51.22415.29 4 45.966 caer مرد 34.45 2-4 39.20 2110 41462 6 40.52+10.35 37.37411.21

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Lordosis relationship with age, gender and sport ا ‎ana aa ee‏ ری ا ‎eto MeL Ae vaGl Ole) ®‏ ۱ 1 ‏یساس‎ ‏سره‎ ‎0 ‎Geb et dl, (OO:

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rdosis relationship with age, gender and sport ie ed ee ON ‏رطق ,مهو اس و))موسحت طن ما‎ 3 in * Lords oad hypetordosis were the wort prevdicat cpoeny the ‏مص‎ (90.0%) ard adult (P0.2%) Pounder respectively ‏ا موه(‎ a. OOS). any a y= nC ۳ ۳ on eed ‏رايا عجوب‎ rae ee 6 0١ | ۱

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۱ eee ‏بلمم نجل‎ © © .©96 eee) | ‏ساسم ضما جما حومسم سم وان‎ 0 _ ‎eae okt eee eee‏ 0مك ‎ee CeCe‏ ‎ ‎ ‎ ‎ ‎ ‏مس لو ی با بح.ؤ6جمكإ_و ‎fli oe eae EQ‏ ‎(CHa ieee ie‏

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rdosis relationship with age, gender and sport مهم م۱۳ ‎®C ad "climber's back" was‏ ‎characterized by an increased thoracic‏ ‎kyphosis, increased lumbar lordosis.‏ ‎The climbing ability level was strongly‏ ‎correlated to the postural adaptations.‏ ‎rls LON)‏ ] le rene Weed tee eee ‏جا نوت امي سسكام عه دز تمصي‎ ‏ی‎ ‎0 ‏عا) لدع‎ 0, ۳۵۱ 1, 3

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EO a Re ek ete a ee nee ee eee ec ee a eee ‏ا‎ ‎See ‏مظاك جا عسوي أصد أله مرجت لحب جو 19) صيصب‎ ke eden Oe ence Mem om Oar 000). , Ohta P. , (999).

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عد سس ]| IAD pie —

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Sustained faulty posture and repetitive movement * Dueole thot ie repeated) plaved tao shortewed poviivc, suck uy the topsvas cowplex dori sitter, wall ‏بلصت‎ ‏ممح جا لجنا 001 لجل‎ short (U0 A). © Repetitive movement Ava a. ۳ also affects everyday ١ ‏سس‎ ‎people Waiters and waitresses, much the same as a mother incorrecto carries her child.

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Sustained faulty posture and repetitive movement * Repetive woveweus cod COUP ‎decors ost ert‏ رما روا وا ‎waste yroups wore prececviceniy. Phir‏ ‎lets‏ توح ‎of‏ مايه ‎hea‏ لمم ع ‎ears.‏ اس ما ‎

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leads to id substitution ists (hamstrings) lizers (erector spinae). LE ‏سم‎ Figure 3.5 Altered reciprocal inhibition and synergistic dominance.

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Heavy abdomen: Pregnancy or Obesity ~ As 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). هو مها مارا اج سوب ‎Nhe‏ * ‎exercises redures‏ مصاع يوام م2 ‎sk be cxrober of‏ تسا لم فلوسا لس جيه ‎prevrswes,‏ ‏یی ‎coon went rekdted ws SS back pata‏ تا له رل لعو .مطح حا “اه تلایا ‎COO).‏ ساس ه00) e008). LW

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Curve is greater veight women

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Compensatory mechanism that result from deformity, such as kyphosis ~ Lumbar 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). ۶ 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).

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wearing high-heeled shoes! ee ae tle eg ers mopar hee tyre Oe ee eee ei Be hee vcd ced fee ek focivaica were deoreused. The back ‏لاه ای‎ ‏وه‎ did ant ater heir uvtvities. (DEOO1K, ۵60660۵۵0۵, eral KLOODGCO, (OF). 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).

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eeled shoes 9 errata phe hoewates carer cat ‏مس اج و بت ال ما اما‎ “he kore Blxica ond ache prntorPexica faoreased io hktcherted crat(Gooni WL, Yoo WY’, Wa GO. 199°).

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eeled shoes 1 (Rosie herd arkmara of bere brocht cht miei br ore sree ‏و رن امه ات مه و وه لو لوا ماما را ام‎ keel inckrtion. Clairdly, potas wit buy back pas say be ‏تخل‎ by hicks heel ‏سي محص مووي‎ of ‏طخ مس‎ oro kab ‏متعم )ما‎ ‏روا اس رم ما‎ (98). ۶ 6/۳۵ Prow a chair while weartey high-heeled shoes dewoads siqnificcrat C6 and RP wore ‏وب لاو لو توص ۳۲ .مین‎ bekoviors dur to usr tobdkrae (Kier et ol. COA).

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eeled shoes ‎Rerenior spe oouiy wes observed iPro Plexiza ord‏ و م6 ‎high kell shoes. The probaced‏ وت ی مروت )روط ری ‎wearer oP shoes wal stlet yr buy cad high heeks by teedvickraks wiht backs pot‏ با سوه مس و ماه مالعا رو ‎eon sae Bor their spin oes‏ :(0006 رازه( ‎Olhsy , Ditohacays,‏ ‎ ‎

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A corrective exercise is only as -good as the assessmen ess (NASM)

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Health risk appraisal ۱4۱۹ Vr Ra eae Ce eee eee captor od fer gptoiory ort veer stcedkoy of the tedviduel’s physical meadtioc aed ot dor provider | ee ‏ب بوب‎

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2. 6۳۱۵۲۵۱ ۱۱۲۵-5۲۷۱5

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Questions Yes No بره What is your current occupation? 2 Does your occupation require extended periods of sitting? re extended periods of repetative 3 Does your occupation movements? (If yes, pleas 4 Does your occupation require you to wear shoes with a heel (dress shoes}? 5 Does your occupation cause you anxiety (mental stress)? ۱ eo Te ‏ا اي‎ A Ne 0 ‏ات‎

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MENTAL STRESS Oe eee eee eel oe ee eat a) ee tae eee ee

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ا REPETITIVE MOVEMENTS , a ee en ee de cna cian cake (oye een

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RECREATION Refers to an individual's physical activities outside of the work environment. . For example, many people like to golf, sh nnis, or engage ina NZ Ta inlet Colao RCN Teoma IL Better designing of a program to fit the: ‏إمأعط دع5دع]]5 01 كعم لاغ عاغ مه غطوأكما دعل ألام,م‎ that can lead to muscle imbalances

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‎HOBBIES‏ ت ‎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 ‎

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MEDICAL HISTORY ۱ (eek an ome a a ‏راجت 9( ,ای‎ cena one pce ‏بوه مج‎

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Past Injuries ON eee ne nea eee oe]

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Past Surgeries ‎eer Re UT Cle els hy‏ ات بل فلت بات ‎and may have similar effects to those of an‏ ‏۳ بو ایا ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎Gr‏ اللا ل ال اا نت9 ات یر ‎Appendectomy (cutting thr ۳۹‏ ‎1 ‎ ‎

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Static postural assessment: ۱۱ جمعخصام عاط" ب عجانذ3ا) ” ‎SEA A‏ ا ۱9 اه وت وتا ۳ * . 7. Levent (eC mee.

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* Static postural ‏5و2‎ 66506۳۱ LOTERGL O1EO ee nea ce atone Relat et ee cures cee oe Od enter nea eens Ce ea eee ‏و‎ Gee eee 0

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Movement assessment See Racer (Oh Ga ext oub eC EUR sel Ke leex NC Om CeCe NC Od Ne) 4100 a eae eee ne ae ee ee ee وت معتهممما كلقط معطلالا ‎muscles that are underactive around a join’‏ terms “overactive” and “underactive” are usec Pav a Roe mute acne on mate necessarily to its own normal functional capacity. At altered length-tension relationships or altered reciprocal ir three) (10). This results in an altered recruitment strate T= Clee uu co lesen ‏کف ری‎ the use of the kinetic chain checkpoints to 5 detect compensation in joint motion, inference: as impairments can be made (1-3,9,10).

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Movement assessment: O. Proasiticcad ‏و‎ ‎0 (Cris) fon seo Eyer

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Transitional Movements Assessment Dee 200 eed woovewed wih a cham i ooe's base oP support (DBGO). ۱۹ ra Se teen eee ae ad ‏موی تسپ‎ 9 ce ee a ‏سم‎ eee eee eee tee ee ‏ا ل‎ cana

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0002 CBSGEGGOEDT Overhead Squat Position * PROCEDORE 0 ‏تس کی‎ ‏الي سیم‎ ©. Cows Puy ‏و وت‎ ‏ل ا‎ 3-57 oe

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—————— LL = &5X > * Transitional Movements ‏شظيضش(5”‎ ‎Assessment 0 5 ما۱۳ و کت لصتم تست لصا وگ Probable Probable Underactive Overactive Muscles Mucele< Hip Flexor Gluteus Maximus dct eh Complex Hamstrings Erector Spinae _ Intrinsic Core Stabilizers Latissimus Dorsi

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MODIFICATIONS TO THE OVERHEAD SQUAT ASSESSMENT Heels Elevated 1 1 te sireick (or extecsbity) recnied eed eg eae ed een eee ee ee eee 0 0 ۰

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bee ae ee ee ere ‏ل ا‎ SQUAT ASSESSMENT ‎a ee oe‏ سا ‎PRN aN rp ee le ‏ل ل يمي‎ ‏ا يي ل‎ ‏ل ين‎ eR ‏يي‎ ‏ا ا ا‎ a ‏مت‎ Roa ‎ ‎0

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* Transitional Movements Assessment "0 Na A a eS Ree Cen eA ai Ee ae RO De eC aac ast ROAM ke ee Pa ee oe ee 2 0 ‏ل ل‎ ea) oe See ae Push-Ups Assessment, Compensations Probable veractve Probable Muscles Underacte Muscles ErecorSomae tsi Coe Stes Hp Fos Gites Maxis eee

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* Transitional Movements Assessment PULLING ASSESSMENT: STANDING ROWS ‏رفری ریا‎ CRC 000 ‏مرچ‎ i acavana Oe er ae ee ey Probable Probable OveractiveMuscles Underactive Muscles Hip Flexors, Brector Intrinsic Core Spinae Stabilizers Low Back Arches EE

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* Transitional Movements Assessment 6 ما« »> . stand wk Peet shouder-utdis wat ond pee potty Porward. ©. Choose a deobbel weight which ‏الق‎ vac perPora (0 repetiows vowPorkby.

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* Transitional Movements Assessment * STANDING OVERHEAD DUMBBELL PRESS Standing Overhead Dumbbell Press Assessment Movement 9» Probable Overactive Muscles Probable Underactive Muscles Hip Flexors Intrinsic Core Broctor Spinae Stabilizers Latissimus Dorsi Gluteus Maximus tne arms bisect tne ears ea Ee wea oe

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shoulder flexion test * PROCEOORE ee Ld 8201706۶ م۱

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DYNAMIC MOVEMENT ASSESSMENTS: Gait assessment ‎Tee 0‏ از لت مت وه مه موه و چم ون ‎

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0 تفص لك 0 Treadmill Walking Assessment Compensations Probable Overactive Muscles Probable Underactive Muscles Hip Flxoe Complex luteus Maximus Intrinsic Cone Stabilizers Hastings ا ‎ae‏ وه وه سس مت توص هت تست ۱3 836) 87665

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Assessment Implementation Options Pe ee el ee ao ol ai Depending on one’s physical capabilities, choose تا ای وتات یت perform safely ‎that take‏ د ‎lala‏ 45-001۳۴۷۱۵ 10 -30 وط۲ع۵۴۴ ‎a NET Tc‏ سا انلیا ا ‎ea ate‏ ‎findings can be a way to help generat‏ ا ا للا ‎ ‎ ‎ ‎

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لفل ف امف 0006 ١ Compensation Potential ROM Observation Low back arches Decreased hip extension Decreased shoulder flexion Decreased hip internal rotation 651) 2008111, 665656655002001“ Compensation One or More of the Following Muscles Test “Weak” Low back arches Gluteus maximus, hamstring complex, or abdominal complex

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Gee OOM coe RoR a a ‏ا‎ ‏بر لاس با سم‎ 0 ‎tae at nas‏ كنا

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ا ‎aa‏ ال يي ل يي ی مت جما ف جامصا وباسجامات با اس و بت زب هروا ‎ed‏ * er en ne ‏ماسب‎ ‎RCs ‏ا‎ ‎eee Retro ene eats ead : ‏ا سي سي مایت ری‎ 0000 ‏ل‎ ete Seed

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تلبت یرب تیب ادا ‎Hip Extension Assessment, Measurement‏

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جما , (لاسسه ‎ee ae ee a Oe‏ * الجمصاا صممصص جد جد لحت بوطلاصيم ‎See ata‏ وف ا ا ل ال الي ل 7 ا الا Od ed eee eed ne Se en

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Shoulder Flexion Assessment, Measurement ° Ahokday he leds are tt exterod rokion, place he tucob oo te ferd border of the sap ut wd pestel flex he shoudler ul excesee srapder wovewed & Pet or the first reset barter & wied.

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Strength assessment Table 8.2 Numerical Score Level of Strength Norm (uses oth Weak (little to no actis مت مسقم صل .(©,6,6) اسجيجمي لممسمي "ا ب قاد بطم مسومم لانن مهم لجمجو رمات ن ”ابر ‎SIRO‏ ‎ee ce oe ss‏ ا ل ا ل 00 ‎eames cnet‏ ا ا ا 0 Pete tate ‏معط‎ )6( درم + 6

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1203 ٩601 Step 2 lace muscle in shortened position, or to point of joint» Place muscle in midrange position and retest compensation strength Ask client to hold that position while applying pressure, * If muscle strength is normal in midrange, Gradually increase pressure. there may be opposing m Client's strength is graded joint hypomobility—inhibit and lengthen, If client can hold the position without compensation If the muscle is weak or compensates in mid- then the muscle is noted as strong. range position, the muscle is likely weak— If the muscle is weak or compensates, move to step 2. reactivate and reintegrale.

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0 0010101: 0000 ‏نات جا ناذا , تاذل قا دان‎ 0010:0000 +0 ‏0ك‎ ee eee een nee a os Te Cone oe ee RC Cel Ce POM oee even tone ter oot eer tele es ‏ب‎ 0 ee ene oer unten eo) a eee

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0 ا ل ل ل ا غ2 | 1 eS OR ‏ل ا‎ Medial Hamstrings Assessment, Execution

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01۵۵۵ ۵۷۵ ۱ ۱ 0 Oe MCs Ae ec

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۱ Ne eee CSU CR eo a eal oo) 1 Oo er ted ee alec cad a 1۱ ere Concent efor an ene To [See ‏مسجم المحجمهك تعات نهم خيجط ستساة)‎ he Ars

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8 ‏اک‎ ‎[۱ Cre (atric 0 CnC en eel Choon Pree Tet Ne ed ne oe ea eee Rn eee NC nce oe aed a crete) Teeny tet ner Rectus Abdominis Assessment, Execution

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۱ ‏کر کر‎ Ore Cates crane ae Pee a Ce ee aed er ee ‏ا‎ ‎Leer ‏ا ا‎ ed eed cee Oc Uae rw Oblique Abdominals Assessment, Execution

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0 CON ead Oe a ec FON od cone BORO eae eto eed Cc ee a Mer even near oot coer teres ON Ca are RO ered cece od ee oe Gluteus Medius Assessment, Execution ] this tr sich exterad roktioa ‏سل لو‎ + Bpply yrakd oad 0 to te kierd epee oP he buver ky het cbove the ack tet ta bor epee oP ‏سا‎ ده لت

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_-— CORRECTIVE-EXERC! 3 CONTINUUM ‏عم‎ انان ی یب دنت تا ‎Integrate‏ اس Lengthening Activation techniques techniques Static Positional stretching isometrics Neuromuscular \solated stretching strengthening

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:Self-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. ٠ ‏وه‎

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© 2. To influence the autonomic nervous system ©The 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. + 80

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ctivation * Activation refers to the stimulation (or reeducation) of underactive myofascial tissue. ® Isolated 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.

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6 ‏مصمناتعو۴‎ 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.

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۱7 rl Integration © Integration 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 MUS Che sitet sterner ‏ص دعاس سل‎

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® 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; 2002 © Intermuscular coordination: the ability of the neuromuscular system to allow all muscles to work together with proper activation and timing between them.

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۲: 12 1-6 (۲ O : ۳-۲ (۱ © KEY APPLICATION POINTS FOR-SELF-MYOFASCIAL RELEASE : °. Outetctes proper posturd ‏وم اب سم‎ GOR, * 0, ‏موه(‎ | drawtecte ameuver ot dl thoes to provide stdbliy to te keobo-pebic-hip powrlex, 9. The cleat way we hie pr her pxirewties to dlr the amount oF wet oo he treckoedt ord, Roll the device shy over the treokvedt aed to decrease the risk oP Purher tose exctoicc. ©. Rekoe oad wot tchied up while Wworkteg oo om aed. Teosioa ta he true betay trevied wil ‏اج‎ ‎he roler Prow pevetrotieg hip the deeper kyery oP eo tour. ©. Pause te rolog wien per poPl afer voto “reese” ts Pel ta he aed pr the poto subsides wad the tome spew (rok OO sevouds wi waxed pds eras ond OO sevoads Por bower pas tberoure) (©).

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Corrective Exercises for Hyperlordosis Daily (unless specified 1 ‏وله‎ Hold tender spots for 30 to 90 seconds otherwise] depending on intensity of application Self-Myofascial Release (دارمط۴۵ مساع0) ۴۱۵0۲ ون

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‎od‏ او ایا رای ‎ ‎Daily (unless specified n/a 1-4 20- to 30-seconds hold otherwise} ‎60-seconds hold for older patients (265 years) ‎Example Static Stretches: Static Kneeling Hip Flexor Stretch ‎ ‎ ‎ ‎

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Static stretches Erector Spinae 00۲5 وباطاکوناها

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Rata eae Gate epetition | Contraction: 7 to 15 seconds | Stretch: 20-30 seconds | Intensity: submaximal, approximately 20-25% of maximal contraction —_— +ممواع مزيا Daily (unless specified otherwise)

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ACUTE VARIABLES FOR ISOLATED STRENGTHENING Frequency Sets Repetitions Duration of Rep 3-5 days per week 1-2 10-15 2 seconds isometric hold at end-range and 4 seconds eccentric Step 3: Activation Key activation exercises via isolated strengthening exercises and/or positional isometrics include the gluteus maximus and abdominal Standing gluteus maximus, [J Standing gluteus maximus, ۳ ‏ون‎ es ۹

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۱ Cld CCl

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Example Isolated Strengthening Exercises: Abdominals/Intrinsic Core Stabilizers Quadruped arm/opposite leg raise, start ‏و۱۳۱‎ ue see hee iu 0 واة رت

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Frequency Sets Repetitions Duration of Rep 6, 50%, 75%, rest between | As needed 1 4 4-second isometric holds at and 100% MVC (2 second contractions)

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ACUTE VARIABLES FOR INTEGRATED DYNAMIC MOVEMENT 3-5 days per week 1-3 10-15 Slow and controlled © Step 4: Integration © An integration exercise that could be implemented for this compensation could be a ball squat to overhead press. CURT Take) Ball Squat to Overhead ‏(طعتصاع) ووعمم لت ترا‎

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متسه :۶ موی ۰ © 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.

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© There 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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© 1. Magee, David J. (2006). Orthopedic Physical Assessment (4™ ed.). saunders elsevier: Philadephia © 2. National Academy of Sports Medicine. (2011). NASM Essentials of Corrective Exercise Training. Baltimore: Lippincott Williams & Wilkins. © 3. Gross, Jeffrey M; Fetto, Joseph, and Rosen, Elaine. (2009). Musculoskeletal Examination (3" ed.). Wiley-Blackwell. © 4. Lowe, Whitney W. (2009). Orthopedic Massage: Theory and techniques (2° ed.). Mosby Elsevier. © 5. Youdas, James W; Garrett, Tom R; Egan,Kathleen S; Therneau,Terry M. Lumbar Lordosis and Pelvic Inclination in Adults With Chronic Low Back Pain. Physical Therapy . Volume 80 . Number 3 . March 2000. ©» 6. Patel, Kesh. (2005). Corrective Exercise: A Practical Approach. London: Hodder Arnold.

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سنا © 7. Borg-Stein J, Dugan S, Gruber J. (2005). Musculoskeletal aspects of pregnancy. Am J Phys Med Rehabil;84. © 8, Min H. Kima, Chung H. Yi, Won G. Yoo c, Bo R. Choi. EMG and kinematics analysis of the trunk and lower extremity during the sit-to- stand task while wearing shoes with different heel heights in healthy young women. Human Movement Science xxx (2011) xxx-xxx. © 9, Malgorzata Grabara, Andrzej Hadzik, (). Postural variables in girls practicing volleyball. Biomedical Human Kinetics 2009; 1, 67 - 71. © 10. Editoral Borad. Performance Conditioning Volleyball 2006; (13):3. © 11. Nissinen M. Spinal posture during pubertal growth. Acta Pediatrica 2008; 84(3): 308-12. © 12. Bahrami M, Farhadi A. The investigation of the incidence and causes of deformities in upper and lower extremities of teenagers’ boy and girl between 11-15 year-old of Lorestan province. Journal of Scientific Research of Lorestan University of Medical Sciences 2006; 8(4).

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سس سس سوم سس سس 13. Vanzi OA, Chih LY, Meves R, Caffaro MASC, Pellegrini JH. Thoracic kyphosis and hamstring: an aesthetic functional correlation. ACTA Bars 2007; 15(2): 93-6. 14. Nourbakhsh MR, Moussavi SJ, Salavati M. Effects of lifestyle anc work-related physical activity on the degree of lumbar lordosis and chronic low back pain in Middle East population. Journal of Spine Disorders 2002; 14(4): 283-92. 15. Mac-thiong JM, Lebelle H, Charleboise M, Hout MP, De Guise JA. Sagital plane analysis of the spine and pelvis in adolescent idiopathic scoliosis according to the coronal cueve type. Spine 2003. 28(13): 1404-9. 16. JANA KRATE “NOVA ‘, KRISTY ‘NA Z “EJGLICOVA ’, MAREK MALY ’, VE “RA FILIPOVA . Prevalence and Risk Factors of PoorPosture in School Children in the Czech Republic. Journal of School Health d March 2007, Vol. 77, No. 3.

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© 17. Nazarian AB, Daneshjoo AH, Ghorbani L, Ghaedi H. The prevalence of lordotic and kyphotic deformities among different age groups. Research in Rehabilitation Science 2009; (5)1. © 18. Cintia Zucareli Pinto Ribeiro, Paula Marie Hanai Akashi, Isabel de Camargo Neves Saccol and André Pedrinelli. Relationship between postural changes and injuries of the locomotor system in indoor soccer athletes, Rev Bras Med Esporte 2003; (9)2 . © 19. Mika, Anna; Oleksy, Lukasz; Edyta, Mikotajczyk; Marchewka, Anna. Evaluation of the influence of low and high heel shoes on erector spine muscle bioelectrical activity assessed at baseline and during movement. Medical Rehabilitation 2009, 13 (3), 1-10. © 20. Hainline B. Low back pain in pregnancy. Adv Neurol; 1994. 64: 65-76.

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© 21. Kargarfard M, Mahdavinezhad R.,Ghasemi Gh.A.,Rouzbahani R.,Ghias majid, Mahdavi Jafari Z.,Dehghani Mahdi. Assessment of Spinal Curvature in Isfahan University Students. Journal of Isfahan Medical School (i.u.m.s) 2010; 27(102):762-776. © 22. Tsai, Li; Wredmark, Torsten; Spinal Posture, Sagittal Mobility, and Subjective Rating of Back Problems in Former Female Elite Gymnasts. Lippincott-Raven Publishers. © 23. VL MURRIE, H WILSON, DCR, W HOLLINGWORTH, NM ANTOUN, and A K DIXON. Supportive cushions produce no practical reduction in lumbar lordosis. The British Journal of Radiology, 75 (2002), 536-538. © 24. C. KISNER, and L. A. COLBY.(2007).Therapeutic Exercise: Foundations and Techniques (5" ed.). F. Philadelphia: F.A. Davis Company.

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0 © 25. Katherine K. Whitcome, LizaJ. Shapiro, Daniel E. Lieberman1 Fetal load and the evolution of lumbar lordosis in bipedal hominins. Vol 450] 13 December 2007| doi:10.1038/nature06342. © 26. Fahrni, 1976; Finneson, 1981; Kendall, 1983; McKenzie, 1981; Wiles, P., and R. Sweetnam,1965( ©27. Gharahgouzlou, F. Investigating the prevalence of upper extermities postural anomalies in lifting load workers in behshahr industrial factory. Behbood, summer 2000; 4(1):58-64. © 28. Lasjouri Gh.,Mirzaei B. The prevalence of postural deformities in pupils aged 11-13 and their relationship with age, height and weight factors. research on sport science spring 2005; 3(6):123- 133. 29. Willner S, Johnson B. Thoracic kyphosis and lumbar lordosis during the growth period in children. Acta Paediatr Scand. 1983 Nov;72(6):873-8.

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© 30. Youdas JW, Hollman JH, Krause DA. The effects of gender, age, and body mass index on standing lumbar curvature in persons without current low back pain. Physiother Theory Pract. 2006 Nov;22(5):229-37. © 31. Milne, J.S.1; Lauder, I.J.cAge effects in kyphosis and lordosis in adults. Annals of Human Biology, Volume 1, Number 3, Number 3/July 1974 , pp. 327-337(11). © 32. A Review on Postural Realignment and its Muscular and Neural Components Young, 2001) © 33. Watson, A.W.S. (1983). Posture and participation in sport. Journal of Sports Medicine and Physical Fitness, 23: 231-239.

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#34. Forster R, Penka G, Bésl T, Schi . Climber's back-form and mobility of the thoracolumbar spine leading to postural adaptations in male high ability rock climbers. Int J Sports Med. 2009 Jan;30(1):53-9. Epub 2008 Jul 23. #35. Neville V, Folland JP. The epidemiology and aetiology of injuries in sailing. Sports Med. 2009;39(2):129-45 doi: 10.2165/00007256-200939020- 00003. "36. Wojtys EM, Ashton-Miller JA, Huston LJ, Moga PJ. The association between athletic training time and the sagittal curvature of the immature spine. Am J Sports Med. 2000 Jul-Aug;28(4):490-8. 587. Uetake T, Ohtsuki F. Sagittal configuration of spinal curvature line in sportsmen using Moire technique. Okajimas Folia Anat Jpn. 1993 Aug;70(2- 3):91-103.

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© 38. Lee CS, Oh WH, Chung Ss, Lee SG, Lee JY. Analysis of the Sagittal Alignment of Normal Spines. © 39. Opila, K.A. Gender and somatotype differences in postural alignment: Response to high-heeled shoes and simulated weight gain. Clinical Biomechanics . Volume 3, Issue 3, August 1988, Pages 145-152. ® 40. Franklin ME, Chenier TC, Brauninger L, Cook H, Harris S. Effect of positive heel inclination on posture. J Orthop Sports Phys Ther. 1995 Feb;21(2):94-9. © 41. Widhe T. Spine: posture, mobility and pain. A longitudinal study from childhood to adolescence. Eur Spine J. 2001 Apr;10(2):118-23.

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42. Pelker RP, Gage JR. The correlation of idiopathic lumbar scoliosis and lumbar lordosis. Clin Orthop Relat Res. 1982 Mar;(163):199-201. 43. Bendix, tom md; sorensen, steen schou; klausen, klaus. lumbar curve, trunk muscles, and line of gravity with different heel heights. march 1984 - volume 9 - issue 2 . lippincott-raven publishers. ©44. Song SH, Yoo JY, Ha SB. Comparison of Gait Analysis Using High- heeled Shoes and High-forefoot Shoes. J Korean Acad Rehabil Med 21(5):1003-1009 Oct 1997. 45. Brent S. Russell, The effect of high-heeled shoes on lumbar lordosis: a narrative review and discussion of the disconnect between Internet content and peer-reviewed literature. Volume 9, Issue 4, Pages 166-173 (December 2010) gournal of chiropractic medicine.

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کاشانیان اکبری و علیزاده. ورزش بر میزان کمر درد * و قوس کمری زنان حامله. دانشگاه علوم پزشکی ایران؛ 45-40 :)69(16 ۰ دانشمندی, علیزاده و قراخانلوءحرکات اصلاحی» سمت: 1387 ۰ ‎elt.‏ حسن جزوه منتشر بشله ن.کمالی؛ م. حاجی احمدی, م. کشانی و . محبوبی. تاثیر جنس و چاقی روی دانشگاه علوم پزشکی بابل» ۱۳۸۲؛ 0۳(0: ۲۳-۱۸.اندازه لوردوز کمر ‎ ‎

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• 1 Advanced Corrective Exercises HYPER LORDOSIS Yousef yarahmadi • 2 o o o Content: Introduction o Normal lordosis o Hyperlordosis o Related muscles o Prevalence of lordosis o Complications of lordosis o Lordosis relationship with age, gender and sports o Common cuases Assessment and Diagnosis o History o Static postrual assessment o Movement assessment o Goniometric Assessment o Strength Assessment Corrective exercise program o Inhibition o Lengthening o Activation o Integration • 3 Normal lumbar lordosis Lordosis: 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 Normal lumbar lordosis • Normal lumbosacral angle is 140° • Normal lumbar lordotic curve is about the 50° normal sacral angle is 30 • Pelvic angle is 30°(Magee, 2006). • The 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). • Picture from magee • 5 Normal lumbar lordosis کمالی میانگین لوردوز کامل کمر را در افراد 20تا 70 سال شهرستان بابل 54.5±11.5گزارش کرده .است ()1382 6 • Normal lumbar lordosis تعيين نورم كايفوز و لوردوز جامعه ايران.پژوهشكده تربيت بدني رضا رجبی(مسئولطرح(• 1387, جنوب شمال غرب شرق مرکز زن 14.40±42 .32 14.56±48 .79 12.24±55 .10 12.79±46 .14 15.30±43. 22 مرد 10.54±38 .65 9.71±37. 68 12.23±35 .92 12.8±43. 91 11.40±36. 94 کل ایران 7 • زن 14.65±46.99 مرد 11.71±38.60 Hyper lordosis • 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 )1387 ، علیزاده و قراخانلو،(دانشمندی • Low back arches forward, creating an in-creased forward curve in the low back.(Cailliet, R, 1988; as cited in Therapeutic Exercise) افزایش گودی کمر به نحوی که از حد طبیعی بیشتر باشد را ،گودی کمر مینامند (دانشمندی )جزوه. • 8 • Hyper lordosis • 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). • 9 MUSCLES  Some muscles around the hip and spine become tight and some become weak and stretched, causing an imbalance. • 1 0 • Tight muscles: • HIP FLEXORSHIP FLEXORS (IN PARTICULAR THE ILIOPSOAS MUSCLE). • Trunk extensors (erector spinae and quadratus lumborum) • 11 • Tight muscles: • 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). • 1 2 • weak muscles: • 1 3 Lower crossed syndrome Vladimir Janda categorizes the body’s muscles: postural or phasic muscles(janda, 1968; as cited Chaitow, 2007) When overused and fatigued, postural muscles 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) • 14 lower crossed syndrome  Specific postural changes in LCS: anterior pelvic tilt, increased lumbar lordosis, lateral lumbar shift, lateral leg rotation, and knee hyperextension. • 15 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). %25.8 جوان و میان سال،فراوانی^ ناهنجاری لوردوز در سه رده سنی^ نوجوان )1388 ، قربانی^ و قایدی، دانش^جو، است (نظریان، گ^زارش شده.  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). 25.49 سال34-19 سیمرغ و همکاران شیوع هایپر لوردوز را در دانشجویان دختر )1338( گزارش کردند. • 16 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 Complications of hyperlordosis • Research has shown low-back pain to be predominant among people who have altered lumbar lordosis (curve in the lumbar spine) Mobility (NASM).impairment in the hip flexor muscles and lumbar extensor muscles Impaired muscle performance due to stretched and weak abdominal muscles Watson reported that 67% of players with lordosis suffered muscular injuries, while in the group without postural changes, only 36% suffered the same injury (1995). • 18 Complications of hyperlordosis 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 structures LBP 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) • 19 Lordosis relationship with age, gender and sport   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). • In 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 Lordosis relationship with age, ‏gender and sport تعيين نورم كايفوز و لوردوز جامعه ايران (رجبی)1387 ، سن 21 • زن مرد -14 40.26±12.19 34.45±11.24 15-24 46.92±12.01 39.20±11.80 25-44 50.34±14.04 41.46±12.56 45-64 51.22±15.29 40.52±10.35 +64 45.96±16.54 37.37±11.21 Lordosis relationship with age, gender and sport • Farhadi and Bahrami reported the prevalence of lordosis: 6.89% in girl and 9.75% boy (2006). • The average of lumbar lordosis in men and women decreases by aging (Nissinen, 2008; Kamali, 2003; Gelb et al, 1995). • Zuluaga et al. reported that lumbar lordosis reaches its highest degree(55°) in adolscence (13-19) and decreases by aging (1995). • . Lordosis was absent in an increasingly large proportion of men and women as age rose above 60 years.(Milne, Lauder, 1974). • 22 ordosis relationship with age, gender and sport • 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). • 23 ordosis relationship with age, gender and sport • 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). . 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). • 24 ordosis relationship with age, gender and sport 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). There was a significantly higher incidence of lordosis in the soccer and football players when compared to the other sportsmen (Young, 2001) • 25 ordosis relationship with age, gender and sport Watson observed that only 26.5% of soccer, rugby and American football players investigated had their lumbar spine 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). • 26 ordosis relationship with age, gender and sport Lordosis angle was also greater in SC versus RC and "climber's 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). • 27 ordosis relationship with age, gender and sport • 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). • 28 COMMON CAUSES • 2 9 Sustained faulty posture and repetitive movement • 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).  Repetitive movement also affects everyday people Waiters and waitresses, much the same as a mother carries her child. •3 0 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. • 3 1 weak abdominal muscles with tight muscles, especially hip flexors or lumbar extensors A 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). •3 2 Heavy abdomen: Pregnancy or Obesity  As 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). •3 3 Heavy abdomen: Pregnancy or obesity • Lumbar lordosis happens due to increase in anterior mass by increasement in mother’s wieght, fetus and breast (Hainline, 1994).  Kamali et al. reporetd Lumbar curve is greater in over-weight women (2004). •3 4 Compensatory mechanism that result from deformity, such as kyphosis   Lumbar 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). •3 5 wearing high-heeled shoes!! • 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). 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). •3 6 Wearing high-heeled shoes!! • 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). •3 7 Wearing high-heeled shoes!! • 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). •3 8 Wearing high-heeled shoes!! • 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). 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). •3 9 • Assessment: A corrective exercise program is only as .good as the assessment process (NASM) • 40 • History: Health risk appraisal 1. 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 . • 41 • History: 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. • 42 • History: 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. • 43 • History: MENTAL STRESS Mental stress or anxiety can lead to a dysfunctional breathing pattern that can further lead to postural distortion and kinetic chain dysfunction. • 44 • History: REPETITIVE MOVEMENTS Repetitive movements can create a pattern overload to muscles and joints that may lead to tissue trauma and eventually kinetic chain dysfunction (2). • 45 • History: RECREATION Refers 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 time .Better 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 • 46 • History: 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 • 47 • History: MEDICAL HISTORY • The 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. • 48 • History: 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). • 49 • History: 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 paradigm • 50 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. Shoulders • 5. Head/Cervical spine (NASM) • • • • • 51 • Static postural assessment • 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). • 52 Movement assessment • THE 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 • Thorough altered movement pattern (1,2,6,7,10,11) 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 Movement assessment: A. Transitional movement assessment: B. Dynamic movement assessment: 1. Gait assessment 1. Overhead squat 2.Pressing 3.Pushing • 54 Transitional Movements Assessment • Transitional movement assessments are assessments that involve movement without a change in one’s base of support (NASM). Reaching downward to pick up something (spinal flexion), 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 an extended position with arms overhead (such as dribbling a basketball, then shooting). Set up drills that replicate the(kisner). • 55 • Transitional Movements Assessment OVERHEAD SQUAT ASSESSMENT • PROCEDURE 1.Feet shoulder-width apart and pointed straight ahead. 2. Elbows fully extended. The upper arm should bisect the torso. • 56 • Transitional Movements Assessment • 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. • 57 • Transitional Movements Assessment 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. • 58 • Transitional Movements Assessment MODIFICATIONS TO THE OVERHEAD SQUAT ASSESSMENT 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. • 59 • Transitional Movements Assessment Pushing assessment: push-up • PROCEDURE • 1. 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. • 60 • Transitional Movements Assessment PULLING ASSESSMENT: STANDING ROWS PROCEDURE 1. Stand in a staggered stance with the toes pointing forward. 2. Pull handles toward the body and return to the starting position. 3. Perform 10 repetitions in a controlled fashion using a 2-0-2 tempo. • 61 • Transitional Movements Assessment PRESSING ASSESSMENT: STANDING OVERHEAD DUMBBELL PRESS • PROCEDURE 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. • 62 • Transitional Movements Assessment PRESSING ASSESSMENT: STANDING OVERHEAD DUMBBELL PRESS Movement press 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 Perform 10 repetitions in a controlled .2 .fashion using a 2-0-2 tempo • 63 • Transitional Movements Assessment • PROCEDURE shoulder ﬂexion test • elbows extended with thumbs up • touch the thumbs against the wall with no compensatory movements such as increasing lumbar lordosis. • 64 Dynamic Movement Assessment 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. • 65 Dynamic Movement Assessment • PURPOSE: To assess one’s dynamic posture during ambulation. • PROCEDURE • Walking 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. • 66 Assessment Implementation Options All of these assessments can become one’s first workout • Depending 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 GONIOMETRIC ASSESSMENT • continuum STRENGTH ASSESSMENT • 68 GONIOMETRIC ASSESSMENT If 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 • Goniometric Assessment • 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 i • 70 • Goniometric Assessment • HIP EXTENSION • 1. Joint motion:a. Extension of iliofemoral joint • 2. Muscles and tissues: Psoas, iliacus, rectus femoris, TFL, sartoriusb. Adductor complex, anterior hip capsule • 3. Antagonists potentially underactive if ROM is limited: a. Gluteus maximus, gluteus medius (posterior ﬁ bers) b. Hamstring complex, adductor magnus • 4. Normal Value (22): 0–10 degrees • 71 • Goniometric Assessment • pelvis off the table passively allow the hip to extend until ﬁrst restriction or compensation (anterior tilting of the • opposite hip is ﬂexed to assist in ﬂattening the low back against the table pelvis or low back arching off the table). • knee of the test leg should be ﬂexed to almost 90 degrees • 72 • Goniometric Assessment • :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. • 73 • Goniometric Assessment • SHOULDER FLEXION 1. Joint motion: a. Flexion of shoulder complex 2. 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 deltoid b. Lower and middle trapezius, rhomboids 4. Normal Value (22): 160 degrees • 74 • Goniometric assessment • 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. • 75 Strength assessment • Overactivity 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 Strength Assessment • 77 Strength Assessment • MEDIAL HAMSTRING COMPLEX: SEMITENDONSUS, AND SEMIMEMBRANOSUS 1. Joint position being tested:a. Knee ﬂexionb. Tibial internal rotation 2. Muscles being assessed:a. Semimembranosus, semitendinosusb. Gastrocnemius, popliteus, gracilis, sartorius plantaris 3. Potentially overactive muscles if strength is limited:a. Quadriceps complex (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius)b. Biceps femoris • 78 Strength knee ﬂexed approximately 50 to 70 degrees. Assessment 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. • • • • • 79 Strength Assessment • • • • • BICEPS FEMORIS 1. Joint position: a. Knee ﬂexion b. Tibial external rotation 2. Muscles: a. Biceps femorisb. Gastrocnemius, plantaris 3. Potentially overactive muscles if strength is limited:a. Quadriceps complex (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius)b. Medial hamstring complex, popliteus, gracilis, sartoriu • 80 • 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 • GLUTEUS MAXIMUS • 1. Joint position: a. Hip extension, external rotation, and abduction • 2. 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 • • • • RECTUS ABDOMINIS 1. Joint:a. Spinal (trunk) ﬂexion 2. Muscles:a. Rectus abdominis b. External obliques, internal obliques 3. 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 • • • • OBLIQUE ABDOMINALS: EXTERNAL AND INTERNAL OBLIQUE 1. Joint position:a. Spinal (trunk) ﬂexion and rotation 2. Muscles: a. External obliques, internal obliques b. Rectus abdominis 3. 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 • LATISSIMUS DORSI • 1. Joint position:a. Shoulder extension, adduction, and internal rotation • 2. Muscles being assessed:a. Latissimus dorsib. Posterior deltoid, teres major, triceps brachii (long head), lower trapezius, rhom-boids, mid-trapezius • 3. 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 GLUTEUS MEDIUS 1. Joint position: a. Hip extension, external rotation, and abduction 2. Muscles being assessed:a. Gluteus mediusb. Gluteus minimus, gluteus maximus (upper ﬁ bers), TFL 3. 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 • 87 CORRECTIVE EXERCISE CONTINUUM (NASM) program88 • Inhibition :Self-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 Inhibition 2. To inﬂuence the autonomic nervous system The 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. • 90 Activation • Activation refers to the stimulation (or reeducation) of underactive myofascial tissue. Isolated 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. • 91 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 Integration Integration 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 • to reestablish postural control and decrease the risk of injury muscles. • 93 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; 2002 Intermuscular coordination: the ability of the neuromuscular system to allow all muscles to work together with proper activation and timing between them. • 94 CORRECTIVE EXERCISES FOR HYPERLORDOSIS  KEY 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). •9 5 Corrective Exercises for Hyperlordosis  Step 1: Inhibit  Key regions to inhibit via foam rolling include the hip ﬂexor complex (rectus femoris) and latissimus dorsi. •9 6 Step 2: Lengthen  Key lengthening exercises via static and/or neuromuscular stretches include the hip ﬂexor complex, erector spinae, and latissimus dorsi. •9 7 • Step 2: Lengthen Static stretches •9 8 • Step 2: Lengthen •9 9 Step 3: Activation  Key activation exercises via isolated strengthening exercises and/or positional isometrics include the gluteus maximus and abdominal complex. •1 0 0 • Step 3: Activation Isolated strengthening •1 0 • Step 3: Activation •1 0 • Step 3: Activation •1 0 • Step 4: Integration Step 4: Integration  An integration exercise that could be implemented for this compensation could be a ball squat to overhead press. •1 0 • Step 4: Integration  This exercise will help teach proper hip hinging while maintaining proper lumbopelvic 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. • 1 0 5 CONCLUSION •1 0 6 There 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. References  1. Magee, David J. (2006). •1 0 7 Orthopedic Physical Assessment (4TH ed.). saunders elsevier: Philadephia  2. National Academy of Sports Medicine. (2011). 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Evaluation of the influence of low and high heel shoes on erector spine muscle bioelectrical activity assessed at baseline and during movement. Medical Rehabilitation 2009, 13 (3), 1-10.  20. Hainline B. Low back pain in pregnancy. Adv Neurol; 1994. 64: 65-76.  21. Kargarfard M, •1 1 1 Mahdavinezhad R.,Ghasemi Gh.A.,Rouzbahani R.,Ghias majid,Mahdavi Jafari Z.,Dehghani Mahdi. Assessment of Spinal Curvature in Isfahan University Students. Journal of Isfahan Medical School (i.u.m.s) 2010; 27(102):762-776.  22. Tsai, Li; Wredmark, Torsten; Spinal Posture, Sagittal Mobility, and Subjective Rating of Back Problems in Former Female Elite Gymnasts. Lippincott-Raven Publishers.  23. V L MURRIE, H WILSON, DCR, W HOLLINGWORTH, N M ANTOUN, and A K DIXON. Supportive cushions produce no practical reduction in lumbar lordosis. The British Journal of Radiology, 75 (2002), 536–538.  24. C. KISNER, and L. A. COLBY.(2007).Therapeutic Exercise: Foundations and Techniques (5th ed.). F. 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Bendix, tom md; sørensen, steen schou; klausen, klaus. lumbar curve, trunk muscles, and line of gravity with different heel heights. march 1984 - volume 9 - issue 2 . lippincott-raven publishers. 44. Song SH, Yoo JY, Ha SB. Comparison of Gait Analysis Using Highheeled Shoes and High-forefoot Shoes. J Korean Acad Rehabil Med 21(5):1003-1009 Oct 1997. 45. Brent S. Russell, The effect of high-heeled shoes on lumbar lordosis: a narrative review and discussion of the disconnect between Internet content and peer-reviewed literature. Volume 9, Issue 4, Pages 166-173 (December 2010) gournal of chiropractic medicine. •1 1 7 کاشانیان ،اکبری و علیزاده .تاثیر ورزش بر میزان کمر درد  و قوس کمری زنان حامله .دانشگاه علوم پزشکی ایران، 1388.؛ 45-40 :)69(16 دانشمندی ،علیزاده و قراخانلو،حرکات اصالحی ،سمت 1387 : .دانشمندی ،حسن .جزوه منتشر نشده ن.کمالی ،م .حاجی احمدی ،م .کشانی و ا .محبوبی .تاثیر جنس و چاقی روی دانشگاه علوم پزشکی بابل1382 ،؛ ..23-18 :)3(5اندازه لوردوز کمر •1 1 8 هشیار سری بود ز سودای تو مست خوش آنکه ز روی تو دلش رفت ز دست بی‌تو همه هیچ نیست در

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