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Muscle Imbalance
Evaluation and Treatment
for the Low Back and Hip
Areas
Jose S. Figueroa, D. O.
Physical Medicine and Rehabilitation,
NMM/OMM
AOCPM&R, Fall 2013

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Case Study
In 1998 a 33 y/o gentleman presents with a 5
year history of right shoulder pain, which did
not stop him functionally, but significantly
affected his sleep.
Diagnosed originally with biceps tendonitis,
and given some OMM treatments with good
but temporary relief.
Dr. Greenman saw him and stated that he had
a muscle imbalance
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Objectives
Learn concepts of neuromuscular imbalances and their
contribution to chronic musculoskeletal dysfunction in the
lumbar, pelvic and hip areas.
Learn the muscles that commonly affect the low back, pelvic
and hip areas.
Be introduced to the evaluation and treatment of muscle
imbalances of the lower quarter:
Evaluate Proprioception
Evaluate for the presence of faulty muscle firing patterns
Diagnose and manually treat tight/short muscles
Diagnose weak or pseudo-paretic muscles
Teach a home exercise prescription to address the tight/short and
weak or pseudoparetic muscles
Follow-up for re-evaluations and exercise adjustments
Teach patients how to self-treat certain common somatic dysfunctions
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Most of the information in this
lecture is derived from the works
of
Phillip Greenman, D.O.(he is the one in the
pictures)
Dr. Vladimir Janda, a specialist in rehabilitation
medicine at the University of Charles, Prague,
Czechoslovakia, deceased in 2006
Road Map
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle firing patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
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Muscle Balance
The relationship between the strength
and the length of the muscles around a
joint or multiple joints.
Ex. of muscles affecting one joint:
Vastus medialis obliquus (knee joint), soleus
(ankle)
Ex. of muscles Affecting multiple joints:
Psoas (lumbar/SI/hip), hamstrings (knee/hip)
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Muscle Imbalance Theory
According to Dr. Janda, it is a malregulation by
the central nervous system (CNS) leading to:
Some muscles becoming tight
Some muscles becoming weak
Loss of control of integrated muscle function
Loss of Symmetry and Control
Caused by some form of musculoskeletal
disturbance
Musculoskeletal Disturbance
Can be caused by acute or chronic events.
Examples include changes in lifestyle, or poor
ergonomics, or trauma, or disease, etc.
Examples: stress, participating in a poorly
designed exercise program, sedentary
lifestyle, joint and/or soft tissue disease or
trauma, spending too much time working in
front of a computer, loss of a limb, etc.
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Reflexes at the level
of the:
Premotor Cortex
Motor Cortex
Brainstem
Spinal Cord
1. Musculoskeletal
Disturbance
Articular
Receptors
Alpha Motor
Neuron
stimulates
muscle fiber to
contract.
Gamma
System:
stimulates
muscle
spindle to
adapt
Alteration in
muscle tone,
affecting joint
position and
function
Creation of Muscle
Imbalances which
maintain the wrong
positions of the
joints
MUSCLE
IMBALANCE
CYCLE
Return to normal
muscle tone
Adds
to
create
Understanding Motor Control
Movement: is performed by combined muscle
pull, which is very controlled in a very
complicated manner
Controlled movements require many CNS signals
(afferent and efferent) with precise timing and
number
CNS controls movement through
proprioception
It produces useful movements that adapt to our
constantly changing environment
Needs precise input from many receptors
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Sit Up Straight, Please
Pelvic Clock
Helps to give you an awareness of the location
of the trunk when in postural balance
Used in the supine, seated and standing
postures
Lets try the pelvic clock SEATED
Work on the Sit Stand Transfer, using
the pelvic clock
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Functional Disturbance
Injuries or diseases can cause muscles to react
differently than normal because of:
Guarding joints or organs
Inability to move properly due to tissue or nerve
damage
Chronic vs. Temporary:
When the injury is chronic, the changes are longer
lasting.
Chronic poor posture re-trains the muscles in
patterns of movements that eventually
become incompatible with normal function
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Muscle Function Disturbance
Chronic articular or muscle dysfunction feeds the
afferent loop with more nociception and abnormal
mechanoreceptor information, perpetuating ongoing
aberrant muscle tone.
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Muscle Imbalances
Some muscles become tight (tonic)
Some muscles become weak (phasic)
Altered motor control (impaired proprioception)
Either muscles do not contract when they are
supposed to, so they act as if they were weak
Or muscles contract too early when moving
certain joints or too much when maintaining
certain postures
Road Map
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle firing patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
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Functional Disturbance
There are two main ways that the muscles
react to functional disturbance:

Some muscles become tight/short
Usually the slow twitch fiber type muscles

Some muscles become weak (or
pseudoparetic)
Usually the fast twitch fiber type muscles
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Slow-twitch Fiber Type
Oxidative metabolism, high capillary
density, greater endurance, characteristic
red color
Twitch speed is slow, making their function
more tonic or postural
Slow-twitch muscles react to functional
disturbance by shortening and tightening.
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Fast-twitch Fiber Type
Glycolytic metabolic pathway, fatigue
rapidly, have low capillary density, whitish
color.
Twitch speed is fast and shorter lasting,
making their function phasic.
Fast-twitch muscles react to functional
disturbance by weakening or becoming
pseudoparetic
Table 1. Common upper and
lower extremity muscles and
their reaction to injury
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Body Region Function:
Primarily
Postural/Tonic
(Short and Tight)
Function:
Primarily Phasic
(Weak)
Pelvic and Hip
Region
Hamstrings
Iliopsoas
Rectus Femoris
Tensor Fascia Lata
Thigh Adductors
Piriformis
Vastus Medialis
Obliq.
Vastus Lateralis
Gluteus Maximus
Gluteus Medius
Gluteus Minimus
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Body Region Function:
Primarily
Postural/Tonic
(Short and Tight)
Function:
Primarily Phasic
(Weak)
Leg

Gastrocnemius
Soleus

Tibialis Anterior
Peroneus

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Body Region Function: Primarily
Postural/Tonic
(Short and Tight)
Function:
Primarily Phasic
(Weak)
Neck and Trunk Erector Spinae
Group
-Lumbar Region
-Cervical Region
Quadratus
Lumborum
Scalenes
Sternocleidomastoid
Deep Cervical
Spine Flexors
Erector Spinae
muscles
-Mid-thoracic
Rectus
Abdominis
External
Obliques
Internal Obliques
Transversus
Abdominis
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Body Region Function:
Primarily
Postural/Tonic
(Short and Tight)
Function:
Primarily Phasic
(Weak)
Shoulder Girdle
Pectoralis Major
Levator Scapulae
Upper Trapezius
Biceps Brachii
Latissimus Dorsi
Middle Trapezius
Lower Trapezius
Rhomboids
Supraspinatus
Infraspinatus
Triceps Brachii
Serratus Anterior
Deltoid
Stand Up, Please
Static Active Stretch: muscle is put on a
passive stretch with little to no movement,
while its antagonist is being used to maintain
the position of the muscle stretched and to
reciprocally inhibit the muscle stretched.
Examples:
Rectus Femoris
Chest stretch
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Road Map
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle firing patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
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Causes of Muscle Imbalance
Noxious stimulus (due to acute or repetitive
trauma, chronic injury, arthritis, space
occupying lesion, neurologic injury,
metabolic disease, loss of a limb, etc.)
Prolonged postural disturbance (resulting in
a prolonged alteration of the center of
gravity, with mechanical responses requiring
long term muscle adaptations)
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Causes of Muscle Imbalance
Excessive physical demands (usually chronic
overuse or under-use or chronic lack of rest-
especially stage IV sleep)
Emotional problems or other psychological factors
(tightness and fatigue that result when we are
"uptight" or stressed, anxious, depressed, etc.)
We show emotion with our muscles
Muscular action tends to create and/or accentuate
emotion
Reflex Pathways are involved in
maintaining muscle imbalances
Co-Contraction:
Lumbar erector spinae and psoas contracting to stabilize an
injured lumbar spine: What would someone look like who has
this?
Reciprocal Inhibition:
Psoas tightening causing weakness of gluteus maximus
Pectorals tightening causing weakness of interscapular muscles
Reciprocal Inhibition leading to Substitution
Hamstrings doing most of the hip extension instead of the
gluteus maximus
Still need to address the offending tight muscle: Iliopsoas
Tensor fascia lata doing most of the hip abduction due to a weak
gluteus medius / minimus
Still need to address the offending tight muscle: Adductor
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Muscle Function Disturbance
This vicious cycle can be interrupted and
reprogrammed through
OMM
Specific Exercises prescribed in the Proper Sequence
Thus, the overall muscle tone and balance can be
returned to (and maintained in) a more normal
state.

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Reflexes at the level of the:
Premotor Cortex, Motor
Cortex, Brainstem
Spinal Cord
1. Musculoskeletal
Disturbance
Articular
Receptors
Alpha Motor
Neuron stimulates
muscle fiber to
contract.
Gamma System:
stimulates muscle
spindle to adapt
Alteration in
muscle tone,
affecting joint
position and
function
Creation of Muscle
Imbalances which
maintain the wrong
positions of the
joints
MUSCLE
IMBALANCE
CYCLE
Return to normal
muscle tone
Adds
to
create
1. OMM
2. Exercise Prescription
1. OMM
2. Exercise Prescription
Functional Capacity!
Despite the osseous pathology of his own
lumbar spine, Dr. Greenman used to
demonstrate all of the exercises in his text and
to his patients.
This demonstrates the functional capacity in
the presence of significant osseous pathology.
This demonstration was a powerful
motivational tool.
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Kneel Up Straight, Please
Pelvic Clock Kneeling
Floor: sit to kneeling transfer
From knees fully bent to knees at 90
0
flexion
Kneeling to kneeling maneuver
One foot on the ground
The other foot with the ball of the foot on the
ground
Kneeling to Stand transfer with or without
assistance
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Road Map
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle firing patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
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Diagnosis of Muscle Imbalances
Three Specific Types of Clinical Testing
Evaluate Proprioception
Through balance testing
Evaluate the sequence of muscle contraction
(muscle firing patterns) during specific
movements to evaluate which muscles contract out
of sequence, acting as if they were weak
Evaluate asymmetry in muscle lengths
Muscles are isolated as much as possible and then
tested for symmetry in their lengths and compared with
estimations of normal

Treatment of Muscle Imbalances
General Principles:
Goal: restoration of proper muscle length, strength
and control of muscle function
Start with OMM
May need a home exercise prescription (HEP)
HEP should address muscle control (i.e.,
proprioception re-training)
When treating muscle imbalances: Quality of movement is
more important than quantity
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General Treatment Sequence
1. Establishing a process of re-evaluations to
monitor progress
2. Establish a level of patient commitment to
follow through
3. Re-training proprioception
home exercises (single leg stance)
PT (more advanced intervention)

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General Treatment Sequence
4. Stretching the tight muscles
manual stretches in the office (Dr. or PT)
home stretches (self-stretches)
5. Re-training or strengthening late contracting
(pseudoparetic) or weak muscles
home strengthening exercises
6. Teaching the patient how to self-treat
specific recurring somatic dysfunctions on
their own
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Road Map
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle firing patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
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DIAGNOSIS AND TREATMENTS OF
COMMON MUSCLE IMBALANCES
OF THE PELVIS AND LOW BACK
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HANDS-ON SESSION
Treating Impaired Proprioception
Retrain balance with bare feet on a carpeted
surface in order to stimulate the
propioceptors of the sole of the foot
Practice shortening the foot-also stimulates
the proprioceptors of the soles
Goal: the capacity to symmetrically stand on
one leg with arms crossed and eyes closed for
30 seconds
Do the best possible if unable to reach goal
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Look to your feet, Please
Remove your shoes
See if you can shorten one of your feet now
Lets test each others SINGLE LEG standing
balance
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Treating Impaired Proprioception
Bilateral exercises that help increase
proprioception and increased body
awareness:
Walking, Swimming (may need mask/snorkel)
Properly taught Pilates
Bilateral Martial Arts movements like some of the
ones found in Tai Chi, Choi Kwang Do, etc.

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Road Map
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle firing patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
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Evaluating Muscle Firing Patterns
of
Lower Quarter Muscles
PELVIC CLOCKS
Three dimensional evaluation of function of
the lumbar spine and pelvis.
Used diagnostically and therapeutically.
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Testing: PELVIC CLOCKS
Clock Orientation
Start Position
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Testing: PELVIC CLOCKS
12 O'clock 6 Oclock
Problems: pubic dysfunction,
iliosacral dysfunction, sacral
dysfunction (base posterior), lumbar
extended dysfunction, tight psoas,
tight paraspinals, weak abdominals
Problems: pubic dysfunction,
iliosacral dysfunction, sacral
dysfunction (base anterior), lumbar
flexed dysfunction
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Testing: PELVIC CLOCKS
3 Oclock 9 Oclock
Problems: Lumbar rotation to the
left, sacral torsion to the right , weak
abdominal obliques, transversus
abdominis
Problems: Lumbar rotation to the
right, sacral torsion to the left, weak
abdominal obliques, transversus
abdominis
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Testing: HIP EXTENSION FIRING
PATTERN
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Testing: HIP EXTENSION FIRING
PATTERN
Hamstrings.
Gluteus maximus.
Contralateral lumbar erector spinae (low).
Ipsilateral lumbar erector spinae (low).

Contralateral lumbar erector spinae (high).
Ipsilateral lumbar erector spinae (high).

Significant finding is late firing of the gluteus
maximus.
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Other Firing Patterns
Hip Abduction Firing Pattern on Sidelying
Normal: Gluteus medius, Tensor fascia lata (TFL),
Quadratus lumborum (QL) and Erector Spinae
Abnormal: substitution with weakness of gluteus
medius and early firing of TFL (causing IR and flexion
of the hip) and QL. Worst scenario is that the motion
is initiated by the firing of the QL.
Pelvic Tilt Heel Slide
Pelvic Tilt with Hip Abduction and External
Rotation
Active Trunk Rotation
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Road Map
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle firing patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
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Evaluating and Treating
Muscle Length Asymmetry
of
Lower Quarter Muscles
Stretching: PSOAS & RECTUS FEMORIS
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Manual Stretching of Muscles
Manual Stretching done at the clinic is very
important because it can significantly increase
the muscle lengths further than self-stretching
alone can.
Supercharges the patients home stretching
routine
Sustained Stretch: 20-30 secs, 2 or 3 reps.
Muscle Energy: Post-isometric Relaxation and
Stretch
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Stretching: RECTUS FEMORIS
PRONE
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Stretching: PSOAS PRONE
Anterior Hip Capsule Stretch
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SELF STRETCH: PSOAS
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SELF STRETCH: RECTUS FEMORIS

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Stretching: ADDUCTORS
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Stretching: ADDUCTORS (Long)
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Stretching: ADDUCTORS (Short)
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SELF STRETCH: ADDUCTORS

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Stretching: PIRIFORMIS
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Stretching: PIRIFORMIS
Above 90 degrees
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Self Stretch: PIRIFORMIS
Above 90 degrees
Below 90 degrees
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Self Stretch: PIRIFORMIS (Prone)
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Stretching: LATISSIMUS DORSI
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Stretching: LATISSIMUS DORSI
Manual Stretch
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Self Stretch: LATISSIMUS DORSI
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Road Map
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle firing patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
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Strengthening / Retraining
of
Lower Quarter Muscles
Strengthening/Retraining:
GLUTEUS MAXIMUS
Prone hip extension.
Bridging.
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Strengthening/Retraining:
GLUTEUS MAXIMUS
1. Contract Gluteus.
2. Contract Gluteus
& hold knee.
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Strengthening/Retraining:
GLUTEUS MAXIMUS
3. Isometric hold. 4.Concentric contraction.
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Strengthening/Retraining:
GLUTEUS MAXIMUS BRIDGING
1. Contract transversus
abdominus or
maintain a slight 12
oclock pelvic tilt.
2. Use two legs to
bridge and contract
buttocks.
3. Single leg bridge.
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Strengthening/Retraining:
GLUTEUS MAXIMUS BRIDGING
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Strengthening/Retraining:
ABDOMINALS
Sit backs.
Curl ups.
Supine leg slides with stable transversus or
posterior pelvic tilt.
Norwegian exercise.
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Strengthening/Retraining:
ABDOMINALS
Transversus abdominus Rectus abdominus
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Strengthening/Retraining:
ABDOMINALS
Oblique abdominals
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Strengthening/Retraining:
ABDOMINALS Sit Backs
Performed in three stages, arms in front, arms
crossed, and hands behind neck.
Maintain a lumbar lordosis throughout.
Strengthens transversus abdominus in
subconscious mode.
Strengthens abdominals in a lengthened
position.
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Strengthening/Retraining:
ABDOMINALS Sit Backs
Start position. Level one.
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Strengthening/Retraining:
ABDOMINALS Sit Backs
Level Two
Level Three
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Road Map
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle firing patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
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Pause shortly. Then move on to
the second part of the program.
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Questions
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