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SCIENTIFICBack Training

Scienti�cBack Training

2nd Edition

byPaul Chek

Corrective Holistic Exercise K

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A C.H.E.K Institute PublicationSan Diego, CA

Scienti�c Back Training

Copyright © 1995, 2011, Apriori Anatomikos, Inc.

Layout design: Joling LeeEditor: Penthea CrozierProof readers: Clare Nelson, Ruth Pyszczynski and Holli ClepperIllustrations: Charlie Aligaen

All rights reserved. All written and artistic content of this publication is protected under international copyright law. Without limiting the rights under copyright reserved above, no portion of this publication may be used, reproduced, stored in or introduced into a retrieval system, or trans-mitted in any form or by any means, electronic or mechanical, including fax, photocopy, recording or otherwise by anyone but the purchaser for his or her own personal use. �is book may not be reproduced in any form without the prior written permission of the copyright owner, Paul Chek, or the publisher, C.H.E.K Institute.

C.H.E.K InstituteSan Diego, CA, USA

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Printed in the USA

Chek, Paul W.

Warning - Disclaimer�e workouts and other health-related activities described in this publica-tion and program presented by the C.H.E.K Institute were developed by the author to be used as an adjunct to improved strengthening, conditioning, health and �tness. �ese programs may not be appropriate for everyone. All individuals, especially those who su�er from any disease or are recovering from any injury, should consult their physician regarding the advisability of undertaking any of the activities suggested in these programs. �e author has been painstaking in his research. However, he is neither responsible nor liable for any harm or injury resulting from this program or the use of the exercises or exercise devices described herein.

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A WORD ABOUT COPYRIGHT

�e information presented in this, or any C.H.E.K Institute publication, seminar, video, DVD or course is the sole property of the author. Copying this material in any form whatsoever is strictly prohibited without written consent from the copyright holder. If you wish to use any materials, such as lecture or workshop handouts, cor-respondence course manuals, diagrams and text or concepts developed or taught by Paul Chek or his certi�ed instructors, please use the following guidelines to avoid legal action:

1. If you wish to make signi�cant use of any copyrighted material, e.g. duplicate a page for a client or use an illustration in a presentation, prior written permission must be sought from the author. Request for Pemis-sion forms are available from the C.H.E.K Institute.

2. Whenever using information gained from any secondary source, always credit the referenced source com-pletely and professionally. In the case of C.H.E.K Institute source, this means the author, C.H.E.K Insti-tute and the course material. Paraphrasing without proper referencing is considered plagiarism. Whether intentional or not, this is theft of intellectual property and the plagiarist may be prosecuted under copyright law (depending upon the form and amount of the plagiary). Any type of impersonation of another’s ideas is entirely unethical and heavily frowned upon in professional circles.

3. Professional referencing usually takes one of two forms: either the original author is indicated by name in the body of the text and a complete reference is included in the list of source material at the end or a num-ber is inserted in the main text beside the borrowed material, with that number corresponding to the refer-ence in the list of credits. �ere are many accepted methods of citing works. �e following are standard; the author’s name; title of book, article, course, video, DVD, etc. Title of journal or magazine (if applicable); publisher or producer (if applicable), date of publication/communication (if oral); page number (if appli-cable).

4. Any C.H.E.K Institute materials or concepts may not be sold, published or made part of any program for which a fee is charged without the prior written permission of the author.


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PLEASE NOTE

*If you have taken this course as a live seminar and you wish to use it as a prerequisite for the C.H.E.K Institute’s Advanced Training Programs, then you will need to complete the exam. Please see page 233 for information on submitting the exam.

*If you purchased this course through the C.H.E.K Institute e-Learning Platform, you will need to log into your account and take the exam online.

PLEASE READ. Important Registration Information

�is manual and exam are registered to the original purchaser of the course, under the number be-low. �is number matches the number on the exam answer sheet. �is number can only be used once. To complete the exam and to receive credit for the course, this registration number must be entered online or the original answer sheet with this number must be sent in to the C.H.E.K Institute. Only one certi�cate will be given for each registration number.

Please Note: If you are part of the course sharing program you will need your own manual with registration number. THIS NUMBER CAN ONLY BE USED ONCE.

Registration Number:

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Table of Contents

COURSE OBJECTIVES .....................................................................................................................11

FUNCTIONAL ANATOMY OF THE BACK .....................................................................................12Transversospinalis Group .....................................................................................................................12

Rotatores ............................................................................................................................................. 12Interspinales......................................................................................................................................... 12Intertransversarii .................................................................................................................................. 12Multi�dus ............................................................................................................................................ 14Semispinalis ......................................................................................................................................... 14

Erector Spinae Group ..........................................................................................................................16Spinalis ................................................................................................................................................ 16Longissimus ......................................................................................................................................... 16Iliocostalis ............................................................................................................................................ 16

Important Back Musculature ...............................................................................................................18Iliopsoas............................................................................................................................................... 18Quadratus Lumborum ......................................................................................................................... 18Latissimus Dorsi .................................................................................................................................. 18

ABDOMINAL MUSCULATURE .......................................................................................................20External Oblique ........................................................................................................................................ 20Internal Oblique ........................................................................................................................................ 20Rectus Abdominis ...................................................................................................................................... 22Transversus Abdominis ............................................................................................................................... 22

UNDERSTANDING LENGTH-TENSION IMBALANCES IN THEMUSCULO-SKELETAL SYSTEM .....................................................................................................24Understanding Tonic/Phasic Relationships ................................................................................................. 24R-C Factor & Joint Stability ....................................................................................................................... 28Posture and Curves ..................................................................................................................................... 32Spinoscapular Muscles as Back Muscles ...................................................................................................... 36Force Couple Relationships of the Inner & Outer Units Shoulder-Spine-Hip Interaction .......................... 38Shoulder Girdle Position and �oracic Kyphosis ........................................................................................ 40Glenohumeral & Spinoscapular Force-couple Mechanism .......................................................................... 42�e Hip Extensor Mechanism .................................................................................................................... 46Sagittal Plane Force-couples ....................................................................................................................... 48Pelvic Girdle In�uence ............................................................................................................................... 50Lumbar Disc Pressures as a Percentage of Standing in Various Positions .................................................... 52Understanding Lumbo-pelvic Rhythm ....................................................................................................... 54Choosing a Lumbar Lifting Position ........................................................................................................... 56


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THE INNER UNIT .............................................................................................................................66Central Generation of Stabilization ............................................................................................................ 66�oracolumbar Fascia Biomechanics .......................................................................................................... 68Hydraulic Ampli�ier Mechanism ............................................................................................................... 68Spine Stabilization & Deep Abdominal Wall Activation ............................................................................. 70Weight-belt Considerations ........................................................................................................................ 72Intrinsic Hoop Tension vs. Extrinsic Hoop Tension and Spine Stabilization ............................................... 72Abs In or Abs Out? ..................................................................................................................................... 74

THE OUTER UNIT ........................................................................................................................... 76Outer Unit Recruitment ..............................................................................................................................76Posterior and Anterior Oblique Systems ......................................................................................................78�e Lateral System ......................................................................................................................................80Loading the Lateral System .........................................................................................................................80�e Deep Longitudinal System ...................................................................................................................82Inner/Outer Unit Synergy ...........................................................................................................................84�e Worlds Greatest Weight Belt .................................................................................................................84Lumbo-Pelvic Rhythm, Lower Abdominal Strength and Lumbar Stability ..................................................86Understanding the Neutral Spine Philosophy ..............................................................................................88

BACK PAIN CONSIDERATIONS ..................................................................................................... 90Back Pain: A Developmental Problem? ........................................................................................................92Developmental De�ciency...........................................................................................................................94Control Centers of Stress .............................................................................................................................96Physiological Load Assessment ....................................................................................................................96Control Systems Overview ..........................................................................................................................98Physiological Load.....................................................................................................................................100Control Centers - Totem Pole of Life .........................................................................................................102Respiratory System ....................................................................................................................................104Mastication ...............................................................................................................................................110Assessing Bite ............................................................................................................................................110�e Visual System .....................................................................................................................................110Vestibular System ......................................................................................................................................112Cranio-Cervical System .............................................................................................................................112Cranio-Cervical Control ...........................................................................................................................114Cranio-Cervical Integration.......................................................................................................................114�e Visceral System ...................................................................................................................................116Limbic/Emotional .....................................................................................................................................118Sacrooccipital System ................................................................................................................................118Slave Joints & Systems ..............................................................................................................................120Practical Applications ................................................................................................................................120Conclusion ................................................................................................................................................120

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ASSESSMENTS ................................................................................................................................ 122Comparative Range of Motion (ROM) Assessments ..................................................................................122Ankle Dorsi�exion ....................................................................................................................................122Hamstring Flexibility at the Knee - Hip at 90 degress................................................................................122Hamstring Flexibility at the Hip - Straight Leg Raise ................................................................................122Sit and Reach Test - Looking at Lumbar Flexion .......................................................................................124Single Knee to Chest Test ..........................................................................................................................124Double Knee to Chest ...............................................................................................................................124Hip Abduction - Testing Adductors ...........................................................................................................126Hip Adductions - Testing Abductors .........................................................................................................126�e Prone Knee Flexion - Testing Quads ...................................................................................................126�e Prone Hip Extension Test - Testing Hip Flexors ..................................................................................126�e McKenzie Press-up Test - Testing Spinal Extension .............................................................................128Internal Hip Rotation Test ........................................................................................................................128External Hip Rotation Test ........................................................................................................................128Seated Trunk Rotation Test - Testing Spinal/Trunk Rotation .....................................................................130Standing Side Flexion Test - Testing Tightness of Quadratus Lumborum ..................................................130Prone Butt Squeeze Test ............................................................................................................................132Scoliosis ....................................................................................................................................................132Recognizing Spinal Rotations ....................................................................................................................134Forward Bend Test ....................................................................................................................................134Wall Standing Test for Lumbar Lordosis or Lumbar Curve ........................................................................136Lumbopelvic Rhythm Test ........................................................................................................................136

CORRECTIVE EXERCISES: PHASE ONE EXERCISES ................................................................ 138Feldenkrais Hip & Pelvis Integrator...........................................................................................................138Feldenkrais Shoulder/Spine Integrator .......................................................................................................140McKenzie Press-up ....................................................................................................................................142Foam Roller Longitudinal Mobilization ....................................................................................................144Foam Roller Segmental Mobilization .........................................................................................................144Horse Stance Vertical .................................................................................................................................146Horse Stance Horizontal ...........................................................................................................................148Horse Stance Alphabet ..............................................................................................................................150Horse Stance Dynamic ..............................................................................................................................152Horse Stance Hip & Shoulder Abduction .................................................................................................154Horse Stance Two Point ............................................................................................................................154Horse Stance One Point ............................................................................................................................156Supine Hip Extension-feet on ball .............................................................................................................158Supine Hip Extension-back on ball ...........................................................................................................158Back Extensions ........................................................................................................................................160


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Reverse Hyper-Extensions .........................................................................................................................162Swiss Ball Side Flexion ..............................................................................................................................164Prone Cobra ..............................................................................................................................................164Supine Lateral Ball Roll .............................................................................................................................166Forward Ball Roll ......................................................................................................................................168Prone Jack Knife ........................................................................................................................................170Using the Total Gym in Phase One ...........................................................................................................172

CORRECTIVE EXERCISES: PHASE TWO EXERCISES .............................................................. 174Functional Back Conditioning - Secondary Back Exercises ........................................................................174Stick Training ............................................................................................................................................174Other Secondary Back Exercises Examples ................................................................................................176Kneeling Back Extensions ..........................................................................................................................178�ree-Point Single Arm Row .....................................................................................................................180�e Lat Pull Over ......................................................................................................................................182�e Lat Pull Down ....................................................................................................................................184Straight Arm Lat Pull Down ......................................................................................................................186Single Arm Cable Push ..............................................................................................................................188Single Arm Cable Row ..............................................................................................................................190Other Standing Cable Rows ......................................................................................................................190Cable Row Variations ................................................................................................................................192�e Low Row ............................................................................................................................................194Wood Chop ..............................................................................................................................................196Reverse Wood Chop ..................................................................................................................................198�oracic Arm Raise Tesr ............................................................................................................................200Tips for Common Gym Exercises ..............................................................................................................200

CORRECTIVE EXERCISES: PHASE THREE EXERCISES .......................................................... 202Squatology ................................................................................................................................................202Setting up the Squat ..................................................................................................................................208�e Science of Squatting Without Injury ..................................................................................................210�e Squat ..................................................................................................................................................210Squatting with Relative Flexibility Imbalance ............................................................................................214Front Squat ...............................................................................................................................................216Dead Lift ...................................................................................................................................................218Waiter Bow Test ........................................................................................................................................220�e Good Morning ...................................................................................................................................220�e Lunge .................................................................................................................................................222Bent Over Row .........................................................................................................................................224Phase Four Exercises ..................................................................................................................................226

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REFERENCES ................................................................................................................................... 228HOW TO COMPLETE YOUR EXAM .............................................................................................. 233CORRESPONDENCE COURSE EXAM .......................................................................................... 235ANSWER SHEET .............................................................................................................................. 253GRADING REQUEST ...................................................................................................................... 255REQUEST FOR PAPER CERTIFICATE ........................................................................................... 257COURSE CRITIQUE ........................................................................................................................ 259REQUEST FOR TESTIMONIALS .................................................................................................... 261PAUL CHEK BIOGRAPHY .............................................................................................................. 263


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How to Complete this Course as CORRESPONDENCE COURSE ONLY

To maximize your learning potential, it is recommended that you complete the course in the following manner:

1. Review the DVDs. �e �rst time through, just watch, listen and absorb the information.

2. At this point, you should read the exam thoroughly. �e purpose is not only to pass the exam, but also to be pro�cient in applying the techniques. �e exam questions will help direct your attention to important concepts and information.

3. Read the manual.

4. �e second time through the DVDs, follow along in the manual and take notes! It is recommended that you stop the DVD – rewind and review – as often as necessary to clarify points that you may not under-stand.

5. Perform all the assessments and exercises you are capable of performing with good form. Repeat this pro-cess at least twice - not necessarily on the same day - and if possible, also practice them on a willing friend or family member.

6. Now that you have viewed the instructional DVDs twice and have read the exam, it’s time to take the exam. Instructions for completing the exam are found on pages 233. �e purpose of this correspondence course is not to trick you, but to make sure that you are pro�cient in the areas of knowledge presented. �e exam is designed to direct your attention to the areas of importance. �e exam is designed to be taken online; the exam in the back of this manual is for you to practice on and keep for reference.

7. If you cannot take the exam online for any reason, you may complete the exam in the manual and return the exam answer sheet and grading request sheet via mail, email or fax to:

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Please note: there is an additional fee for submitting your test to be graded by hand. Please see page 255 for details.

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Course Objectives

At the conclusion of this course students will be able to:

1. Explain the functional anatomy of the back and how it integrates with the rest of the body.

2. Explain the Inner and Outer Unit relationships and how to apply principles of functional anatomy when selecting stretches and exercises for preventing and alleviating back pain.

3. Explain the basics of a control system approach as part of a comprehensive, holistic program for prevention and resolution of back pain.

4. Perform useful assessment techniques for e�ective program development.

5. Perform a joint ROM assessment for the spine and lower extremities and explain how joint restriction a�ects movement e�ciency.

6. Identify exercises to strategically address each given client’s need.

7. Prepare for more comprehensive training o�ered through the C.H.E.K Institute’s Advanced Training Programs.


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Functional Anatomy of the Back

TRANSVERSOSPINALIS GROUP

RotatoresOrigin: Transverse processes of all vertebra.

Insertion: Spinous processes of all vertebra, inserting on vertebra directly above origin.

Action: Extension of spine and rotation to opposite side.

Nerve Innervation: Segmental innervation from dorsal rami.

InterspinalesOrigin: Inferior surfaces of spinous processes of C2-T3 and T11-S1.

Insertion: Superior surface of the spinous process directly below the respective origin vertebra, C3-T4, T12 - S2.

Action: Segmental extension.


IntertransversariiOrigin: Transverse process of cervical, lumbar, and T1-2, T11-12, vertebra.

Insertion: Directly on vertebral above origin.

Action: Lateral �exion of the spine. Proprioception.


Figures 1-12 from Primal Partners program.

Figure 1: Rotatores

Figure 2: Interspinales

Figure 3: Intertransversarii

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Multi�dusOrigin: Sacrum, posterior superior iliac spine, transverse processes of all vertebra up to C-4.

Insertion: Spinous processes of all vertebrae, inserting 2 to 4 vertebra above origin.

Action: Bilaterally - extension of the spine.Unilaterally - rotation to opposite side.

Nerve Innervation: Segmentally innervated by the dorsal rami.

SemispinalisOrigin: By strong fascia from the mammillary processes of S1, L5, and L2: from the mammillary processes of L1 and T12 it arises directly. Insertion: �oracic and cervical spinous processes and occiput. �is muscle spans 5-7 vertebrae. Action: Bilaterally - extension of the spine vertebrae.Unilaterally - rotation to the opposite side.

Nerve Innervation: Segmental innervation from the dorsal rami.

Figure 4: Multi�dus

Figure 5: Semispinalis

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ERECTOR SPINAE GROUP

SpinalisOrigin: Spinous processes of T11-L2 (3).

Insertion: Tips of spinous processes of (C7) T1-T9.

Action: Bilateral contraction results in spinal extension, unilateral contraction results in ipsilateral side �exion.

Nerve Innervation: Dorsal rami of thoracic nerves T6 - T8.

LongissimusOrigin: �oracolumbar aponeurosis, lumbar and thoracic transverse processes.

Insertion: Cervical and thoracic transverse processes, mastoid process.

Action: Bilaterally - extension of the spine.Unilaterally - ipsilateral side �exion of the spine.


IliocostalisOrigin: �oracolumbar aponeurosis, anterior lateral aspect of the pos-terior superior iliac spine and posterior aspect of ribs 3-12.

Insertion: Posterior tubercles of transverse processes C3 (4)-6 and ribs 11-1.

Action: Bilaterally - extension of the spine.Unilaterally - ipsilateral side �exion.

Nerve Innervation: Segmental innervation by the dorsal rami.

Figure 6: Spinalis

Figure 7: Longissimus

Figure 8: Iliocostalis

Figure 9: Iliocostalis

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IMPORTANT BACK MUSCULATURE

IliopsoasOrigin: Psoas major, anterior aspect of lumbar vertebrae, anteriorlum-bar transverse processes and lumbar discs.

Iliacus: Inner surface of ilium.

Insertion: Lesser trochanter of femur.

Action: Flexion and lateral rotation of the thigh. When the extremity is �xed, bilateral contraction of the muscle rotates the pelvis and trunk in opposite directions. Bridges spine and pelvis.

Nerve Innervation: Innervated by L1-L3 (femoral nerve), sometimes by T12 and L4.

Quadratus LumborumOrigin: Posterior iliac crest.

Insertion: Twelfth rib and transverse processes of lumbar vertebrae.

Action: Lateral �exion of the trunk when the pelvis acts as the anchor and hiking of the hip when the trunk is stabilized.

Nerve Innervation: T-12 and L1-3.

Latissimus DorsiOrigin: �oracolumbar aponeurosis from T7 to iliac crest, lower 3 or 4 ribs, and the inferior angle of the scapula.

Insertion: Bicipital groove of humerus and crest of the lesser tubercle.

Action: Extension, medial rotation and adduction of the humerus. Bridges arm and spine.

Nerve Innervation: �oracodorsal nerve (C6, 7, 8).

Figure 10: Iliopsoas

Figure 11: Quadratus Lumborum

Figure 12: Latissimus Dorsi

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Abdominal Musculature

External ObliqueOrigin: By interdigitating slips from the lower 8 ribs.

Insertion: Fibers from the lower ribs insert into anterior half of outer lip of iliac crest, the remaining �bers insert into the wide aponeurosis of the anterior abdominal wall.

Action: Acting bilaterally they will �ex the trunk; their major in�uence being to tilt the pelvis posteri-orly. With unilateral stimulation there is an ipsilateral side �exion and contralateral trunk rotation.

Internal ObliqueOrigin: Lumbar fascia, anterior two thirds of iliac crest and lateral two thirds of inguinal ligament.

Insertion: Ribs 9-12, and the linea alba.

Action: On bilateral stimulation they bend the trunk forward. On unilateral stimulation there will be ipsilateral rotation and side �exion. In lateral �exion, the internal and external obliques cooperate. In right rotation (as shown on the diagram), the right internal oblique is synergistic with the left external oblique. �e opposite is true of left rotation of the trunk. When the trunk is anchored and the pelvis is free, muscle func-tion are paradoxic.

Figure 13: Internal and External Obliques

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Rectus AbdominisOrigin: Pubis symphysis and crest of pubis.

Insertion: Costal cartilages of ribs 5-7 and xyphoid process.

Action: With the legs �xed, this muscle �exes the trunk as in a sit-up. If the trunk is �xed, there will be elevation and posterior rotation of the pelvis. Uni-lateral stimulation causes ipsilateral side �exion. �e rectus abdominis also serves to increase intra-abdom-inal pressure and aids in forced expiration.

Transversus AbdominisOrigin: Internal surfaces of costal cartilages 7-12, thoracolumbar fascia and iliac crest.

Insertion: Linea alba.

Action: Increases intra-abdominal pressure. �rough the same mechanism the transversus abdominis can apply traction to the deep lamina of the posterior layer of thoracolumbar fascia; this creates an exten-sion force on the lumbar spine.

Figure 14: Rectus Abdominis

Figure 15: Transversus Abdominis

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NOTES


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Understanding Length-Tension Imbalances in theMusculo-Skeletal System

Understanding Tonic/Phasic Relationships

It is very important to stretch tight muscles prior to exercising. It has been shown by Janda that tonic muscles have a propensity for shortening and tightening, often becoming facilitated.8 Phasic muscles tend to become long and weak. If a muscle group becomes facilitated, it will try to take over the function of synergistic and antagonistic muscles, resulting in perpetuation of muscle imbalance and often overuse injury to the facilitated muscles.

Tonic Muscle Facilitation

• Postural function

• > 50% slow twitch

• Low stimulation threshold

• Faulty loading causes shortening and may cause hy-pertrophy

• Inhibit phasic antagonists

Phasic Muscle Inhibition

• Used for movement

• > 50% fast twitch

• React to faulty loading by lengthening and weaken-ing

• Commonly inhibited by tonic antagonists

• Prone to weakness with aging

Figure 16: Result of a message from the brain on tonic and phasic muscles.

Tonic

Phasic

In �gure 16, the brain sends out a message for a speci�c movement. �e low resistance tonic back muscles receive greater input than the higher resistance phasic abdominal muscles and produce a distortion of the original message sent by the brain. Instead of a perfect shot, the end result shows up as a hook, slice, thin, fat or some other poor shot.

Law of FacilitationWhen an impulse passes once through a given set of neurons to the exclusion of others, it will tend to do so again, and each time it does the resistance will be lower.

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Tonic Muscles Phasic Muscles

SCMLevator ScapuliiUpper TrapeziiScaleniiPectoralis MinorBiceps BrachiiWrist FlexorsCervical ErectorsLumbar ErectorsQuadratus LumborumHamstrings (?)IliopsoasRectus FemorisAdductorsPiriformisTensor Fascia LataeGastroc/Soleus

Cervical FlexorsLower and Middle TrapeziiSerratus AnteriorDeltoidsWrist Extensors�oracic ErectorsAbdominal MusclesVastus LateralisVastus MedialisGluteus MaximusGluteus MediusGluteus MinimusAnterior TibialisPeroneals

Table 1: Tonic and Phasic Muscles

Figure 17: Electromyographic activity of selected trunk muscles during exercises, before and after stretching.

First recording – Before stretching the tight trunk extensors: The EMG of trunk extensors and �exors taken during an abdominal curl shows activity in the facilitated, overactive erector spinae, as well as in the rectus abdominis. Second recording – After stretching the tight trunk extensors: The EMG shows almost zero activity in the erector spinae and increased activity of the rectus abdominis. Conclusion: Contrary to what might be expected, an abdominal curl will not improve the balance between trunk extensors and trunk �exors in a client with facilitated lumbar erector spinae, unless the tight trunk extensor muscles are �rst stretched.

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R-C Factor & Joint Stability

�e intact R-C Factor (put forth by Major Bertrand De Jarnette D.C. in 1942) is a must for joint stability and optimal posture (R = resistance and C = contraction). Consider that the center of gravity (CG) of the head is anterior to the axis of rotation of the craniocervical junction, therefore gravity is creating a constant force, pro-ducing a �exion moment on the head/neck complex. �e force of gravity on the head/neck complex must be counterbalanced by a resistance.

Because the head sits atop a �exible column (neck), should the extensors of the neck contract adequately to counter the force of gravity on the head without a contraction (the “C” in the formula) from the neck �exors, the head will simply migrate forward, as demonstrated. �is will result in poor posture and faulty joint mechan-ics and degradation of motor control.

F F

R++R+

C -C+

C++

C++R -

R -

Figure 18: R-C Factor and Joint Stability

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Figure 19: Poor Posture

A. Forward Head Posture

B. Increased thoracic kyphosis and steep �rst rib angle

C. Increased pelvic tilt

Figure 20

Figure 21

Figure 19 shows the e�ects of common gym exercises such as a bench press with excessive load (Figure 20) and repetitive crunches from the �oor. (Figure 21).

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Posture and Curves

Posture is the position from which movement begins and ends. Ideal posture is that state of muscular and skeletal balance which protects the supporting structures of the body against injury or progressive deformity, irrespective of the attitude in which these structures are working or resting (Figure 22). It is during a state of ideal posture that the muscles will function most e�ciently.

Figure 23 shows the e�ects of imbalances between the trunk �exors and trunk extensors. As the abdominal mus-culature becomes progressively stronger than their antagonists, the following postural aberrations may be seen:

• Short, tight upper abdominal musculature

• Depressed sternum

• Forward head

• Increased thoracic kyphosis (often with the apex at T7-9)

Figure 22: Ideal Posture

Figure 23: Poor Posture

A. Forward Head Posture

B. Increased thoracic kyphosis and steep �rst rib angle

C. Increased anterior pelvic tiltWhat will you stretch?

What will you strengthen?

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�e Lower Cross Syndrome is shown in Figure 24. In this case, there is shortening of the lumbar erectors, ilio-psoas, rectus femoris and tensor fascia latae, with lengthening of the lower abdominal musculature, hamstrings, thoracic extensors and super�cial cervical �exors. �is posture is frequently the result of an imbalanced exercise program.

Figure 25B demonstrates the Sway Back posture, or Layered Syndrome. Here the hamstrings and lower abdomi-nals are short and tight, while the lumbar erectors, rectus femoris and iliopsoas are long and most likely weak.

To correct these cases of faulty alignment, the long weak muscles must be strengthened and shortened, while the short tight muscles must be stretched. �e stretching should take place prior to the strengthening.

Figure 24: Lower Cross Syndrome

A. Flat back B. Sway back

Figure 25

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Spinoscapular Muscles as Back Muscles

Muscles that contribute to stability and mobility of the back include the:

1. Levator Scapula2. Rhomboid Minor & Major3. Infraspinatus & Teres Minor4. Lower Trapezius5. Middle Trapezius6. Upper Trapezius

1

2

3

4

5

6

Figure 26: Spinoscapular Muscles as Back Muscles

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Shoulder-Spine-Hip Interaction

In the natural round back lifting posture, the lats pull the load closer to the body as the gluteus maximus and hamstrings work to extend the spine. �e lastissi-mus dorsi and gluteus maximus create opposing ten-sion forces through the thoraco-lumbar fascia. �e tension created works to create a suspension bridge e�ect on the spine, minimizing compression of spinal vertebra. �e suspension bridge mechanism is also dependent upon a functional abdominal wall. Figure 27 demonstrates the intimate relationship between the back and shoulder as provided by the latissimus dorsi muscles.

Force-Couple Relationships of the Inner & Outer Units

Figure 27:Adapted from Mechanical Low Back Pain by Porter�eld and DeRosa14.

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Shoulder Girdle Position and Thoracic Kyphosis

As the spino-scapular muscles weaken and lengthen, the scapula (one or both) begin to migrate forward as seen in Figure 28. �is forward migration of the shoulder girdle places aberrant strain on the sterno-clavicular joint as the shoulder girdle’s weight is transmitted into the sternum (Figure 29). �is depresses the sternum, �exing the ribs, which pulls the head forward (Figure 30). �ere is now altered weight bearing relationships in the up-per quarter, placing great strain on the supraspinous ligaments at the C7-T2 levels. �e head increases its relative weight as it moves forward, often leading to cervical strain and headache.

Figure 28: Steep �rst rib angle

Figure 29: Strain on shoulder girdle

Figure 30: Forward Head Posture

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Glenohumeral & Spinoscapular Force-couple Mechanism

As the arm is externally rotated or abducted in a hori-zontal plane (as in a prone row), the scapular adductor musculature (mid-trap and rhomboid) become pro-gressively more active to aid in completion of an end-range movement. �is is a normal movement pattern that can become faulty under the in�uence of poor training technique. �e following are examples of how this may occur.

Use of too much weight during prone row or exter-nal shoulder rotation exercises. �is causes the range of motion to be shortened because as the scapulo-humeral muscles shorten, they lose their mechani-cal advantage, due to interdigitation of the actin and myosin �laments. Because the scapular adductors are frequently weak, and because many lifters habitu-ally chop their range of motion, a faulty movement pattern is developed that will lead to overuse of the scapulo-humeral musculature and under-utilization of the scapular adductors. �is is not good because it also fosters rounded shoulders and a forward head, as well as promotion and maintenance of an Upper Cross Syndrome (muscle imbalance).

Faulty pulling technique during any rowing exercise can alter recruitment sequence, posture and predis-pose your client to back pain!

Figure 31: Bent Over Row

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An exerciser who has a rotator cu� weakness, or a muscle imbalance between the medial and lateral rotatores of the shoulder (very common), may fatigue early in the infraspinatus, teres minor and major, posterior deltoid and long head of the triceps during rowing or other pulling exercises. �is often leads to compensatory overuse of the scapular adductors, followed shortly, in most cases, by pain in the interscapular region from overuse.

To prevent development of such faulty movement patterns, the following is recommended:

1. Always train through a full range of motion.2. Choose weights allowing a complete cycle of motion.3. If you are training to failure, you must use a well-trained spotter!

- If your spotter is not able to identify poor technique he/she, out of ignorance, will allow you to develop faulty movement patterns that are likely to be the source of an injury in the coming months.

- If you know proper technique, you are responsible for training your spotter.

- If you are a trainer, you must intervene at least once on those performing with poor technique in your gym!

4. Use hands on techniques to access the muscles to be used at end range.

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The Hip Extensor Mechanism

�e gluteus maximus and hamstrings work in concert to produce posterior pelvic tilt. At approximately 45% of trunk extension, when lifting an object o� the ground the erector spinae become progressively more active, taking the load out of the posterior ligamentous system. It is the gluteus maximus and hamstrings that are prime movers of the load during the initiation of any lift requiring more than 45 degrees of trunk �exion.

If the knees are not partially bent, approximately 20°, the gluteus maximus will not become active. In such cases the load must initially be lifted by the hamstrings alone (Figure 32). �is will often lead to faulty motor pattern-ing, predisposing the lifter to injury of the hamstring complex and, possibly, the back.

Figure 32: Faulty Position Figure 33: Proper Position

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Sagittal Plane Force-couples

�e posture of the pelvis is in�uenced by the resting tension of the �exors and extensors of the hips and trunk. If the quadriceps and iliopsoas, for example, develop higher resting tone than the antagonistic hamstrings and lower abdominal musculature, an anterior pelvic tilt will result (Figure 36). As an exercise specialist, it is your job to design a program which encourages increased tone in the musculature responsible for correcting this faulty posture.

It is important to note that postures to the extremes of either anterior or posterior pelvic tilt are commonly as-sociated with back pain. �is is likely because the pelvis has tremendous in�uence on the lumbar curvature via both ligamentous attachments and it’s ability to alter the sacral base angle.

�exorsextensors

extensors�exors

Figure 34: Sagittal Plane Forces Figure 35: E�ects of �exors and extensors on the body

Figure 36: E�ects of �exors and extensors on the pelvis

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Pelvic Girdle In�uence

• Psoas muscles are recognized as the most common source of muscle imbalance in the human body.8

• Psoas shortness often retards core control.Figure 37: Psoas

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Lumbar Disc Pressures as a Percentage of Standing in Various Postures

Table 2:From: Nachemson, A.L. Spine, “�e Lumbar Spine, an Orthopedic Challenge”, 1:59, 1976.

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Understanding Lumbo-pelvic Rhythm

In Figure 38, line 1, the lumbar erector musculature are shown to be very active for the �rst 45° of trunk �exion, at which time the erector musculature begin to become less active and the ligaments (Figure 38, line 2) begin to play a progressively more dominant role in support of the trunk. As the ligaments take on the support function for the lumbar erectors, the hip extensors become the prime movers by eccentric contraction (Figure 38, line 3). �e erector musculature makes a signi�cant contribution to the extension movement through passive tension of the series elastic element.

When returning from a forward �exed lifting posture, as shown here, the pelvis initiates trunk extension via concentric contraction of the hamstrings and gluteus maximus as shown in Figure 38, line 3. �e thoraco-lumbar fascia acts as a strong support member of the lumbar spine and is held taut by contraction from the latissimus dorsi, internal oblique and transversus abdominis, and by traction created by the posterior pelvic tilt of the pelvis. As the trunk approaches 45° extension, the ensuing contraction/expansion of the erector spinae musculature activates the hydraulic support mechanism.

1

2

3L: Ligamentous system

M: Muscular system

Figure 38: Modi�ed from Low Back Pain Syndrome by Cailliet1.

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Choosing a Lumbar Lifting Position

Normal lumbo-pelvic rhythm is essential for:

• E�cient force-couple action between the hip exten-sor mechanism and the trunk extensor mechanism.

• Transference of load from the hip extensor mecha-nism to the trunk when lifting and trunk to hip when setting down an object.

• Protection of the lumbar discs by minimizing disc pressure between 45° and 90° trunk �exion/exten-sion during the concentric and eccentric phases of loading.

• Di�erentiation of lumbar lifting postures, it’s your choice!

• �ere is signi�cant evidence supporting the use of sustained lordosis when performing heavy lifts (Figure 40). �ere is also very strong evidence that the body is designed to use a kyphotic lifting posture (Figure 39) in conjunction with normal lumbo-pelvic rhythm. For further reading on the function of the posterior ligamentous system, I recommend �e Spinal Engine by Serge Gracovetsky3.

Figure 39: Kyphotic Lifting Posture

Figure 40: Lordotic Lifting Posture

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Study 1Erector Spinae Activation and Movement Dynamics About the Lumbar Spine in Lordotic

and Kyphotic Squat Lifting

By James A. Holmes MA, PT, Margot S. Damaser BS and Steven L. Lehman PhDSpine, Vol. 17, 1992. (pg. 327-334)

• During unloaded lifting there are greater changes in the angle of the lumbar spine when using the kyphotic posture (60-70°) versus using the lordotic posture (10-25°) for the entire lift.

• In lordotic lifts the EMG activity is highest at the beginning of the lift and tapers o� through the rest of the movement.

• �e initial torques at L3 from both postures are highest at the beginning of the lift due to inertial forces. �e inertial forces accounted for 8-19% of the total torque at the L3 joint.

• �e maximum EMG amplitude for loaded lifts (lifting a 30 pound (13.6 kg) box) were approximately 50% higher for lordotic and 30% higher for kyphotic lifting postures than without a load. �is is an example of how the lordotic lifting posture may increase the chances of muscles strain in the lumbar erectors while per-forming heavy lifts from low levels.

• Torques during the lifts are approximately the same, although they are sustained by a highly �exed spine in the kyphotic position.

• Lifts in this study were accomplished over a 1.5 second time period. If the lift time was cut in half (.75 sec-ond) the accelerations and inertial torques would be four times as large.

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Study 2Myoelectric Activity and Sequencing of Selected

Trunk Muscles During Isokinetic Lifting

By Donald A. Noe et.al. Spine, Vol. 17, No. 2, 1992. (pg. 225-229)

�is study compared trained weightlifters to a control group of asymptomatic non-weightlifters in the perfor-mance of �oor to knuckle (waist) isokinetic dead lifts. Speeds of testing were 30.5 cm/second and 45.7 cm/second.

Findings: Weightlifters and control subjects used a similar strategy with the latissimus dorsi. �is muscle is used extensively during the �rst 70-80% of the lift height to both tighten the thoracolumbar fascia and bring the load closer to the body, improving the body’s mechanical advantage.

Weightlifters were able to achieve maximum force at 50% of their lift height while non-lifters achieved maxi-mum force at 67% of their lift height. Based on known biomechanical factors, this would implicate improved use of the gluteus maximus and hamstrings during the �rst half of the lift in the trained weightlifters versus the control.

�e fact that trained lifters achieved maximum force earlier and maintained it longer is likely due to the fol-lowing:

1. Mechanical and neural training e�ects which allow them to optimally sequence the synergistic action of their muscles.

2. Trained lifters showed a greater amount of gluteus maximus activity in the early stages of the lift. �is is important for the following reasons:

- Posterior rotation of the pelvis works synergistically with the latissimus dorsi to bring the load closer to the trunk, improving the mechanical advantage of the other muscle groups.

- �e gluteus maximus is able to provide a stable pelvis against which the erectors can extend the trunk.

- Although not mentioned in this study, the posterior rotation of the pelvis by the gluteus maximus trac-tions the thoracolumbar fascia inferiorly against the pull of the latissimus dorsi superiorly, which when coupled with the abdominal mechanism creates the best possible environment for the hydraulic ampli-�er mechanism. �ey do mention the latissimus dorsi/thoracolumbar facia mechanism without the glu-teus maximus force couple.

�e controls were found to activate the quadriceps initially during the lift to extend the knees, with quadriceps activity steadily levelling o� between 67-83% of the lift height. At this time the responsibility of completing the lift was passed over to the erector spinae and gluteus maximus. �e trained lifter was found to initiate the lift with a combination of quadriceps and gluteus maximus activity. �e simultaneous extension of both the hips and the knees results in signi�cant early force production, stabilizing the trunk and pelvis, which improves the mechanical advantage for other muscle groups, particularly the erector spinae.

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Paul’s comments: It becomes evident that transference of strategy from the trained weightlifter to the worker, who by trade is more susceptible to lifting-related back injuries, is an important transition for both doctors, therapists and trainers.

An important step in this direction is teaching the untrained lifter/worker to more e�ectively utilize the gluteus maximus and quadriceps to maintain activity throughout the lift, thereby reducing the load on the erector spinae. Strength training of the individual muscle groups, followed by integration training would be helpful. An example would be the natural progression of the sedentary individual from simple (single joint) exercises to more complex multi-joint exercises.

Study 3The E�ects of Lumbar Posture on Lifting

By Dennis L. Hart PT, Ph.D., Terrence J. Stobbe Ph.D. and Majid Jaraiedi Ph.D.Spine, Vol. 12, No. 2, 1987. (pg. 138-145)

In a study of twenty laborers, a 157 pound (71 kg) crate was lifted to three di�erent heights to determine if �exion movements, trunk muscle or trunk muscle activity were a�ected by lifting postures. �e results were as follows:

• During the study there were 10 painful lifting episodes, 80% of which occurred while using the kyphotic lifting posture. �e straight spine posture accounted for 10%, while the lumbar lordotic posture also resulted in 10% of the painful lifts.

• �e lordotic lifting posture minimized ligamentous strain and disc compression forces.

• When comparing the EMG activity of the erector spinae during the lifts with both a lordotic and kyphotic posture (under the same acceleration factors), the lower EMG activity was found with the kyphotic posture. Because the forces are the same, and the EMG activity is lower in the kyphotic posture, the increased load on the connective tissues may increase the probability of sprain, and of muscular strain.

• �e lordotic posture may stabilize the lumbar spine better than other postures and may o�er reduced prob-ability of injury under those stable conditions.

• �e di�erent postures appear to be under di�erent motor control programs.

• �e kyphotic posture or exaggerated posterior pelvic tilt is not recommended for lifting tasks, particularly from the lower hand heights.

�e current results support the previous �ndings that emphasize the need for lordosis and do not support the �ndings that the best posture for lifting uses lumbar kyphosis.

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Study 4The Loads on the Lumbar Spine During Extreme Weightlifting

By Hans Granhed MD, Ragnar Jonson MS and Tommy Hansson MD, PhD.Spine, Vol. 12, No. 2, 1987. (pg. 146-149)

�is study showed that the bones adapt to repetitive heavy lifting, as evidenced by increases in bone mineral content in those lifters who lifted over 1,000 tons of weight annually. �is is believed to be one reason the hu-man spine can tolerate extraordinary loads.

It is well known that ligaments will hypertrophy when exposed to repeated stress. �is fact has relevance to the fact that the kyphotic posture utilizes the posterior ligamentous system and is likely the way we are designed to lift.

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THE INNER UNIT

Central Generation of Stabilization

�e Inner Unit became a term describing the functional synergy between the transversus abdominis and pos-terior �bers of the internal obliques, pelvic �oor muscles, multi�dus and lumbar portions of the longisssimus and iliocostalis, as well as the diaphragm. Research showed that the Inner Unit was under separate neurological control from the other muscles of the core (rectus abdominis, external obliques and anterior �bers of the inter-nal obliques). �is explained why exercises targeting muscles such as the rectus abdominis, external obliques and psoas, the same muscles exercised with traditional abdominal conditioning programs used in gyms and athletic programs worldwide, were very ine�ective at stabilizing the spine and reducing chronic back pain.

To accomplish automatic re�ex control of the Inner Unit requires speci�c isolation training to enhance sensory-motor control. Once control has been establish, activation of the Inner Unit must be programmed into all movement patterns commonly used by the host. Failure to condition the Inner Unit to a high level of speci�city often results in spinal injury due to instability.

Core

Pelvis and Shoulder Girdle

Leg-Arm

Figure 41 Figure 42

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Thoracolumbar Fascia Biomechanics

Lateral traction from the transversus abdominis (TVA) and the internal oblique (IO) are transferred into the thoracolumbar fascia through the lateral raphe. �e �bers of the posterior layer of thoracolumbar fascia travel inferiorly, inserting into the spinous processes of L4 and L5 and �bers from the deep lamina traverse upward to the spinous processes of L2 and L3. Because of this orientation, lateral traction on the lateral raphe by the TVA and IO results in an extension force on the lumbar spine. �is abdominal mechanism is what is termed the critical point. At approximately 90% of maximum lumbar �exion (45°) there is a change from muscular to ligamentous support, and vice versa when coming from �exion to extension. It is during this transfer phase (critical point) that abdominal support for the lumbar spine is of great importance. If the abdominal muscu-lature are weak or uncoordinated there is a momentary loss of support for the lumbar spine, greatly increasing the chance of an injury.

Hydraulic Ampli�er Mechanism

As the erector spinae musculature contract, they expand. Because they are encased in a sheath of thoracolumbar fascia, their expansion creates intercompartmental pressure (ICP). �is ICP creates “hoop tension” within the fascial sheath, with the net e�ect being a pressure or hydraulic erection force.

When the trunk is forward bent to near maximal lumbar �exion, the erector musculature are electrically silent. At this point there is tremendous elastic tension created in the erector musculature. �is tension force is added to that of the stored elastic energy of the posterior spinal ligaments, as well as the force created by the abdominals through the thoracolumbar fascia. Intra-abdominal pressure, thoracolumbar fascia gain and hydraulic erection all act as a force couple with the gluteus maximus and hamstrings to perform lifts from a forward bend position.

12th rib

TVA

psoas

Figure 43: �oracolumbar Fascia Biomechanics

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Spine Stabilization & Deep Abdominal Wall Activation

�e intra-abdominal pressure mechanism alleviates between 12% and 36% of the load (A) in the lumbar spine at the L4 and L5 levels. As the abdominal mus-culature contracts against the viscera (B), the organs are pushed superiorly into the contracted diaphragm and inferiorly into the pelvic basin. �e result is eleva-tion of the diaphragm, which through it’s attachments to the L2 and L3 vertebrae creates a decompression force (C).

A

B

C

Figure 44: Intra-abdominal pressure mechanism

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Weight-belt Considerations

Intrinsic Hoop Tension vs. Extrinsic Hoop Tension and Spine Stabilization

Figure 45, A1: Because the transversus abdominis and internal oblique muscles place lateral tension on the thoracolumbar fascia, which is intimate with the transverse processes and spinous processes of the lower lumbar segments (Figure 45, A2), intrinsically generated hoop tension actually provides segmental stability.

Figure 45, B1: Tightening a weight belt around the waistline compresses the abdominal viscera, but there is no direct connection to the spine itself.

Figure 45, B2: Although the belt provides gross stability/immobility through increased intra-abdominal pres-sure, the compressive loading and faulty recruitment patterns often associated with lifting with belts may con-tinue to produce aberrant motions at segmental levels of spinal joint structures. Once the belt is removed, the same faulty recruitment patterns, unaided by the gross stability of the belt often result in joint derangement, particularly in the L4/5 and L5/S1 motion segments.

Figure 45

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Abs In or Abs Out?

1. Prior to initiating any lift of adequate intensity to stop natural breathing, the breath is drawn inward, charging the thoracic cavity above the diaphragm. �e downward movement of the diaphragm pushes the viscera down, resulting in distension of the abdominal wall.

2. Just prior to initiating the lift, the umbilicus is drawn inward against the viscera, creating the hoop tension e�ect demonstrated on pg. 72 Figures 45, A1 & 2. �e breath may be held on descent or it may be released through pursed lips, depending on lift intensity and client health concerns.

3. As the body descends in the squat, or is exposed to greater �exion movements in any lift, the dia-phragm contracts to meet the demands of stability as necessitated by the load, further contraction of the powerful diaphragm against the abdominal results in an eccentric load on the TVA. Eccentric loading of the TVA in concert with progressively stronger recruitment from the outer layer of the abdominal wall often results in the umbilicus mov-ing outward.

1

2 3

3

Hilton’s Law: �e principle that the nerve supplying a joint also supplies both the muscles that move the joint and the skin covering the articular insertion of those muscles.

Figure 46

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THE OUTER UNIT

�e Outer Unit consists primarily of phasic muscles. �ere are several muscles, such as the obliques, quadratus lumborum, hamstrings and adductors, which serve a dual role, acting in a tonic role as stabilizers and a phasic role as prime movers. To be technically correct, we may say that Outer Unit functions are predominantly phasic functions geared toward movement.

Figure 48: Posterior and Anterior Oblique Systems

Outer Unit Recruitment

Foot -> Ankle -> Leg

Pelvis -> Core

Shoulder Girdle

Arm -> Hand

Figure 47

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Posterior Oblique System

In the propulsive phase of gait, there is a phasic con-traction of the gluteus maximus, which occurs in con-cert with that of the contralateral latissimus dorsi as it extends the arm as a means of counter rotation. �is timed contraction produces tension in the thoraco-lumbar fascia that will assist in stabilizing the sacro-iliac joint of the stance leg. Vleeming quotes Margaria, who states that the posterior oblique system may act like a smart spring, storing and releasing energy in the thoracolumbar fascia mechanism, which would re-duce the metabolic cost of walking.

Anterior Oblique System

�e adductors work in concert with the internal oblique and opposite external oblique abdominal muscles to both stabilize the body on top of the stance leg and to rotate the pelvis forward, positioning the pelvis and hip optimally for the succeeding heel-strike.

Figure 50: Loading the Anterior Oblique System

Figure 49: Loading the Posterior Oblique System

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Loading the Lateral System

�e Lateral System consists of a working relation-ship between the gluteus medius, (Figure 51 B) glu-teus minimus and ipsilateral adductors (Figure 51 C). �ere is also research indicating a working relation-ship between the gluteus medius and adductors of one leg with the opposite quadratus lumborum (Figure 51 A). Clinical experience strongly suggests that the oblique musculature is synergistic with the quadratus lumborum during the lateral sling functions, such as in a box step-up.

As you step up, the body must stabilize atop the left leg (see Figure 53). Contraction of the left gluteus me-dius and adductors stabilize the pelvis in concert with activation of the contralateral quadratus lumborum, which works to elevate the pelvis enough to ensure adequate freeway space for the swinging leg. Should the lateral system fatigue, you will be forced to progressively rely on passive supports, such as ligaments and discs in the pelvis and spine. Such lateral system dysfunction is a common source of injury in the back and legs.

The Lateral System

Figure 51 A: Quadratus lumborumB: Gluteus medius, minimusC: Adductors Figure 52

A

B

C

A: Quadratus lumborumB: Gluteus medius, minimusC: Adductors

Figure 53

B

A

C

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The Deep Longitudinal System

In Figure 54, the actions of the DLS can be seen in a boy running bases in a baseball game. As the right leg goes through swing phase there is posterior rotation of the right ilium relative to the sacrum (A), assisting in what is termed form closure or passive closure of the SI joint. In preparation for heel strike in the late swing phase of gait, the biceps femoris works to control both hip �exion and knee extension. �e action of the biceps femoris is transferred upward through the sacrotuberous ligament (B), assisting in force closure of the sacroiliac joint. �ere is a dual action in the lower leg with the contraction of the biceps femoris causing tension through the peroneus longus (C), which in concert with the anterior tibialis, stabilize the foot and ankle, creating a working platform the body can move across. When the foot strikes the ground, kinetic energy will be captured in the thoracolumbar fascia (D) for use in the propulsive phase. Kinetic energy will be dissipated through the paraspi-nal system and should be nulli�ed before reaching the occiput.

Figure 54: �e Deep Longitudinal System

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Inner/Outer Unit Synergy

THE WORLDS GREATEST WEIGHT BELT Inner and Outer Unit Integration

Figure 55 A: If your Outer Unit is dominant over your Inner Unit, as you bend forward to pick up a load, a string placed around the waist will become tighter as you pass through the critical point (~90% lumbar �exion). If the load is signi�cant enough to require activation of both Inner and Outer Units, the string will have become loose as you bend forward and tight as you lift the load.

Figure 55 B: When the Inner Unit is strong enough to provide adequate stabilization, you will stay under the stabilization threshold as you pass through the sticking point. Staying under the stabilization threshold is indicated by the fact that the rectus abdominis and external oblique musculature have not shortened and thickened, pressing on the string (Figure 55 B).

Figure 55 Figure 56: Inner Unit and Outer Unit Synergy

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Lumbo-Pelvic Rhythm, Lower Abdominal Strength and Lumbar Stability

Corsets and belts:

• Alter normal lumbo-pelvic rhythm

• May cause excessive L5-S1 loading due to a tracking e�ect

• Encourage faulty recruitment of the abdominal wall, resulting in loss of force closure of the SI joint

A B

A. SMA & WeaknessB. Excess Gross Stabilization

A

B

A. Functionally integrated deep abdomi-nal wall and interior external oblique recruitment as needed to control lumbosacral & lumbo-pelvic rhythm.

B. Abdominal wall dyscoordination syndrome typical of the low back pain patient.

Figure 57

Figure 58

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Understanding the Neutral Spine Philosophy

�ere are numerous interpretations of what the neu-tral spine philosophy really is. Although many believe it to mean that the spine is held rigidly in a �xed neu-tral position, this is an extremist’s interpretation. �e neutral spine range must be determined for each indi-vidual and is based on his/her own available range of motion (ROM), as well as considering pain-free range when working with exercisers experiencing back prob-lems.

As shown in Figure 59, neutral can be de�ned as the range between either extreme in any plane of motion. It should be noted that as one approaches end ranges of motion, there is always increased joint forces as well as stress on related soft tissues and ligamentous restraints. With this in mind, I suggest looking at the neutral spine with the idea that neutral is always the operating zone between extreme ROM in any plane(s).

Today, back pain patients are currently taught that they should keep their spines in anatomical neutral as much as possible. �is is especially important because of the following reasons:

1. Increased disc compression forces at end ranges of motion in the sagittal and frontal planes.2. Facet joints are compressed and often aggravated at end ranges of extension, rotation and on the ipsilateral

side in side-bending.3. End range movements of �exion coupled with rotation are especially harmful to the annulus �brosis.4. Anatomical neutral, or the position of comfort (often with natural spinal curves) is taught as the position to

try to maintain to minimize the stress on the lumbar spine and encourage dissipation of the stress through the upper and lower extremity joints (especially the hips).

I recommend that all exercise enthusiasts utilize the neutral spine philosophy whenever possible due to the fact that 85% of us will have a serious bout of low back pain at some point in our lives. �e only reward for un-necessary wear and tear is pain and early degenerative changes. Remember that degeneration aberrates function.

Figure 59

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Back Pain Considerations

MOTOR LEARNING

Motor learning: A set of processes with practice or experience leading to relatively permanent changes in skilled behavior. �ree de�ning characteristics of skilled performance are speed, accuracy and consistency.16

PSYCHO-NEUROMUSCULAR CONTROL

WheelOf

Movement

PYSCHO-NEUROMUSCULAR CONTROL

SENSORY-MOTOR PROCESSING

Stimuli

Challenge?-Terrain

-Predators

-Weather

-Competition

Ext. Environ. Int. Environ.

Control Centers

S.I.D

R.S.

R.P.

S.I.D

R.S.

R.P.

- Extroception

- Proprioception

- Interoception

Reflex Cognitive

SENSORY-MOTOR PROCESSING

Repetition is the mother of skill, provided there is skill in the repetitions. Engram motor programming is the goal. An engram can be de�ned as a neurophysiologi-cal phenomenon that contains the motor information necessary to perform a complex movement.10

Muscle imbalance may result from occupational or recreational activities in which there is persistent use of certain muscles without adequate exercise of oppos-ing muscles. Imbalance that a�ects body alignment is an important factor in many painful postural condi-tions.

Repetitive movement causes faults in the movement system elements (musculoskeletal, neurological and biomechanical systems) which leads to movement im-balances.

Mechanisms producing movement imbalances:

1. Changes in the force-couple acting on joint(s)2. Faults in the elements of movement:

- Muscle lengths and changes in the length-ten-sion curve

- Stability provided by connective tissue

- Relative �exibility

- Pattern of recruitment of synergists

- Forces acting on joints (kinetics)

Figure 60: Psycho-Neuromuscular Control

Figure 61: Sensory-Motor Processing

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Back Pain: A Developmental Problem?

• Back pain and muscle imbalance syndromes may result from childhood developmental dysfunction in about 20% of adults today.8

• To begin to understand how to apply exercise technology, you must �rst understand the etiology of back pain and problems.

• Tonic/Phasic Di�erentiation:

- Reptilian crawling

- Mammalian crawling

TONIC/PHASIC DIFFERENTIATION - REPTILIAN CRAWLINGTONIC/PHASIC DIFFERENTIATION

Reptilian Crawling

MAMMALIAN CRAWLINGMAMMALIAN CRAWLING

Figure 62: Reptilian Crawling

Figure 63: Mammilian Crawling

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Developmental De�ciency

• �e torso serves as a critical link between the upper and lower extremities. (Figure 64).

• Children who are underdeveloped in the reptilian and mammalian crawl phase of development fre-quently display poor posture, muscle imbalance and chronic pain syndromes as adolescents and adults. (Figure 65).

• Premature use of walkers and Jolly Jumpers impair development.

C++

C++R -

R -

Figure 64 Figure 65

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Control Centers of Stress

• Everything made by Mother Nature and man is under the in�uence of control systems, control centers and the Laws of Nature.

• To perform a good evaluation of your client, you must be skilled, and you must be conscious and cognitively alert.

• Would you �y without a pre�ight check? �e greater the load, the greater the risk.

Physiological Load Assessment

• Past medical history

• Current medical history

• Control systems survey

• Response selection

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Subtle Body

Gross Body

During any evaluation or during any therapeutic intervention or exercise program, it must be remembered that all gross and subtle control systems work synergistically. �e body will always seek the path of least resistance while attempting to maintain homeostasis.

Adopted from Posture & Craniofacial Pain by Paul Chek

M.S. Visceral Hormonal Limbic

Physical Emotional Mental Spiritual

Control Systems Overview

SUBTLE BODY INTEGRATIONS AND ENERGY KINETICS

Figure 66: Subtle Body Integrations and Energy Kinetics

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Physiological Load

All stressors enter the body and are interpreted by exoreceptors, proprioceptors and interocepters, which inform the control systems via nervous, hormonal and immune communication systems. Stressors are theorized to summate in the human body, resulting in an overall stress response. While a given amount of physiological stress is necessary for optimal physiology, progressively higher levels of stress decrease the body’s ability to adapt and may result in a prolonged catabolic response. As the client becomes more symtomatic, their response tolerance for exercise diminishes.

Figure 67: Physiological Load

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RESPIRATORY SYSTEM

Respiration:

• Mobilizes CSF to nourish and remove metabolic waste from the CNS

• Provides oxygen for cellular metabolism

• Maintains acid/alkaline balance

• Moves life-force energy (Chi, Prana) through the body

Control Centers - Totem Pole of Life

Respiratory

Mastication

Visual

Auditory/Vestibular

Upper Cervical

Visceral

Limbic/Emotional

Sacro-coccygeal

Slave Joints

Figure 68: Control Centers - Totem Pole of Life

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Respiratory System

• Any exercise stimulus producing chronic adaptation of C>R in the R-C factor, results in structural adaptations that retard respiratory e�ciency (Figure 69).

• Exercises such as those shown in Figures 70-71 can retard respiration e�ciency.

• �e results are far reaching and frequently overlooked or misinterpreted.

Figure 69: R-C Factor

R= resistanceC= contraction(see page 26 for more information on the R-C Factor)

Figure 70

Figure 71

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Respiratory System

Category IAnteroposterior

Sway Category III

Category IILateral Sway

Phases of compensation to maintain cerebral spinal pump mechanism as proposed by De Jarnette. �is is a classical demonstration of the phases of compensation demonstrated in a client su�ering blockage of the sacroiliac joint, with or without low back pain. Disc bulges are a common end product decompensation.

Figure 72 Figure 73

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• �e abdominals are stabilizers that serve respiratory function.

• �e diaphragm is a respiratory muscle that serves stabilizer functions.

Respiratory System

RIB CAGE MOBILIZATION

Figure 74: Rib Cage Mobilization

Figure 75: Abdominal Function During Respiration

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Mastication

ASSESSING BITE

• CRN V

• Communicates with all CRN

• Periodontal re�exes via acupuncture meridians to all tissues of the body

• Centric occlusion

• Eccentric occlusion

The Visual System

• Focal Vision

- Character recognition and target acquisition

• Ambient Vision

- Proprioception

- Compensates for proprioceptive de�ciencies

• Lloyd Mills, an ophthalmologist, and C.L. Lowman, an orthropedist, noticed the connection between pos-ture and ocular dysfunction in 1915.

• Gross ocular muscle defects and irregular astigmatism, of notable degree, occurred in the proportion of about 3.2:1.

• As far back as 1916, Weeks was quoted as believing that the habit of tilting the head to one side was a very common one, occurring in 25% of the patients who consulted him for errors of refraction or of the extrinsic ocular muscles.

Hit and slide assessment: When you click your teeth together standing in good posture you should only hear one click.

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Vestibular System

• Hearing

• Balance

• Postural righting

Cranio-Cervical System

• Highly integrated with ocular, vestibular, pelvic, foot and ankle proprioceptive systems

• Origin of tonic neck re�exes:

- Suboccipital spindle cell density of 150-200/gram

- Intertransverse muscles at 200-500 spindle cells/gram

• Around 70% proprioception in gait from C0-C3-4

- Blocked upper cervical proprioception in monkeys results in falling during gait and climbing!

- Cervical mechanoreceptors re�ex to limbs and trunk

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Cranio-Cervical Control

• Upper cervical balance

• Good alignment

• Rotational e�ciency

• Good engrams

• Pain free

Cranio-Cervical Integration

Righting re�exes – keeping the head in a normal position and adjusting the body parts in relation to the head and vice versa. �ese reactions tend to be dominant when moving across a �xed or stable surface.

Equilibrium Reactions (Tilting Re�exes) – �ese reactions are developed in us as children for the purpose of maintaining or regaining control over the body’s center of gravity, thus preventing us from falling. �ese reac-tions tend to be dominant when on an unstable surface.

Figure 76

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The Visceral System

• �e visceral, circulatory and immune systems are supported by free-movement in a 3-dimensional environment under the in�uence of gravity.

• Today, visceral ptosis secondary to Inner Unit dysfunction is common among both the exercising and non-exercising populations.

• Visceral health

- Women su�er more than men

• Musculoskeletal strain

• Reduced vitality

- Increased likelihood of prescription drug use

• Any condition reducing visceral support, motility or health will adversely a�ect the circulatory, lymphatic and immune systems.

- Subtle and gross energetics is a two-way street in the recovery process from back pain.

• When the abdominal wall is dysfunctional, the intestinal tract may fall, compressing a women’s sex organs.

• Back pain and painful menstruation commonly result

- Dysfunction in males is less pronounced, but exists

• �e Abdominal Brain - Solar Plexus

• Visceral Somatic Re�exes

• Torso �xation and stabilization:

- Negates TVA activation

- Does not provide natural deformation of torso

- Creates localized circulatory stress without global circulatory support

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Limbic/Emotional

�e limbic/emotional symbol is a �oating symbol on the C.H.E.K Institute totem pole system. �e limbic/emotional aspects of any human being are powerful enough to override any bodily system, even causing death.

Sacrooccipital System

• Sacrum and occiput serve as functional links in the cerebral spinal pump mechanism.

• A neuromechanical relationship exists between the occiput and sacrum, the temporal bones and ipsilat-eral illium and the sphenoid and coccyx.

Figure 77

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Slave Joints & Systems

MUSCULAR SYSTEMS

Inner Unit system(s) - Stabilizer/phasic

Outer Unit systems - Mobilizer & phasic

SKELETAL JOINTS

• Spine (C3-L5)

• Hip, knee, ankle and foot

Practical Application

• Review history for red �ags and potentional control center problems

• Sectionalize problem

• Localize problem and coach accordingly

• Mutlidisciplinary integration

• Re-evaluate

Now that you have additional information on what to look for, start asking questions related to the totem pole.

• �ere is no “back” - the body is fully integrated!

• Stability and mobility are pattern speci�c!

• Always look to control centers before addressing slaves!

• When in doubt, refer them out!

Conclusion

Whenever working with a client presenting with low back pain or chronic musculoskeletal dysfunction, it is imperrative that the exercise professional seek medical assistance. It is highly unlikely that long-term resolution can be achieved without restoring function to all control systems! �e C.H.E.K approach is a multi-disciplinary approach and is based on a coaching model, not a treatment model.

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ASSESSMENTSComparative Range of Motion (ROM) Assessments

Note: Always test right and left; anytime you have more than a 10% di�erence from side to side is a concern as it causes torsion. It is best to use a goniometer (used for measuring joint angles) for these assessments to compare results when doing a re-evaluation.

ANKLE DORSIFLEXION Keys to ObserveTo assess ankle dorsi�exion, have client lie supine on a table with legs straight. Have the client pull their toes toward them as far as they can. �is is assessing gastrocnemius �exibility when the knee is straight. To assess soleus �exibility, have the client bend the knee to at least 15°.

Normal is 20°

Note: Any tension on gastrocnemius places tension on hamstrings and a�ects the whole body.

HAMSTRING FLEXIBILITY AT THE KNEE – HIP AT 90 DEGREESKeys to ObserveClient lies supine on table with legs straight. Placing your hand under client’s back, �nger on L3, have the client bend the hip to 90°, foot in anatomical neutral. Force the leg straight to avoid getting a faulty reading. Ask the client to raise their lower leg and have the cli-ent stop lifting their leg when you feel them starting to �atten their lumbar curve.

Normal is 170°

HAMSTRING FLEXIBILITY AT THE HIP - STRAIGHT LEG RAISEKeys to ObserveClient lies supine on table, with legs straight, foot in anatomical neutral, placing your hand under client’s back, �nger on L3 (Figure 77). Ask the client to raise their leg and have the client stop lifting their leg when you feel them starting to �atten their lumbar curve.

Normal is 90°

Figure 78: Ankle Dorsi�exion

Figure 79: Hamstring Flexibility at Knee

Figure 80: Hamstring Flexibility at Hip

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SIT AND REACH TEST – LOOKING AT LUMBAR FLEXIONKeys to ObserveUse goniometer and place it on the shelf of the sa-crum. As they bend forward see how much is coming from lumbar spine. �e further back the goniometer goes, the tighter the hamstrings are. Are they going into lumbar �exion or keeping lumbar lordosis? �is tells you if the hamstrings are tight relative to the low back.

SINGLE KNEE TO CHEST TEST Keys to ObserveWhat are the hamstring and glutes doing to the spine? Does the spine move before 125°? If so, it is an insult to the system.

Client lies supine on table, with legs straight, foot in anatomical neutral, placing your hand under client’s back, �nger on L3. Take one leg, bend the knee and lift the leg into hip �exion, knee coming into chest. Stop lifting when you feel them starting to �atten their lumbar curve.

Normal is 125°

DOUBLE KNEE TO CHESTKeys to Observe�is tests the relative �exibility of the hamstrings and glutes relative to the low back. Failing the double knee to chest test when you pass the single knee to chest test means the resting tone for the thighs overrides the resting tone of the lumbar spine.

Client lies supine on table, with legs straight, foot in anatomical neutral, placing your hand under client’s back, �nger on L3. Take both legs, bend the knees and lift the legs into hip �exion, knees coming into chest. Stop lifting when you feel them starting to �at-ten their lumbar curve.

Normal is 110°

Figure 81: Sit snd Reach Test

Figure 82:Single Knee to Chest Test

Figure 83: Double Knee to Chest

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HIP ABDUCTION - TESTING ADDUCTORSKeys to ObserveClient lies supine on table, with legs straight, foot in anatomical neutral. Block the pelvis by placing hand on shelf of the ilium. Keep foot in anatomical neutral the entire time. Take the leg on the side opposite you are holding the pelvis and move foot out until you feel pelvis beginning to move.

Normal is 35°

HIP ADDUCTION - TESTING ABDUCTORSKeys to ObserveClient lies supine on table, with legs straight, foot in anatomical neutral. Block the pelvis by placing hand on shelf of the ilium. Keep foot in anatomical neutral the entire time. Take the leg on the opposite side you are holding the pelvis and ask client to lift their leg and move foot toward you until you feel the pelvis beginning to move.

Normal is 35°

THE PRONE KNEE FLEXION-TESTING QUADSKeys to ObserveClient lies prone on table, with legs straight, foot in anatomical neutral. Anchor the pelvis and bend one knee toward the butt, watching for when the pelvis starts to rotate anteriorly. Watch for wash boarding of the low back.

Normal is getting the heels to the butt

THE PRONE HIP EXTENSION TEST – TESTING HIP FLEXORS Keys to ObserveClient lies prone on table with legs straight, foot in anatomical neutral. Keeping the leg straight, anchor the pelvis and lift the leg up. Watch for wash boarding of the spine and anterior pelvic tilt.

Normal is 30°

Note: A better test is the Ober’s test.

Figure 84: Hip Abduction

Figure 85: Hip Adduction

Figure 86: Prone Knee Flexion

Figure 87: Prone Hip Extension

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THE MCKENZIE PRESS-UP TEST - TEST-ING SPINAL EXTENSIONKeys to ObserveClient lies supine and positions the hands so the wrists are level with the shoulders to standardize the mea-surement. Client relaxes butt and inhales and then exhales as they come up as far as they can. Place your hand on client’s pelvis. When client’s pelvis starts to come o� table, have them stop. Look at spine to see if there is equal extension throughout the spine, are the vertebra coming together?

Normal lumbar extension is when client can fully extend arms with pelvis anchored to the table or �oor.

INTERNAL HIP ROTATION TEST Keys to ObserveClient lies supine on a table, bend the right knee keeping femur straight on the table, anchor left pelvis lightly so you can feel when it tries to move and bring the right foot out (internal rotation) until the pelvis tries to move. (Direction of rotation is indicated by knee, not foot). Repeat on other side.

Note: You can test both sides at the same time to compare right and left.

Normal internal rotation is 40°

EXTERNAL HIP ROTATION TEST Keys to ObserveClient lies supine on a table, bend the right knee keep-ing femur straight on the table, anchor right pelvis lightly so you can feel when it tries to move and bring the right foot toward the body (external rotation) un-til the pelvis tries to move. (Direction of rotation is indicated by knee not foot).

Note: You can test both sides at the same time to compare right and left.

Normal external rotation is 45°

Figure 88: McKenzie Press-up

Figure 89: Internal Hip Rotation Test

Figure 90: External Hip Rotation Test

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THE SEATED TRUNK ROTATION TEST – TESTING SPINAL/TRUNK ROTATION Keys to Observe�e client sits on a table, legs hanging o� the end, with knees up against table to minimize pelvic rota-tion, hands across chest and have them turn their body as far as they can. �ey should be able to rotate shoulders to 90°. �is tells us how much trunk rota-tion the client has with the pelvis anchored.

Can also test with client lying on back, arms out to side palms up, and knees at 90°. Client should be able to rotate the thighs all the way to the �oor without op-posite shoulder coming o� the �oor. �is tells us how much trunk rotation they have with the trunk anchored.

Normal is 90°

STANDING SIDE FLEXION TEST –TESTING THE TIGHTNESS OF THE QUADRATUS LUMBORUMKeys to ObserveClient stands against a table with feet together, bare feet, arms to the side, client needs to side bend as though they are following a wall. �ey cannot rotate or let opposite foot come o� the �oor. Client side bends and tries to get the �nger tips to the knee. Mea-sure how far they can get the middle �nger on each side. If the client cannot reach their knee they need to stretch, the stretch is the same as the test.

Figure 91: Seated Trunk Rotation Test

Figure 92: Standing Side Flexion Test

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PRONE BUTT SQUEEZE TESTKeys to ObserveHave the client lie prone on a table or the �oor and ask the client to pick up their legs, with straight legs. (you can bend the legs to take hamstrings out of the test) up in the air as high as they can and then you check the tone of the glutes. Assess to see if the cli-ent has the ability to tighten the glutes equally. If the client cannot tighten glutes equally, that tells you the client needs a comprehensive assessment of the spine and all the control factors.

Note: Assesses for a compressive pathology that re-duces normal conduction through a nerve, shows up as an inablility to actively recruit the glutes from one side to the other. You know someone needs this test if when looking at the gluteal skyline you see that one butt cheek is larger than the other when they are lay-ing prone. Sometimes people have a larger butt cheek on the their dominant side. If they have a larger butt cheek on the side they are not dominant on, you need to perform the prone butt squeeze.

SCOLIOSISFunctional Scoliosis Term that describes spinal rotation due to compensation somewhere in the system. Can be neutralized.

Strucutal Scoliosis As client grew through puberty, their spine was crooked and the force of growing through puberty with a crooked spine causes the bones to grow crooked. �is cannot be easily corrected.

Assessments

Figure 93: Prone Butt Squeeze Test

Figure 94

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Recognizing Spinal RotationsKnow When to Refer Out

FORWARD BEND TESTKeys to ObserveWhen beginning an exercise program containing axial loading of the spine (squats, military press, etc.), or ex-ercises which place signi�cant �exion stress on the spine (low pulls, dead lifts, good mornings), it is important to identify any form of scoliosis.

If a structural scoliosis is present, when the exerciser bends forward there will be prominence of the ribs on the convex side (rib hump) of the curve (Figure 95). In a functional scoliosis, when the exerciser stands with their back toward you they may have one hip higher than the other and the spinal curves can be seen (Figure 96). Unlike the structural scoliosis, when the exerciser with functional scoliosis bends forward, the spine straightens and looks normal.

If an exerciser presents a history of back or neck pain, it is important to check their spinal alignment with visual inspection and the forward bend test. If you identify either type of scoliosis, a thorough examination by a spine rehabilitation specialist is necessary. �is is because excess stress often builds up at the transitional vertebra as a result of gravitational stress and axial loading from exercise. �e transitional vertebra are often in the apex of a lateral curve or transitional zone, atlas, thoracic apex, lumbar apex, lumbosacral junction. It is often in these locations that pain will develop.

Figure 95

Figure 96Referenced for educational purposes from �eraputic Exercise.

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WALL STANDING TEST FOR LUMBAR LORDOSIS OR LUMBAR CURVEKeys to ObserveHave your client stand with their back, buttocks, heels, shoulders and head against the wall and place their hand behind their back at belt line level.15 (Figure 97).

Normal lordosis: �e thickest part of the hand will just �ll the gap between the wall and the back.

Excess lumbar curvature: �e hand will slide right through.

Flat back (reduced lordosis): Only the �ngers will �t behind the back.

Note: �is technique provides only a good guestimate. It is not meant to be objectively sound, but is fairly reliable.1

Note: �is test gives you an indication of which exercises to give clients to help get their curve toward normal.

LUMBOPELVIC RHYTHM TEST Keys to Observe• �is test assesses the relationship between the lumbar spine and pelvis

with regard to forward bending.

• �is test requires good palpitary skills.

• Hold the clients pelvis at the ASIS and PSIS and ask the client to bend over like they are picking up a pair of socks. What you are feeling for is when their pelvis begins to move.

• At the point their pelvis begins to move, take a measurement.

• Normal lumbo-pelvic angle is 50°.

If a client measure less than 50° the following dysfunctions may be present:• Premature stretch of hamstrings (hypermobility).

• Reduced �exion in the lumbar spine causing guarding in the lumbar spine and reduces the pumping mechanism in the lumbar spine.

If a clients moves after 50° the following dysfunctions may be present:• Hamstrings and glutes are restricted.

• Posterior ligamentous system is stretched out.

Figure 97

Figure 98: LumboPelvic Rhythm Test

Note: �is tests assesses the relationship between the lum-bar spine and the pelvis with regard to forward bending.

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Corrective Back ExercisesDynamic Warm-ups and Self Mobilizations Phase One

Part 1 of 2

Phase One ExercisesExercises with no axial loading, this includes standing. �ese exercises should be used with any client who experiences pain in a standing position or when accepting an axial load.

FELDENKRAIS HIP & PELVIS INTEGRATORKeys to ObserveSet up• Lie on your back and bend your right leg, with your

right arm at your side left arm extended.

Execution• Gently push onto your right foot, so that you just

barely lift your pelvis up until L5 starts to lift and then relax (You should use as little e�ort as possible, imagine that you have a puppet string attached to the front of your pelvis that is lifting you up). Con-tinue to do this one vertebra at a time and return to the start position one vertebra at a time until you lift each vertebra of the spine. �e exercise ends when the client rolls all the way over on their side, the head and neck are relaxed. Whenever you come back to start, you reverse the movement one verte-bra at a time.

• Perform 10-20 repetitions, progressively rolling your pelvis forward, lifting just a little more of your spine o� the ground with each repetition.

• Repeat on the other side.

Note: Clients will try to lift in big blocks so be sure they move one vertebra at a time, so thatthey learn to move those restricted areas.

Figure 99: Feldenkrais Hip & Pelvis Integrator

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FELDENKRAIS SHOULDER/SPINE INTEGRATORKeys to ObservePhase I• Lie on your side with a foam roller, or towel just big enough to maintain good neutral neck alignment,

placed under your head. Your neck should be parallel with the �oor. Tongue on the roof of the mouth.

• Your hips and knees should be at 90°angles with your feet on top of each other.

• Place your top hand on your forehead and gently rotate your neck backwards as you inhale. Watch for any areas that are stuck. Client should be in complete relaxation.

• Exhale and return to the start position.

• Perform 16-20 reps, at a slow tempo, allowing your neck to rotate a little further and your arm to drop a little closer to the �oor each time. You should use as little energy as possible.

Phase II• Assume the same starting position as Phase I, but place your

arms out in front and on top of each other.

• Exhale as you reach forward then slowly bring the top arm across the body all the way until the hand touches the shoulder.

Phase III• Phase III is performed much the same as Phase II, except

you will also be moving your top leg forward over the bot-tom leg. �e feet stay together and the arms remain still. Client will �nd their natural breathing rhythm.

• Let the torso move naturally. Do not try to keep the move-ment isolated to the pelvis.

Phase IV• �is is the most challenging phase, combining Phase II and Phase III. Slide top hand back to to where hand

is on shoulder and slide top leg forward and return to start position.

• �e client has to time it so the hand and leg reach the end position at the same time. Perform 16-20 reps.

Note: If someone has trouble doing this exercise start with the side they havethe easiest time doing the exercise.

Figure 100: Phase I

Figure 100: Phase II

Figure 100: Phase III

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MCKENZIE PRESS-UPKeys to ObserveSet up• Lie face down on the �oor with your hands placed

just outside the top of your shoulders.

Execution• Inhale deeply and press your upper body upward

as though doing a push-up, but keep your pelvis on the ground. It is important to relax the glutes and spinal muscles while performing the McKenzie Press-up.

• As you push your body upward, exhale.

• Repeat 10 times, beginning with one set and work up to 3 sets.

Note: You may also perform a standing back extension in a similar manner. Back extensions should follow any activity involving prolonged or loaded �exion. �is is a phase two exercise so use with caution if your client is still in phase one.

Figure 101: McKenzie Press-up

Figure 102: Standing Back Extension

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FOAM ROLLER LONGITUDINAL MOBILIZATIONKeys to Observe• Client lies on the foam roller with their head on one

end and sacrum on the other.

• Client relaxes completely.

• Start with 1 minute and progress to 15 minutes. Best to do right before exercise and bed.

• You can also let the head turn left and knees right and alternate back and forth to get a gentle rotation on the spine.

Note: �e more thoracic kyphosis they have, the less time they spend on the foam roller.If it is too uncomfortable, then place a towel under the head.

FOAM ROLLER SEGMENTAL MOBILIZATION Keys to Observe• Place the roller horizontal along the area where it is

hard for them to extend the thoracic spine.

• Have the client cradle their neck and lie back over the roller until it feels like the vertebra is being mo-bilized, after 3 seconds come forward and then lay back again.

• Mobilize each vertebra in the zone of restriction at least 3 times.

• Exhale as you go backwards. Only come up until you decompress the joint.

• Do not mobilize above or below the restriction.

Note: �is mobilization can cause a kinetic shift, so be sure to cradle the neck.

Figure 103: Foam Roller Longitudinal Mobilization

Figure 104: Foam Roller Segmental Mobilization

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HORSE STANCE VERTICALKeys to ObserveSet up:• To start, place your wrists directly below the shoul-

ders and your knees directly below the respective hip joints, thigh is vertical. �e legs are parallel and the elbows should remain turned back toward the thighs with the �ngers directed forward.

• Place a dowel rod along your spine and hold perfect spinal alignment. Bend the arms with elbows facing backwards until the dowel rod is horizontal. �e space between your lower back and the rod should be about the thickness of your hand. �e dowel rod should make 3 points of contact, the head, middle back and sacrum.

Execution:• Activate the TVA by drawing the belly button inward.

• Lift one hand o� the �oor just enough to slide a sheet of paper between the hand and the �oor. �e opposite knee is then elevated o� the �oor to the same height.

• Hold for 10 seconds and switch sides.

• Perform 10 times on each side for a total of 20 reps.

Modi�cation:If a client has trouble maintaining bent elbows to keep the dowel rod horizontal, have them place forearms on a bench or box.

Note: When performing corrective exercises with a dowel rod, the dowel rod should be 6 feet by 1 3/8 inches, the same as a typical closet rod. �e 3 points of contact on the dowel rod for postural alignment are the head, middle back and sacrum.

Corrective and Non-compressive ExercisesPhase One Part 2 of 2

Figure 105: Horse Stance Vertical

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HORSE STANCE HORIZONTALKeys to ObserveSet up:• Start with wrists directly below the shoulders, elbows turned back and knees directly below the respective

hip joints. �e legs are parallel and the elbows should remain turned back toward the thighs, with the �ngers directed forward.

• Place a dowel rod along your spine and hold perfect spinal alignment, with the rod parallel to the �oor. �e space between your lower back and the rod should be about the thickness of your hand. Activate the TVA by drawing the belly button inward.

Execution:• Raise one arm to a point 45° o� the mid line of the

body, in the same horizontal plane as the back.

• Elevate the opposite leg to the point at which your leg is in the same horizontal plane as your torso. Keep the shoulder girdle and pelvis parallel to the �oor.

• Hold for 10 seconds and switch sides.

• Perform 10 times on each side for a total of 20 reps.

Modi�cation:If client has di�culty performing the exercise with arm and leg, break the exercise in half and have them use only the leg or only the arm and then integrate the arm and leg when they become better. Figure 106: Horse Stance Horizontal

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HORSE STANCE ALPHABETKeys to ObserveSet up:• Begin in the same position as the horse stance horizontal.

Execution:• Elevate the opposite leg to the point at which your

leg is in the same horizontal plane as your torso. With the extended leg draw the letters of the alpha-bet. Start with small letters of 2-3 inches high and progress to larger letters.

• Perform as many as you can with good form. �e goal is to work the entire alphabet for one set.

Progression:As the client gets better, they can increase the letter size to 4-6 inches and then progress to adding the alphabet with the arm.

Figure 107: Horse Stance Alphabet

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HORSE STANCE DYNAMICKeys to ObserveSet up:

Note: �is exercise should not be performed by anyone with symptoms of spinal disc pathology due to the repeated �exion performed. �is should only be performed once the client can master horse stance alphabet.

• �e start position is the same as the other horse stance exercises.

Execution:• Flex the trunk and bring the elbow and opposite

knee as close together as possible (or even overlap), activating the abdominal musculature.

• When returning from the �exion phase to the ex-tension phase, be careful not to allow the exerciser to hyperextend the lumbar and cervical spines.

• In the start position, the face should always be kept parallel to the �oor to avoid excessive use of the commonly shortened cervical extensors. Excessive use of these muscles will contribute to forward head posture.

• Perform 10 on each side. �e exercise should be descended if the client starts to break form.

Figure 108: Horse Stance Dynamic

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HORSE STANCE HIP AND SHOULDER ABDUCTIONKeys to ObserveSet up:

Note: �is exercise should not be performed by anyone with symptoms of spinal disc pathology due to the repeated �exions performed. �is should only be performed once the client can master horse stance dynamic.

• �e start position is the same as the other horse stance exercises.

Execution:• Abduct the left hip and right shoulder at the same time without letting the pelvis rotate.

• Perform 10 reps on each side. �e exercise should be descended if the client starts to break form.

Note: Conditions the stabilizers of core and extremeties in the transverse plane.

HORSE STANCE TWO POINTKeys to ObserveSet up:• �e start position is the same as the other horse

stance exercises.

Execution:• Client must be spotted during exercise.

• �e client shifts toward the spotter abducting the left hip and left shoulder at the same time. When the client is alone they can do it next to a wall.

• Start with one side, one rep and change. �en progress to 10 reps on one side and change sides.

Note: Excellent combination of balance and stability.

Figure 109: Horse Stance Hip and Shoulder Abduction

Figure 110: Horse Stance Two Point

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HORSE STANCE ONE POINT Keys to ObserveSet up:• �e start position is the same as the other horse stance exercises.

Execution:• Balance on one point (one knee) as long as you can

using all the techniques you learned with the previ-ous horse stance exercises. �is would be an exercise you would do �rst in program design. Do one side then the other until you are fatigued.

Note: Hardest of the horse stance exercises.

Horse Stance Review - Faults and Fixes • Head drops down o� the rod, could be rectus abdominis activation, work with client to activate the TVA.

• Mark curve where you hold the rod if the back moves away get them to activate the TVA.

• Client does not have the shoulder strength and wing the scapula. Teach client how to activate the protractors of the scapula by having client drop chest toward �oor and press back up without bending arms.

• Clients go into hyperlordosis and head goes up. To correct, draw belly button in and lengthen the spine as you tuck chin.

• If the pelvis twists, they have poor core activation. Be sure to get client to activate core.

• Client gets fatigued, their shoulders start dropping down. Reset the client by having them bring shoulders up. A mirror is useful so they can see what you are asking them to do. �ey may also need to turn the elbows in.

• Remember to stretch the tight muscles before the horse stance, and you may need to stretch those muscles every set to get the body to work correctly.

Figure 111: Horse Stance One Point

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SUPINE HIP EXTENSION-BACK ON BALLKeys to ObserveSet up:• Place the head and shoulders on the Swiss ball, neck

in neutral.

Execution:• Keeping the shins vertical at all times, drop the pel-

vis straight down until the knees are fully �exed. Keep the shins vertical and extend the hips by ac-tivating the gluteus maximus and pushing o� the back half of your feet, heels. Have the client lift the toes to make sure they are pressing through the heels.

• Extend the hips to the point at which the torso is �at or parallel to the �oor.

SUPINE HIP EXTENSION-FEET ON BALLKeys to ObserveSet up:• Beginners place calves on the Swiss ball and arms

perpendicular to the long axis of the body with palms up. �e closer the arms are to the body, the harder the exercise becomes!

Execution:• Extend from the hips until the ankle, hip and shoul-

der joints are all in the same plane. Avoid extending beyond this point as it may place excessive stress on the cervical spine! If the exercise is uncomfortable on the neck, cervical stress can be reduced by using a 45cm Swiss ball or even a basketball.

Figure 112: Supine Hip Extension - Feet on Ball

Figure 113: Supine Hip Extension -Back on Ball

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BACK EXTENSIONSKeys to ObserveSet up:• Position the hip bones level with the end of the pad,

preferably on an incline back extension.

Execution:• With your arms at your side, extend the torso until

the body is parallel with the �oor by activating the hamstrings, glutes and back muscles.

Modi�cation:If a client has a disc injury, adjust the pad so the pel-vis can move and the client can activate glutes while maintaining a lumbar curve. Clients with disc injuries should be careful not to �ex the lumbar spine until they have progressed to that level safely.

Progressions:• Arms across chest, �nger tips behind the ears, arms

out at a 45° angle, thumbs pointing to the ceiling.

• To change the maximum loading zone, hold onto a medicine ball or weight plate. Start by bringing the weight to your chest and slowly extend the weight out while lowering the torso to the starting posi-tion. Bring the weight back towards the chest while extending the torso. �is technique will maximally load the muscle at its mid-range and provide a more even load throughout the exercise.

• �is exercise may also be performed over a Swiss ball.

Figure 114: Back Extensions

Figure 115: Swiss Ball Back Extensions

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REVERSE HYPER-EXTENSIONSKeys to ObserveSet up:Reverse hyper-extension exercises reverse the recruit-ment pattern used in the back extension exercises. You will now be loading with the weight of the legs (either one or both).

• Lie face down over a Swiss ball, or on a back exten-sion bench.

Execution:• To isolate the glutes, lift one leg at a time, keeping

the knees bent. Progress to a straight leg and then to both legs at the same time.

• Be sure not to hyperextend the spine.

Progression:• Add weight as the client needs to increase intensity.

Note: �is is a good exercise to strengthen the back when clients have pain bending forward.

Figure 116: Reverse Hyper-extension using Swiss ball

Figure 117: Reverse Hyper-extension on a back extension bench

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SWISS BALL SIDE FLEXIONKeys to ObserveSet up:• Place a Swiss ball under your hip and anchor one or

both or your feet along the bottom of a wall.

Execution:• Hold your top leg as straight as possible and in-line

with your torso, shoulders and head, then lie over the ball to stretch the oblique abdominal muscles. Beginners should place their arms at their sides. Progress to placing your arms across the chest as shown, and then to having your �ngertips behind the ears.

• From the bottom position (stretched over the ball), initiate the side �exion movement from the trunk.

• Side bend the spine one level at a time until the shoulders and head come up.

• On the way down, the spine should side-�ex over the ball one segment at a time starting from the bottom up.

Progression: • Perform dynamically without support and then wind milling the arms keeping head, shoulder and hip align-

ment.

PRONE COBRAKeys to ObserveSet up:• Lie face down on a mat or comfortable surface and

rest your arms at your side.

Execution:• Lift your torso while simultaneously squeezing

your shoulder blades together and externally rotat-ing your arms, thumbs pointing up.

• When you have reached the proper end position, your palms should face away from your body, your head and neck should be in neutral alignment and your toes touching the ground. Hold as long as possible and rest half the time of the hold. �e goal is to be able to hold for 3 minutes for one set.

Notes: Do not allow your head to roll backward. If this happens, you will perpetuate shortness of the muscles at the base of your skull and the exercise will only serve to maintain poor posture. If glutes and hamstrings are working here it is ok, as that will make the upper back work harder.

Figure 118: Swiss ball Side Flexion

Figure 119: Prone Cobra

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SUPINE LATERAL BALL ROLLKeys to ObserveSet up:• Place head and shoulders on Swiss ball in anatomical neutral, fattest part of the ball is under the manubrium.

• Elevate hips until torso is as �at as a table top and the knee is directly over the ankle.

• Tongue in physiological rest position, on the roof the mouth behind the top teeth.

• Arms at 90° to the long axis of the body with the palms up.

Execution:• Roll laterally, holding this exact position. Do not allow the head to �ex, arms to lose their parallel relation-

ship to the �oor, or the hips to drop. Make sure client is not crooked using 2 sticks, one across pelvis and one across the clavicle. �e sticks should be parallel.

• As the client transfers to the other side, do not worry about alignment until they get to the end hold position.

• Tempo considerations: For stabilizer endurance, hold the end positions for 10 seconds on each side, 10 reps each side. For strength, hold the farthest lateral position for a “one-thousand-one” count.

Notes: �is is a big bang exercise, excellent for training in all planes and movement and training all the sling systems of the body. �is is still a phase one back exercise, so progressions should be limited until the client reaches phase three or four. �is exercise is best performed at the beginning of an exercise program as it is highly physiologically demanding.

Figure 120: Supine Lateral Ball Roll

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FORWARD BALL ROLLKeys to ObserveSet up:• Start in a kneeling position with your forearms on the Swiss ball and your palms facing each other.

• Take a deep breath and gently draw your belly button toward the spine. Make sure to maintain good spinal alignment by placing a dowel rod on the 3-points of contact, head, middle back and sacrum. Have cli-ent place their hand behind their back and the dowel rod to make sure the gap is only as wide as the thickness of their hand.

Execution:• Begin rolling forward, moving equally from the hip and shoulder joints.

• Stop just short of the point at which you start to lose your ability to hold the spine in perfect alignment. �e key to good performance with this exercise is stopping at this point. Pushing past this point will magnify imbalances.

• At the endpoint, roll back to the starting position as you exhale.

• Tempo considerations - stabilizer endurance = roll out to 40% e�ort and hold end position for up to 2 min-utes, decreasing the load as needed to maintain time under tension (hold as long as you can and rest half the time, as with prone cobra). For strength = 8-12 reps as described above.

Progression: • Client can draw the alphabet with the forearms to

increase intensity.

• End stage exercise is to perform the same exercise with one arm following the same rules and tempo. Switch arms each rep.

Figure 121: Forward Ball Roll

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PRONE JACK KNIFEKeys to ObserveSet up:• Have client roll over the Swiss ball to start position,

with the shins or feet on ball.

• Hold a neutral spinal position, maintaining 3- points of contact on a dowel rod, and have client place their hand behind their back and the dow-el rod to make sure the gap is only as wide as the thickness of their hand.

Execution:• Prior to �exing the hips, draw the belly button in-

ward, making sure the hips do not drive upwards. If the hips do drive upward, use a smaller ball.

• Do not allow hip �exion to over�ow into the low back, causing lumbar �exion. �e exercise is a “hip-back disassociation” exercise. �e spine should not fall into extension nor should the spine go into �ex-ion or the hips lift at any point during the exercise.

• Breath on a naturally occurring cycle.

Modi�cations:• A second ball can be placed under the upper body, to assist with support. Gradually de�ate this ball as the

exerciser gets stronger, so more of the weight is taken by the upper body.

• Beginners can place their shins on the ball, although this makes it harder to bend the knees and draw the ball inwards.

• If a client cannot do this exercise they can work up to it using a prone bridge working up to a 2 minute hold. Once they can hold the prone bridge for 2 minutes they can progress to the prone jack knife. �e hold times for the prone bridge are hold as long as you can and rest half the time for as many sets as you can do, working toward a total work time of 2 minutes.

Figure 122: Prone Jack Knife

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Using the Total Gym in Phase One

�e Total Gym is a powerful technology for phase one back clients because you can do a great deal of exercises without loading the spine. �e total gym uses just your body weight and allows people to energize their body and keep the muscles active during recovery from injuries. When a movement looks like a squat, for example, the muscles turn on like the client is doing a squat. Remember to only use this as long as you need to and then progress the exercises when your client is ready.

Exercises that can be performed are:

• Squats (It is easy to use a lumbar support when clients are supine on the total gym)

• Lat Pull Over

• Pec Fly

• Prone Chin Up

Contact C.H.E.K Institute for information on Total Gym

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Corrective Exercises Phase two

Phase Two Exercises:Exercises with no axial loading beyond body weight, non-compressive loading may be utilized, such as cable wood chops. Compression should be limited to muscle contraction.

FUNCTIONAL BACK CONDITIONING - SECONDARY BACK EXERCISESSecondary back exercises are used to take people from phase one to phase two back exercises and introduce compressive loading to the spine. �ese exercises also teach the spine to stabilize in a standing position, as phase one was on the �oor or Swiss ball. Loading is performed around the spine, while watching clients’ posture, so they have perfect posture the entire time.

STICK TRAININGKeys to Observe:• Make sure the exerciser maintains a neutral spine,

and good posture while performing stick exercises.

• Use isometric or isotonic contractions as dictated by your program’s goals and needs analysis.

• Watch for compensations while applying load to the stick.

• Remember, you have a signi�cant mechanical ad-vantage in force production when applying force to the end of a stick six feet long.

• �e stick is a very good way to begin to train in planes of motion that previously were a challenge to your client. An example is a client who has a history of pain with trunk rotation during certain exercises, who can now be trained in the transverse plane (rotation) under the controlled environment provided by the stick.

• When training in ranges previously associated with pain, isometric exercises are often a safe beginning.

Set up:• Client stands with a stable stance, knees soft and stable, draw belly button as you need it.

• A 5 pound soft diver weight is placed on the top of the head to increase load through cervical spine as this increases proprioceptive information from neck, giving the client a good sense of body alignment all the way down through their feet.

Execution:• Client holds the stick horizontal for easy loading. �e trainer then presses down on stick to activate extensors,

and pushes up on stick activating �exors. Correct posture must be maintained the entire time.

• Rotation load can be created by pushing stick left and right or angle stick to change position of load.

Figure 123: Stick Training

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Progressions: • Next hold stick vertical. Changing angle changes stress on body.

• Next level client holds stick horizontal and the client must push against you as you hold the stick and then pull back. �is will help client get over any apprehension they may have moving into secondary back exer-cises.

Variables: Amount of seconds each position is held depends on goal. Postural=long holds, pumping e�ect=short holds.

Note: If the bag comes o� head, the client is working too hard for a secondary back exercise.

OTHER SECONDARY BACK EXERCISES EXAMPLES: Secondary back exercises are an excellent way to indirectly exercise the back. It is important to always appreciate that a weight held in the hand at arms length in front of you is equivalent to ten times that same weight in the low back due to the force created by the lever arm. With this in mind, you can alter the load through the back by simply changing the length of the lever arm.

• Single arm biceps curl – do not move the back. �e client needs to work to hold the back still, as the biceps curl the weight, the weight is trying to tip the body sideways and the other side of the body has to work to stabilize the body. Load-ing the body in the unilateral plane triggers the muscles on the opposite side of the body to start performing stabilizer functions.

• Upright row – keeping the load light, so there is no pain and just activating back muscles. Pull weight up to shoulders to trigger muscles to activate around the spine.

• Single arm overhead press to recruit muscles through the core and change the recruitment pattern of the muscles.

• Shoulder abduction - at arms length, the weight in the hand causes 10x the load on the low back, if client bends the elbow it is only 5x load when abducted. Change the angle to load di�erently, using shoulder �exion.

• Can add curl to press.

• Counter weight side �exion.

Note: Surrounding the dragon is performed when you change the angle so the client is working all the way around the spine to get all the stabilizers working.

Figure 124: Bicep Curl

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KNEELING BACK EXTENSIONSKeys to ObserveSet up:• Begin kneeling on short bench for balance, hands behind the back.

Execution:• Bend slowly forward allowing hips to move backward, allowing the lumbar spine to �ex, as this exercise is

designed to strengthen the lumbar erectors speci�cally. Both static and dynamic contractions may be used, depending on whether the emphasis is postural or for such purposes as lifting on the job.

Note: If the client still has pain or a disc bulge, tape the back or hold skin to make sure client keeps a lumbar curve. Progress to �exion of spine, as client is no longer in pain.

• As you come down, start at waist and bend naturally, until head touches the mat.

• Return to start position by moving head and neck and as you come up hips come forward. Hands at their side.

Modi�cations:• If knee or ankle �exibility is limited, a step or an exercise mat may be used to allow proper form and pain

free function.

• Avoid this exercise if there are any signs or symptoms of disc injury present, unless the back is taped as shown in Figure 125.

Progressions:�e resistance to the back musculature can be modi�ed by putting the arms at the sides and progressing to across the chest, then raise elbows, �nger tips to ears, arms up and out at 45°, thumbs to ceiling as you go down. Always spot client.

Phase Two Back Exercises

Figure 125: Kneeling Back Extension - back taped

Figure 126: Kneeling Back Extension

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THREE-POINT SINGLE ARM ROWKeys to Observe• �is exercise allows client the safety and security

of a weight lifting and safely intrucing a rotational load on the spine.

• Determine which portion of the force couple is to be trained:

- Scapular adduction alone

- �e complete force couple

• Avoid looking up while performing the exercise, as this will contribute to forward head posture.

• �e plane of the dumbbell handle has an in�uence on which musculature is being emphasized:

- Frontal plane - more load through scapular adductors

- Sagittal plane - encourages latissimus dorsi involvement

• Choose a weight that allows utilization of the complete force-couple action and range of motion.

Set up:• Standing with right leg forward and right hand on bench, the left hand is a working hand, allowing the pos-

terior sling to work.

• Positon the client so they have a natural curve and gently draw belly button in and eyes level with horizon.

Execution:• Start with a neutral hand position, draw the dumbbell back starting the movement with the back. Do not

hike shoulder up.

• If someone has forward head posture turn the dumbbell handle so it is turned 90°, hand pronated.

Modi�cations:You can also do this exercises without bending elbow and just recruit the scapula adductors if client has trouble initiating movement with the back.

Figure 127: �ree-Point Single Arm Row

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THE LAT PULL OVERKeys to Observe• If a neutral spine posture cannot be maintained, the

weight being used is too heavy.

• Do not hyperextend the lumbar spine as the arms are brought into �exion under load, this will not only encourage shortening of the latissimus dorsi musculature, but will be the genesis of a faulty movement pattern that is commonly found in low back pain clients with an extension syndrome (pain with movement into lumbar extension).

• �e relative load on the working musculature is in-creased as the arms are straightend during the lift.

Set up:• Client lies on a bench, making sure the feet are placed in a position where the client is comfortable, so they

can move the dumbbell without the back being arched.

Execution:• Drop the dumbbell back behind the head while maintaining a neutral curve, without letting the back go into

lordosis.

• �e exercise is concluded when you have as much stretch on the lats as they can handle and return to where the arms are vertical.

Note: With shorter females, the weight bench may be too big and it forces them into lumbar lordosis. It is best to place a step box under her feet so the client can maintain optimal posture or have them place feet on the bench (this may make them more unstable, so be careful).

Figure 128: �e Lat Pull Over

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THE LAT PULL DOWNKeys to Observe:• Position the exerciser appropriately under the boom to achieve ideal load to body alignment. An example of

faulty positioning is when the exerciser is positioned posterior to the cable boom, attempting to do behind the head pull downs, which leads to forward head posture (Figure 129B). Choose a weight that allows full range of motion training.

• Avoid excessive use of one single pattern of motion (i.e. constantly using the same handles in the same pat-tern of motion).

• Remember that the more vertical the body, the greater the workload on the scapular rotator musculature. As the body reclines, there is less scapular rotation and increased scapular adduction/abduction, which equates to increased strengthening in the scapular adductor musculature, with progressively decreased latissimus dorsi activity.

• Watch for asymmetries in the shoulders and shoulder girdle during the exercise. Such �ndings as an elevated shoulder or winging scapula are indicators of shoulder dysfunction.

• �e lats are major gross stabilizers of the spine, the shoulder, and the pelvic girdle. It is a bridge muscle. Overdeveloped lats on one side can induce a rotation on the spine (scoliosis). Look at lats and see if there is symmetry in their development (you can do a single arm lat pull test and chose a weight they can do no more than 10 reps, compare to other side, there should not a be 10% di�erence).

Set Up:• Doing the lat pull down with an injured spine should not be done sitting, as it increases the load on the

lumbar discs. �e client should be kneeling to start with to keep hips in a neutral position, which will keep the load o� the lumbar spine.

Execution:• �e weight should be light. Pull the bar toward chest to where it naturally goes, passing just in front of the

nose (Figure 129A).

• Keep the forearms following the line of the cable to avoid internal shoulder rotation.

Modi�cation:Can also be done in a split stance position on �oor, one knee on �oor.

Figure 129: Lat Pull Dowm

A B

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STRAIGHT ARM LAT PULL DOWNKeys to ObserveSet Up:• Draw your belly button in and keep a neutral spine as you stand in front of the

lat pull down.

• Start with a pronated grip, knees soft, arms straight and do not allow the lumbar curvature to change.

Execution:• With your arms out straight, slowly lower the weight matching the intensity

with which the belly button is drawn in with the load.

• Variables: 8-12 reps is a normal load.

Notes: As people come through the sticking point, they let the pelvis tip forward and are not recruiting the core. �e load must be light enough so that this does not happen.

�is exercise does not compress spine when you push down on the load. �e only load to the spine is the contraction of the lats themselves. �is is an excellent form of teaching core activation and control, as the lats are used to pull heavy objects toward the body making this a very integrated exercise.

�is exercise is performed in the sagittal plane.

Key Points for the Lat Pull Down:• Do not pull the bar behind head, as it is damaging to shoulder.

• Use a natural pull, so you initiate the movement from your shoulders and let the bar come to it’s natural rest point.

• �e prone grip opens the chest, so inhalation will facilitate the exercise, therefore, this exercise should be coupled with inhalation. If you use a reverse grip, supinated - exhale as you pull.

• Grips – always begin with the most complex grip – prone, then supinated, then the neutral grip which is the least complex. Start with the most neurologically demanding exercise �rst to avoid injury.

Figure 130: Straight Arm Lat Pull Down

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SINGLE ARM CABLE PUSHKeys to Observe• Start with the hardest exercise �rst, so that the ner-

vous system is fresh.

• Always maintain perfect spinal and postural align-ment.

• Draw the umbilicus inward prior to initiation of any pushing motion.

• Perform isolation, then integration, by mastering the weight shift �rst, then the twist and then the push.

Set Up:• Set the cable at shoulder level.

• Client holds the handle in one hand, furthest from the machine to begin weight shift phase �rst, with-out using the push.

Execution:• �e client uses a weight shift of 70% load on inside leg and 30% on outside leg and then they move side to

side, keeping the weight shift even.

• Once they have the weight shift mastered, they integrate the twist, allowing the back foot to pivot.

• Once they have the twist pattern, then move the cable to the other hand and add the cable push so the weight shift is integrated with the push.

• Introduce reciprocity by pulling the other arm back as you push the other arm forward, the mass of the arm causes a counter rotational load, decreasing the torque on the spine and shoulder.

• Allow full protraction and retraction of the scapula with each repetition.

• Limit horizontal abduction of the shoulder to 10° prior to meeting passive end range of motion in any client’s individual shoulder.

• Keep the head and eyes forward, as though watching an opponent.

• Let the movement emanate from the core, do not push with just the arm.

Figure 131: Single Arm Cable Push

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SINGLE ARM CABLE ROWKeys to Observe • Begin with the same progression as in standing cable push.

• �e biggest muscles should initate the movement and the littlest muscles should �nish the movement.

• If they cannot get the weight shift, then have them stay in a split stance and work the pull, as they push with the other arm. Next integrate torso and then integrate weight shift.

OTHER STANDING CABLE ROWS Keys to Observe• Maintain good spinal alignment, avoid losing lumbar lordosis.

• �ere should be synergistic timing to the shoulder and shoulder blade motions. Do not allow the scapula to terminate motion before, or after, arm motion.

• NEVER FIXATE YOUR SCAPULA DURING PULLING EXERCISES, unless instructed by a physical therapist for speci�c therapeutic reasons! �is can develop faulty muscle sequencing.

• Keep knees bent to assure maximum pelvic stability.

• Prior to initiation of a rowing motion, always draw the umbilicus inward to activate the deep abdominal wall.

• Keep your head up and eyes on the horizon, to avoid head and trunk �exion, which leads to poor posture.

Figure 132: Single Arm Cable Row Figure 133: Single Arm Cable Row Figure 134: Single Arm Cable Row

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CABLE ROW VARIATIONS:

• Changing the angle changes the exercises. Research shows there is a 15° carry over in any exercise, so for va-riety you need to change the exercise at least 15°.

• High pull uses same form as the horizontal pull, reach right along the cable and have the reciprocity arm fol-low the same line of travel as the working arm.

• Low pull uses same guidelines.

• Split stance with a double pull on cables. Mechanics are the same, but you need a system that allows you to pull two cables at once. Same rules on teaching the exercises, follow steps of isolation to integration.

Figure 135: Cable Row Variations



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THE LOW ROW Keys to Observe:• Decide which part of the force couple you want to emphasize (hip extensors, trunk extensors or scapular ad-

ductors), or whether the whole extensor mechanism will be exercised.

• �e low row is a good exercise for people who are not ready for a dead lift, but need to begin working the functions of a pulling exercise.

• Remember that the higher the feet rest in relation to the buttocks during a seated row or low pull, the more restricted the pelvis becomes. �is results in elevated lumbar erector activity. As the feet go lower, the pelvis is freed up and the thoracic extensors and scapular adductors tend to participate more because of the relatively longer lever arm between the load (handles and cable) and the base of support (feet).

• If people have tight hamstrings, raise them up by having them sit on a box (Figure 138) and open the legs up so the pelvis can move freely. You want to be careful that the client does not have excessive �exion of the lumbar spine.

• Choose an appropriate weight to avoid losing form and encouraging faulty motor patterning.

• Decide where emphasis will be placed via arm position and handle type.

- Arms in sagittal plane with neutral grip=latissimus dorsi domination.

- Arms in horizontal plane with cable handles and pronated grip=increased scapular adductor activity.

Set up:• Sit facing a low cable holding the attachment with both hands making sure the lumbar spine has lordosis.

Execution:• Pull the weight toward the abdomen initiating the pull from the middle back.

• Always work full ROM unless speci�ed by functional analysis.

Note: You may need to tape the back. If they cannot do the low row, then they need to do the kneeling back extension. You can also isolate by not letting the pelvis move to limit the movement to the low back, so that they learn to use the low back muscles to strenghen them. Once they can do that, then integrate the pelvis.

Figure 138 Figure 139

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WOOD CHOPKeys to Observe• �e isolation then integration principles should

be taught �rst, as with the single arm cable push, weight shift, twist, chop.

Set Up:• Place the outside hand on the handle �rst and place

the inside hand on top with the cable in a high po-sition.

• From a stable stance, draw the belly button inward prior to initiating the wood chop motion.

• Keep the head and eyes looking forward, as if you were watching an opponent in front of you.

Execution:• Begin with the weight shift by holding handle at chest level and work the weight shift 70% to 30%. Initiate

the shift by �rst dropping your body weight, bending the knees and then shift.

• Next hold the cable to the chest and shift with a 90° rotation. �e client can turn their shoulder and look away or look straight ahead, depending on their goals.

• Next hold the cable with the hand furthest from the cable on the bottom and move the arms like you are cracking a whip.

• As the arms goes up, inhale and exhale as you go down.

• Focus on rotating the body, allowing only minimal �exion.

• When integrating the exercise, make sure the client can do it as one movement.

Notes: �e start position should place a stretch on the abdominals, if not move away from the cable column. In the �nish position, the hands should be above the foot. In the dynamic wood chop, arms and legs should �nish moving together.

�is is a very e�ective pattern for any functional environment, as it is a primal twist pattern.

Variables: 8-12 reps left and right.

Figure 140: Wood Chop

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REVERSE WOOD CHOPKeys to Observe• Perform the thoracic arm raise test prior to teach-

ing the reverse wood chop. �e client must pass the thoracic arm raise test on page 200, in order to perform the reverse wood chop without harming the shoulder.

• Begin with the same isolation to integration prin-ciples as taught with the wood chop.

Set Up:• �e �rst hand on the handle should be the hand

from the side you’re pulling toward.

• In the start position, your hands should be just lat-eral to the foot closest to the cable handle.

• From a stable stance, draw the belly button inward prior to initiating the reverse wood chop motion.

• Keep the head and eyes looking forward, as if you were watching an opponent in front of you.

Execution:• Focus on rotating the spine while concurrently extending the thoracic spine.

Note: �ose unable to straighten their thoracic curvature should refrain from performing this exercise as it may cause trauma to the shoulder joints!

• In the �nish position, there should not be excessive lumbar extension. �is is particularly important to watch for in anyone with restricted thoracic motion!

• Beginners should use a moderate tempo with loads allowing 15-20 repetitions and should restrict themselves to one set until the body has time to adapt to the exercise.

Note: If someone does a lot of one sided exercises, you may use the reverse wood chop in the opposite direction.

Figure 141: Reverse Wood Chop

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Tips for Common Gym Exercises

THE LEG PRESS

To prevent injury to the low back, do not allow an exerciser to drop any deeper into a machine squat than they can go with keeping the sacrum on the supporting surface. If the sacrum rises o� the support surface under excessive loads used during a leg press, the incidence of injury to both the posterior ligamentous system and the disc rises dramatically. Such an injury can be career ending, so be careful.

OTHER PHASE TWO EXERCISES

Body weight Primal Pattern® movements

Total Gym / Gravity exercises

Swiss ball exercises at <60% maximum intensity

Pilates-style exercises

THORACIC ARM RAISE TESTKeys to Observe• Place the client up against a post or a wall, with

their back �at against the surface, feet 12 inches from wall.

• �en have the client raise arms up in the air toward the wall without any part of their back coming o� the wall. If a client raises their arms and the pelvis tilts forward and the head comes forward, then they fail the test. (Figure 142B)

• Client needs to be able to �atten spine against the wall and keep it �at as they raise their arms over-head to touch wall behind them. (Figure 142A)

Figure 142: �oracic Arm Raise Test

A: Pass B: Fail

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Exercises with axial loading beyond body weight, generally used for work and sport speci�c conditioning. �is is the beginning of base conditioning and does not go beyond base conditioning.

SQUATOLOGY - THE SQUAT ASSESSMENT:Keys to Observe:• Having clients pick up a variety of weights or dumbbells in the bend pattern will have such a high level of

carry over to assess their squat pattern.

• Start by having client pick up a light load and look at their lifting posture. Is it lordotic? kyphotic? As you work toward heavier loads, when do they switch from a kyphotic lifting posture to a lordotic lifting posture. �at is the point where they respect the load.

• If someone keeps lifting with a round back they will begin to get ligament laxity. Keep increasing weight until you see a change. Look for torsion in the pelvis or if one side of the pelvis is higher on one side. If pelvis is higher on one side, but there is no torsion or scoliosis, then it is normal and functional.

• When you see torsion in the pelvis under heavy load, you need to go back to comparative range of motion (ROM) tests. Intensity will bring dysfunction.

Using the Squat Pattern as an Assessment of Orthopedic Health: • First look at stance, as the stance is what connects you to the ground.

• Look at symmetry between feet, is it noticeably assymentrical (if yes, go back to comparative ROM tests).

• Is one leg too far forward? It shows up as a rotating bar (body is trying to eleviate torque on the spine). If the pattern stays that way, it causes joint instabilities.

• Have client squat on a plumb line to see if they are standing with one leg further o� from the midline. Shows up as over use of one leg relative to the other.

• You can use bathroom scales and calibrate them with 60 pound dumbbells and have the person stand with one foot on each scale to see what their weight shift is. You do not want to see a weight shift of greater than 5 pounds. If they have a weight shift greater than 5 pounds, it puts a lot of torque on the body.

• Look at how body moves in the sagittal plane – watch for relationship of shoulders and hips as the client comes up out of the squat. �e timing should be the same.

• Does the butt come up faster than the shoulders? if so, it will put excessive load on the lumbar spine (legs are relatively stronger than the low back muscles).

• If clients do not have enough strength in lumbar region they round their back.

• If they are weak in the shoulder girdle, as they go down in the squat they round their upper back and as they come up they round out. �is is an indicator the client needs postural conditioning.

Phase Three Exercises

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E�ect of joint blockage on the Squat Movement Pattern: • Look at the body from the back with plumbline and see if there are large deviations (more than one inch).

Ankle Restriction (restriction in dorsi�exion): • See if there is a shift to one side, the bar will be low on the side of the leg they are using the most, or you will

see a twist, indicating joint restriction in ankle. Client will lean toward overworking leg. �is will overload the stabilizers of the back on the opposite side and you get a QL or lumbar erector injury.

Knee Restriction (can’t bend beyond 90 degrees): • Adaptation are similar to ankle restriction. As client squats, they will lean away from restriction and get a side

bend in the trunk. With more weight, you get a rotation shift as well.

Hip Restriction (restriction in hip �exion caused by shortness of hamstrings):• Client will shift away from restriction and come up on to toes to get down into a squat. Causes tremendous

damage to joints, ligaments, tendons etc.

• Clients will put boards under their heels or work boots with high heels to get into their squat. �is supports the orthopedic dysfunction and drives the imbalance deeper into their system. �is does not create a func-tional squat that will have carry over into the real world.

Squat Assessment - Force-couple Relationships:• �e muscles that turn the pelvis are also the muscles that a�ect your rib cage. When you watch someone’s lift-

ing posture, and they go into excessive lordosis, the head will look toward the ground but the body will bring the eyes on the horizon and the result is craning of the neck, causing tremendous load on the facet joints. Clients will end up with pain in the neck.

• Excessive kyphosis in the spine will also disrupt the muscular relationships along the spine. If the pelvis rolls under when they squat, they crane their head forward. When someone squats with a bar, the end of the bar should be in the space occupied by the foot if you drop a plumbline from the end of the bar. When the pelvis tips forward it causes femoral anterversion, leading to pronation. If you tip the pelvis backward, the head has to come forward to counter balance the body.

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Abdominal Wall Function: If the weight is not challenging the abdominal wall with respond di�erently. If the spine is injured clients will need to learn to activate the abdominal wall even under light loads. What you want during a squat is an inhala-tion with expansion of the abdomen and then prior to initating the squat, the abdominal wall should draw in and you should see the belly button come in or feel to see if it is drawing in. Initiate squat and as they come up through the squat, slowly let the air out through pursed lips, so you do not lose pressure in the thoracic cavity to create spinal sti�ness. You do not want to see the belly just hang out. If the abdominal wall is not working correctly, you have a naked spine (see article Back Strong and Beltless). �e heavier the load the sooner they have to turn on RA and EO to get gross stabilization of the spine. When they get close to that sticking point, the EO and RA have to counter balance the tension on the low back. Look at sequencing.

Overhead Squat as an Assessment:• Prerequsite is when they lean against a wall they

should be able to reduce their lumbar and thoracic curve �at against the wall. If not, they should not do an overhead squat assessment.

• First, push bar overhead and look for a wide grip.

• As they squat, we want to see if they can get down in the squat position, the plumbline should not come over their toes when dropped down from the end of the bar. �is requires the thoracic spine to go into extension, so watch for vertebra locked into �exion.

• If the vertebra are locked in extension, the joint needs to be mobilized and then do the overhead squat right away in order to reeducate the nervous system on how to do the exercise properly.

• Watch for symmetry side to side, is the bar rotat-ing? Tilting?

Figure 143: Overhead Squat Assessment

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SETTING UP THE SQUATFinding your best squat stance

Stance: �e client should assume the most comfort-able stance they would have if they had to have a bow-el movement outside in the woods. Stand up without moving feet and take note of the foot position and key bone land marks.

Natural variations will occur and feet may not be ex-actly in the same position due to di�erences in the body and bone structure. If deviations are more than an inch or 20° for example, then that is out of the norm and needs to be corrected.

If someone cannot get into a squat position you know they cannot perform a full squat without modi�cations and they need a comparative range of motion assessment.

If you change a client’s feet too much, bringing the feet closer together, it will shift client forward and crowd the hip joint. �is places excessive stress on the lumbar spine.

If feet are too wide apart, then the hips are more open, and the trunk is more vertical and the adductors get a tremendous increase in tension and those muscles will become extremely sore. �e positive side is you won’t blow the back out.

Setting up the Bar :Proper Set Up:• �e height of the bar is between the nipple line and collar bone

• Bar height is always racked to shortest person when working with a partner.

• �e bar should be resting over T1 and T2.

• �e hands need to be close together so that the scapula adductors are working to hold the thoracic spine in an optimal position, preventing the heavy load from bending you forward.

• Stand close to the bar, get under the bar, and pick it up by standing up, not leaning over. Make sure you step only ½ step back so you are close to the rack.

Common Mistakes:• If the bar is too low they have to bend over too far.

• Clients are too far from the bar when they go to take it o� the rack, causing excessive forward lean and too much lordosis.

• Walking back 2 or 3 steps causing exhausted clients to have to walk back to rack it.

• If the rack is too high and you go onto toes, you are very unstable under load.

• �e bar should never touch any of the cervical vertebra. �e load on the bar as you descend creates a sheer force on the vertebra and stretches the ligaments in the lower cervical spine.

Figure 144: Setting up the Squat

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SQUATOLOGYThe Science of Squatting Without Injury

THE SQUATKeys to Observe:

Set Up:Before Beginning• �e rack height of the bar should be approximately mid-chest between the nipples and the collar bone.

• Assure that the bar is evenly loaded and that the weight is properly secured.

Execution:To Start• Hands are placed on the bar slightly wider than shoulder width, (or as wide

as needed to stabilize the load) using a complete thumb and �ngers grip. It is important that the hands are not too wide so the client can activate the scapula adductors.

• Step under the bar with both feet.

• Place the bar in the center of the upper back over T1 and T2. �e bar should rest across the posterior deltoids and upper trapezius muscles. Do not rest the bar on the spines of the scapulii as this can lead to bruising of the bone and may cause pain. (Figure 145).

• Prior to lifting the bar from the rack, pull the shoulder blades together, elevate the chest and assure that there is a stable lordosis of the lumbar spine. (Figure 146).

• Straighten both legs, lifting the bar o� the rack and take 1/2 step back.

• In preparation for squatting, position the feet shoulder width or wider, with the toes turned out up to 30° in your natural squat stance.

�e Descent• Holding the torso rigid with a lumbar lordosis, inhale, drawing the belly button inward to activate the TVA

and begin bending at the knees, followed by the hips. �e drawing in of the TVA should match the intensity of the load.

• Tongue should be on the roof of the mouth to activate the cervical �exor mechanism.

• Keep the weight balanced between the forefoot and heels, always maintaining full foot contact with the ground during the complete descent. (Figure 147).

• �e knees should track over the second toes during the descent.

• Keep your eyes about 15° above the horizon as you descend in a slow controlled manner. Always maintain a rigid torso, minimizing stress on the spine, while taking full advantage of the large hip joints.

• Keep the weight within the base of support.

Figure 145: Squat Execution

Figure 146: Squat Execution

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�e Ascent• Ascend to the start position with control and push forward with hips. (Figure

148).

• Keep your hips under the bar as much as possible, keeping the bar balanced between the ball of the foot and the heel.

• Avoid pronation (medial rotation) and adduction (bringing knees together) of knees.

• Be smooth throughout the motion to avoid jamming or jarring the bar at the top of the motion.

• Exhale after passing the sticking point through pursed lips.

• Re-breath before beginning the descent again.

Racking the Bar• Take small steps as needed toward the rack until the bar hits the rack and bend

knees to drop the bar into place. Some coaches recommend racking the bar be-hind you, although many lifters prefer racking in front of them where they can see the racking pegs.

• What is most important is that the rack is set to the correct height for the bar to be placed directly on to it without strain on the lifter.

Special Considerations• A comparative range of motion assessment should be completed prior to per-

forming the squat to assure prevention of injury.

• Be sure to question the exerciser about any pending injury that may be causing pain at a conscious or subconscious level. If there is such an injury, the brain will always encourage movement away from the painful side to prevent exacerbation of the injury.

• Address any faulty movement patterns prior to loading. If the exercise is per-formed with incorrect form, the athlete is likely to develop an injury due to faulty loading.

• �e knee should be allowed to bend forward naturally to protect the back. Individuals with long femurs may have to allow the knee to come forward, past the toes in order to protect their back. �is is ok as long as the bar is in the zone between the front and back of the foot.

• Using safety pins for the squat is ideal for clients lifting heavy loads or having di�culty maintaining lumbar lordosis in a full squat. �e safety pins should be just below the end range of the bar so they don’t bounce the bar o� pins. Leave a little room so they can dump bar if it is too heavy a load.

• Best position for trainer to be in is at an angle where you can see the back of body and front of body in the mirror. You may need to move to the side if you have to be sure the bar is in the “zone.” Watch head and neck alignment, hand position, charging abdominal cavity, are they initiating the squat from knees, are knees pronating?

Figure 147: Squat Descent

Figure 148: Squat Ascent

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SQUATTING WITH A RELATIVE FLEXIBILITY IMBALANCE

Poor Form�is client was a serious recreational lifter who experienced low back pain. Upon evaluating his squat form, the following discrepancies were found:

• Excessive lumbar and trunk �exion. �is brings the bar and load forward of the base of support, increasing the length of the lever arm, predisposing the back to injury. (Figure 149).

• Limited knee and hip �exion resulting in compensation by the relatively more �exible back.

• Uneven weight distribution on the feet (weight too far forward): �is contributes to excessive pronation at the feet and can lead to both plantar fascitis and/or achilles tendon injury.

Good FormWhen the client is made to hold good form, he falls 50% short of a full squat (Figure 150). �is is an indication of the excessive range of motion demands previously being placed on his back. �is client regularly squatted with 315 pounds (143 kg)!

Limited Knee Flexion�is is one indication of poor �exibility in the lower extremities. Normal knee �exion requires the heel touch the gluteus maximus. �is client falls almost 30° short. (Figure 151).

Figure 151: Limited Knee FlexionFigure 149: Poor Form Figure 150: Good Form

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FRONT SQUAT

Keys to Observe:• �is is an excellent squat for back pain clients and

is more functional than a back squat as it mimics every day life.

• �e bar being in front of the body causes a more upright position of the spine which is safer for back pain clients.

• It puts a tremendous amount of work in the apex of the thoracic curvature, which helps improve pos-ture.

Set Up:• Follow the same set up as with the squat.

Execution:• Execution is the same as with the squat, except for

hand placement.

Hand Placement:• Place two �ngers on bar and bring elbows up un-

til they point straight ahead and the bar comes in toward your neck and rests on your deltoids. �e technique is the same as the back squat except that the elbows are up.

• You can use no hands if clients lack the �exibility to get the elbows up with hands on the bar. Instead, keep the elbows up and place the bar across del-toids. �is encourages good technique or the bar will fall.

Figure 152: Front Squat

Figure 153: Front Squat

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DEAD LIFTKeys to Observe:• Maintain a lordosis in the initiation of the descent. If a rigid lordosis is held,

heavier loads may pull the lumbar spine to a straight con�guration. �is is safer than a lumbar kyphosis.

• Keep the eyes level with the horizon in order to maintain activation of the trunk extensors.

• Avoid using the dead lift as an entry level exercise. It is very stressful to the lumbo-sacral region and is frequently associated with injury in the inexperienced lifter. �e Waiter’s Bow Test is a good assessment to see if clients have the ham-string �exibility to perform a dead lift without blocks. See page 220, Figure 156.

• Always keep the knees bent to 20° in order to activate the hip extensor mecha-nism. Otherwise, faulty motor patterning is inevitable. Keeping the knees locked as in a straight legged dead lift can lead to hyperactivation of the hamstrings and lumbar erectors. �is will inhibit the gluteus maximus. �is is a faulty movement pattern frequently associ-ated with both low back and upper hamstring strain.

Set Up:• Sumo dead lift is prefered, wide stance.

• Squat like you are going to have a bowel movement, but hands need to touch the ground. Shin and bar should be touching each other to minimize excessive load on the back. Use a split grip (with double overhand the bar will try to roll out of your �ngers) and switch grip each set.

• Head and neck in neutral like the squat, breathing is like the squat.

Execution:• Ascent: Bar to knees, stand-up. Be sure to use butt and legs until bar begins to

pass your knees and then simply stand up.

• Descent: Bar to knees and legs to �oor. Bar close to shins.

• Hands should hang straight down out of the shoulder. If hands are too close together it can impinge on the shoulder, if they are too wide, it puts an odd traction on the hands.

• Turn antecubital space forward, or elbows back, to activate the rhomboid muscles. Re-breath at top of the movement to activate the stabilizer system. �is is important as most people don’t have strong stabilizer sys-tems.

Sumo dead lift vs. Traditional dead lift: When should you use either one?�e conventional dead lift pattern puts an excessive forward lean on the body, causing a tremendous load on the SI Joint, causing the the hips to adduct. With a sumo stance, as the femur moves into abduction it is almost in perfect alignment with the ilium, and the force-couple relationships of the glutes on one side and lats on the other side pins the SI joint together as a stable complex. �e sumo dead lift is a safer, more practical, orthopedi-cally sound exercise which has a functional carry over.

Figure 154: Deadlift

Figure 155: Breathing Squat - hands on ground

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WAITERS BOW TEST Keys to Observe:• Assesses hamstring �exibility to see if client needs a

dead lift rack – this will keep client from rounding their back.

Set Up:• Find belly button and go directly behind the belly

button and grab the skin.

• Have client put feet and knees together, knees locked straight, and have them bend forward at hip joint with hand up as if they are serving wine.

• Client stops when skin comes out of your �ngers.

• Measure at the axis of the knee joint, normal is 50°. If it is less than 50°, they need blocks during a dead lift to lift the weight up.

• Remember client needs to be able to reach the bar in proper position without losing the skin in a bend posi-tion.

THE GOOD MORNING

�e mechanics of the dead lift are much the same as the good morning exercise. In the good morning ex-ercise, the weight is often placed across the shoulders, as in a squat exercise. When you bend forward at the hip to perform the good morning, there is signi�cant load placed in the lumbo-sacral region, just as in the dead lift.

�e only signi�cant di�erence between the two exer-cises is that during a dead lift the weight is lowered to the �oor, which requires bending of the knees, where as during the good morning exercise, the knees and ankles are static, while the trunk is �exed from the hip.

Both exercises are advanced, with the potential to cause injury if performed incorrectly. I recommend having a well trained spotter, trainer or coach pres-ent for those without signi�cant lifting experience and training.

Figure 156: Waiters Bow Test

Figure 157: �e Good Morning

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THE LUNGEKeys to Observe:• Racking the bar is the same as in the squat section.

• Front lunges are more functional, as they help keep good upright posture and clients do not lean for-ward.

Set Up:• Place a wooden dowel rod or weight bar across your

back.

• Grip the bar as close to your body as you comfort-ably can. �is activates the scapula retractors and helps your chest to stay lifted, avoiding rounded shoulders and poor posture.

• Take a deep, diaphragmatic breath (�ll the belly then �ll the chest) and gently draw your belly but-ton inward toward your spine. �is will activate the transversus abdominis and related deep stabilizer muscles of the spine.

Execution:• Hold an upright posture throughout the exercise, with chest up, shoulders back, and head looking forward.

Without looking down at your feet, step forward with a big step, into the lunge with your left leg. If your step length is correct, your shin will be vertical. If possible, check your form in a mirror so that you do not have to look down towards the �oor.

• Allow your body to descend into the lunge as deeply as possible, or until the trailing knee is just o� the �oor. Do not let the front knee drop inward or wag side to side, knee should track over second toe. Your weight should be equally distributed over both legs and your body centered between both feet; a plumb line from the end of the bar should fall half way between the front and back foot.

• Push o� the heel of the front foot to return to the start position. If you have di�culties returning to a stand-ing position with one step, you may use a double-step method (step up half-way and then take a second step to the start position).

• Release the air through pursed lips as you return to the start. Do not let the air just escape unrestricted. Purs-ing the lips maintains the pressure in the thoracic cavity and helps to sti�en the spine. Using this technique is especially important when you are lifting heavier loads.

Notes: Running shoes can cause issues in the lunge, as they are too soft, and this creates an unstable environment. Use a multidirectional shoe.

Front lunge is the same as the front squat, the trunk is very vertical.

Figure 158: �e Lunge

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BENT OVER ROWKeys to Observe:• Do not allow the back to round into kyphosis.

• Keep the head in neutral alignment in order to avoid shortening the suboccipital muscles under load.

• Keep the knees bent to 20° to activate the iliotibial band and gluteus maximus. �is provides much needed support for load sharing in the low back.

• Choose loads allowing maintenance of good form.

Set Up:• Approach bar and grab the bar with hands just out-

side knees.

Execution:• Activate the core, lift testicles, or perform a kegel prior to lifting.

• Pull the bar to the knees, keeping the eyes just above the horizon.

• Cue client to pull, as if puppet strings were on the elbows, so they have a natural pull.

• Use a prone grip to strengthen across the shoulder girdle.

• �e reverse grip, supinated, will get more load through biceps. If you use both grips in the same workout use the prone grip �rst.

Progressions:• Single arm cross body row requires a lot more hand strength, which in turn causes the brain to activate the

core muscles and stabilizers. Using wrist straps will not activate stabilizers. Reach across to the outside of the bar and pull the bar up and across, with free hand resting on leg, or in an advanced form of the exercise, use free arm to create a rotation.

• Single arm dumbbell row: Use a single dumbbell and step forward with the opposite leg of working hand. You can row, placing the free hand on the opposite leg.

• More advanced version is to use the free hand to push, as the weighted hand pulls, to create a rotation. Work di�erent grips.

Figure 159: Bent Over Row

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Phase Four Exercises

�is includes sports speci�c conditioning to meet demands of the work or sport. At Phase Four there should not be any concern for modi�cations. �e only limits are the client’s own biomotor abilities.

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References

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2. Daniels and Worthingham. �erapeutic Exercise for Body Alignment and Function, 2nd ed. Philadelphia, PA: W.B. Saunders Co., 1977.

3. Gracovetsky, Serge. �e Spinal Engine. New York, NY: Springer, 1988.

4. Granhed, Jonson and Hansson. “�e Loads on the lumbar Spine During Extreme Weight Lifting,” Spine. Vol. 12, No. 2, 1987: 146-149

5. Hart, Stobbe, and Jaraiedi. “�e E�ects of Lumbar Posture on Lifting,” Spine. Vol. 12, No. 2, 1987: 138-145.

6. Holmes, Damaser, and Lehman. “Erector Spinae Activation and Movement Dynamics About the Lumbar Spine in Lordotic and Kyphotic Squat Lifting,” Spine. Vol. 17, 1992: 327-334.

7. Kapandji, I.A. �e Physiology of the Joints. New York, NY: Churchill Livingstone, 1974.

8. Koor, I.M. �e Neurobiologic Mechanisms in Manipulative �erapy. (“Muscles, Entral Nervous Motor Regulation and Back Problems” Janda). New York, NY: Plenum Press, 1978.

9. Magee, D.J. Orthopedic Physical Assessment, 2nd ed.Philadelphia, PA: W.B. Saunders, 1992

10. Mayer et.al. “Contemporary Conservative Care for Painful Spinal Disorders.” Lea and Febiger: 1991. Pg. 325.

11. Nachemson, A.L. “�e Lumbar Spine, an Orthopedic Challenge,” Spine. 1:59, 1976.

12. Noe, Donald et al. “Myoelectric Activity and Sequencing of Selected Trunk Muscles During Isokinetic Lifting,” Spine. Vol. 17, No. 2, 1992: 225-229.

13. Pauly, John. “An Electromyographic Analysis of Certain Movements and Exercises: Some Deep Muscles of the Back,” Anat. Rec. 155: 223-234.

14. Porter�eld and DeRosa. Mechanical Low Back Pain. W.B. Saunders Co: 1991.

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18. Waddell, G. �e Back Pain Revolution. New York: Churchill Livingstone, 1998.

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20. Webster, D. �e Iron Game. Scotland: John Geddes Printers Irvine, 1976.

21. Lovett, R. Lateral Curvature of the Spine and Round Shoulders Philadelphia: P. Blakiston’s Son & Co., 1912.

22. Steindler, A. Post-Graduate Lectures on Orthopedic Diagnosis and Indications Charles C �omas, 1951.

23. Richardson C., Jull G., Hodges P. and Hides J. �erapeutic Exercise For Spinal Segmental Stabilization In Low Back Pain Scienti�c Basis And Clinical Approach. London, New York, Philidelphia, Sydney, Toronto: Churchill Livingstone,1999.

24. Ed by: Vleeming A., Mooney V., Snijders C.J., Dorman T.A. and Stoeckart R. Movement, Stability & Low Back Pain �e Essential Role of the Pelvis. New York, Edinburgh, London, Madrid, Melbourne, San Francisco and Tokyo: Churchill Livingstone, 1997.

25. Dart R.A. �e Double-Spiral Arangement Of �e Voluntary Musculature In �e Human Body. Surgeons’ Hall Journal Vol. 10, No. 2. Oct. 1946 March 1947.

26. Hodges P. W., Richardson C.A. Feedforward contraction of transversus abdominis is not in�uenced by the direction of arm movement. Exp Brain Res (1997) 114:362-370.

27. Aruin S.A., Latash M.L. Directional speci�city of postural muscles in feed-forward postural reactions dur-ing fast voluntary arm movements. Exp Brain Res (1995) 103:323-332.

28. Cresswell A.G., Grundstrom H., �orstensson A. Observations on intra-abdominal pressure and patterns of abdominal intra-muscular activity in man. Acta Physiol Scand 1992, 144, 409-418.

29. Hodges P.W., Richardson C.A. Contraction of the Abdominal Muscles Associated With Movement of the Lower Limb. Physical �erapy. Vol. 77 No. 2 February, 1997.

30. Norris C.M. Functional load abdominal training: part 1. Journal Of Bodywork And Movement �erapies July 1999.

31. Lee D. �e Pelvic Girdle (2nd. Ed.) An Approach to the Examination and Treatment of the Lumbo-Pel-vic-Hip Region. Edinburgh, London, New York, Philadelphia, Sydney, Toronto: Churchill Livingstone, 1999.

32. Richardson C.A., Jull G.A. Muscle control pain control. What exercises would you prescribe? Manual �erapy(1995) 1, 2-10.

33. Bogduk N., Towmey L.T. Clinical Anatomy of the Lumbar Spine (2nd. Ed.).Melbourne, Edinburgh, Lon-don, New York and Tokyo: Churchill Livingstone, 1991.

34. Wirhed, R. Athletic Ability & the Anatomy of Motion. Wolfe Medical Publications Ltd., 1984.

35. White, A. and Panjabi, M. Clinical Biomechanics of the Spine 2nd. ED. J.B. Lippincott Co., 1990.


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36. Cholewicki, J., Juluru, K., McGill, S. Intra-abdominal Pressure Mechanism for Stabilizing the Lumbar Spine. Journal of Biomechanics 32 (1999) 13-17.

37. Bogkuk, N. Clinical Anatomy of the Lumbar Spine and Sacrum 3rd. ED. Churchill Livingstone, 1999.

38. Chek P. Scienti�c Core Conditioning. (DVD correspondence course) Vista, CA: Chek Institute, 1993-20011.

39. Chek P. �e Outer Unit. Published at www.personaltraining.com.au

40. Ziglar Z. How To Stay Motivated. (tape series) . Carrollton, TX: �e Zig Ziglar Corp.

41. Lahad A., Malter A.D., Berg A.O., Deyo R.A. �e e�ectiveness of four interventions for the prevention of low back pain. JAMA 1994;272:1286-91.

42. Majkowski G.R., Jovag B.W., Taylor B.T., Taylor M.S., Allison S.C., Stetts D.M., Clayton R.L. �e Ef-fect of Back Belt Use on Isometric Lifting Force and Fatigue of the Lumbar Paraspinal Muscles. Spine Vol. 23, No. 19, pp 2104-2109, 1998.

43. National Institute for Occupational Safety and Health. Workplace use of back belts: Review and recom-mendations. Rockville, MD: Department of Health and Human Services (National Institute of Occupa-tional Safety and Health) Publication No. 94-122, 1994

44. Mitchell L.V., Lawler F.H., Bowen D., Mote W., Asundi P., Purswell J. E�ectiveness and cost-e�ectiveness of employer-issued back belts in areas of high risk for back injury. J Occup Med 1994 Jan;36(1):90-94.

45. �omas J.S., Lavender S.A., Corcos D.M., Andersson G.B. E�ect of lifting belts on trunk muscle activa-tion during a suddenly applied load. Hum Factors 1999 Dec;41(4): 670-6.

46. Reyna J.R., Leggett S.H., Kenny K., Holmes B. and Mooney V. �e E�ect of Lumbar Belts on Isolated Lumbar Muscle Strength and Dynamic Capacity. Spine Vol. 20 No. 1 pp 68-73, 1995.

47. McGill S.M., Norman R.W., Sharratt M.T. �e e�ect of an abdominal belt on trunk muscle activity and intra-abdominal pressure during squat lifts. Ergonomics 1990 Feb;33(2):147-60.

48. Hodgson E.A. Occupational back belt use: a literature review. AAOHN J 1996 Sep;44(9): 438-43.

49. Ciriello V.M., Snook S.H. �e e�ect of back belts on lumbar muscle fatigue. Spine 1995 Jun 1;20(11):1271-8; discussion 1278.

50. Cholewicki J., Juluru K., Radebold A., Panjabi M.M., Magill S.M. Lumbar spine stability can be aug-mented with an abdominal belt and/or increased intra- abdominal pressure. Eur Spine J 1999;8(5): 388-95.

51. Smith E.B., Rasmussen A.A., Lechner D.E., Gossman M.R., Quintana J.B. �e e�ects of lumbosacral support belts and abdominal muscle strength on functional lifting ability in healthy women. Spine 1996 Feb 1;21(3):356-66.

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52. Zatsiorskii V.M., Sazanov V.P. A Waist-Corset For Decreasing �e Risk Of Injury To �e Spine When Lifting Weights And Doing Strength Exercises.Teoriya I Praktika Fizicheskii Kultury 3:15-17, 1987.

53. Bourne N.D., Reilly T. E�ect of a weightlifting belt on spinal shrinkage. Br J Sports Med 1991 Dec;25(4): 209-12.

54. Lander J.E., Simonton R.L., Giacobbe J.K.F. �e e�ectiveness of weight-belts during the squat exercise. Medicine and Science In Sports And Exercise Vol. 22, No. 1 Feb. 1990 pp 117-26.

55. Miyamoto K., Iinuma N., Maeda M., Wada E., Shimizu K. E�ects of abdominal belts on intra-abdom-inal pressure, intra-muscular pressure in the erector spinae muscles and myoelectrical activities of trunk muscles. Clinical Biomechanics, Feb. 1999 14(2): 79-87.

56. Drechsler A. �e Weightlifting Encyclopedia: A Guide To World Class. Whitestone, New York: Perfor-mance A is A Communications, 1998.

57. Axelsson P., Johnsson R., Stromqvist B. E�ect of lumbar orthosis on intervertebral mobioity. A roentgen sterophotogrammetric analysis. Spine 1992 Jun;17(6): 678-81.

58. Miller R.A., Hardcastle P., Renwick S.E. Lower spinal mobility and external immobilization in the nor-mal and pathologic condition. Orthop Rev 1992 Jun;21(6):753-7.

59. Bauer J.A., Fry A., Carter C. �e Use of Lumbar Supporting Weight Belts While Performing Squats: Erector Spinae Electromyographic Activity. Journal of Strength and Conditioning Research. 1999, 13: 384-388.

60. Hodges P. Richardson C., Jull G. Evaluation of the relationship between laboratory and clinical tests of transversus abdominis function. Physiotherapy Research International 1996;1(1):30-40.

61. Cholewicki J., Juluru K., McGill S. Intra-abdominal pressure mechanism for stabilizing the lumbar spine. Journal of Biomechanics 32 (1999) 13-17.

62. Keith A. Menders Of �e Maimed �e Anatomical & Physiological Principles Underlying �e Treat-ment Of Injuries To Muscles, Nerves, Bones & Joints. Robert E. Kreiger Publishing Co, 1975.

63. Abreu B.C. Physical Disabilities Manual. (pp 137) New York: Raven Press, 1981.

64. Fortin J.D. Weight Lifting (Ch. 45, p. 496) In: Watkins R.G., �e Spine In Sports St. Louis: Mosby, 1996.

65. Brownstein B., Bronner S. Functional Movement In Orthopedic And Sports Physical �erapy New York, London, Edinburgh, Melbourne, San Francisco, Tokyo: Churchill Livingstone, 1997.

66. Gill K.P., Callaghan M.J. �e Measurement of Lumbar Proprioception in Individuals With and Without Back Pain. Spine Vol. 23, No. 3, pp 371-77.

67. Steadman’s Medical Electronic Dictionary. Baltimore, MD: Williams & Wilkins, 1996.


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68. Hanna T. Somatics: Reawakening the Mind’s Control of Movement, Flexibility, and Health. Cambridge, Massachusetts: Perseus Books, 1988.

69. Chek P. Corrective and High-performance Exercise Kinesiology Certi�cation Manual Level II (four year internship program course manual) Encinitas, CA: C.H.E.K Institute.

70. Lander J.E., Hundley J.R., Somonton R.L. �e e�ectiveness of weight-belts during multiple repetitions of the squat exercise. Medcine and Science In Sports and Exercise 1992 May;24(5):603-9.

71. McGorry R.W., Hsiang S.M. �e e�ect of industrial back belts and breathing technique on trunk and pelvic coordination during a lifting task. Spine 1999 Jun 1;24(11):1124-30.

72. Chek P. Equal But Not the Same Considerations for Training Females (correspondence course) Encinitas, CA: C.H.E.K Institute. 1996-2011.

73. DonTigny R.L. Function of the Lumbosacroiliac Complex as a Self-Compensating Force-Couple with a Variable-Dependent Transverse Axis: A �eoretical Analysis. Journal of Manual and Manipulative �era-py Vol. 2:3, 87-93.

74. Janda V. Muscles, Central Nervous Motor Regulation and Back Pain. (27-41) In: Korr I.M. (Ed.) �e Neurobiologic Mechanisms in Manipulative �erapy. New York and London: Plenum Press, 1978.

75. Kegel A.H. Progressive Resistance Exercise In �e Functional Restoration Of �e Perineal Muscles. American Journal of Obstetrics and Gynecology August, 1948.

76. Chek P. Advanced Program Design (Correspondence Course) Encinitas, CA: C.H.E.K Institute, 1997, 1999.

77. Curl, Darry ed. “Posture and Craniofacial Pain,” Chiropractic Approach to Head Pain. Wilkins & Wil-liams, 1994.

78. Chek, P. �e Golf Biomechanic’s Manual. San Diego, CA: A C.H.E.K Institute publication, 1999-2009.

79. Schmidt, R.A. and Wrisberg, C.A. Motor Learning and Performance 2nd ed. Champaign, IL: Human Kinetics, 2000.

80. Duorak & Duorak. Manual Medical Diagnostics. New York, NY: �eime Medical Publishers, 1990.

81. Levit, Karel. Manipulative �erapy in Rehabilitation of the Motor System. Boston: Butterworths, 1985.

82. Chek, P. “Back Strong & Beltless.” Personal Training on the Net. www.personaltraing.com.au. Internet. November, 2001.

83. De Jarnette, Major Bertrand D.C. �e Sacrooccipital Technique of Spinal �erapy. Nebraska City, NE: Privately published, 1940.

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Scienti�c Back TrainingCorrespondence Course Test

(Revised 2011)

1. �e 2 functional muscle groups of the spine are the _______.

A. Semispinalis and quadratus lumborum groupsB. Posterior and anterior sling groupsC. Transversospinalis and erector spinae groupsD. Upper cross and lower cross groups

2. �e ____________muscles resist anterior shear of the vertebra and control rotation of the vertebra.

A. RotatoresB. InterspinalesC. Multi�dusD. Longissimus

3. �e ________muscle bridges the spine and the leg.

A. Quadratus lumborumB. IliopsoasC. Latissimus dorsiD. Sartorius

4. �e iliopsoas shares a re�ex neurological relationship with which organ?

A. LiverB. SpleenC. BladderD. Kidney

5. Unilateral shortening in the ________tends to hike up the hip.

A. Latissimus dorsiB. Multi�dusC. External obliqueD. Quadratus lumborum


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6. �e ____________muscle bridges the spine to the humerus.

A. IliopsoasB. SemispinalisC. Latissimus dorsiD. Biceps brachii

7. When lifting an object from the �oor, the �rst 45° of trunk extension is provided by which muscles?

A. Transverso-spinalB. Erector spinaeC. Hamstrings and gluteus maximusD. All the above

8. �e abdominal wall has ______ nerve innervations.

A. 6B. 2C. 9D. 1

9. If the external oblique and internal oblique on the same side contract, they will produce _________.

A. RotationB. FlexionC. ExtensionD. Side �exion

10. Tonic muscles tend to __________ and _____________.

A. Lengthen; WeakenB. Shorten; WeakenC. Lengthen; TightenD. Shorten; Tighten

11. When shortened, the anterior �bers of the gluteus medius and the tensor fascia latae will restrict which motion at the hip?

A. Internal rotationB. AbductionC. External rotationD. Flexion

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12. When squatting, a plumb line dropped from the end of the bar should _______.

A. Always be outside the toes at the bottom of a full squatB. Always line up with the hip joint at the bottom of the squatC. Always stay within the space occupied by the feet at any time during the squatD. None of the above

13. Which muscles below are primarily phasic?

A. Peroneals, wrist extensors, abdominalsB. Adductors, piriformis, scaleniiC. Iliopsoas, rectus femoris, quadratus lumborumD. Wrist �exors, tensor fascia latae, lumbar erectors

14. When the abdominals are de�cient, the ________ muscles have to help stabilize the spine.

A. Erector spinaeB. HamstringsC. IliopsoasD. Latissimus dorsi

15. �e ___________________muscles control thoracic curvature.

A. GlenohumeralB. SpinoscapularC. Semispinalis D. Rotator cu�

16. Which muscles want to pull a load toward you when lifting it from the �oor?

A. RhomboidsB. Pectoralis majorC. Latissimus dorsiD. Serratus anterior

17. Increased _______ kyphosis increases the angle in the _______.

A. �oracic; First RibB. Lumbar; Q angleC. Lumbar; 12th RibD. Cervical; Clavicle


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18. A man with a 16-pound head, that has a forward head posture of 2 inches, has a load of ________ on his _______.

A. 16 pounds; neck �exorsB. 8 pounds; lumbar extensorsC. 32 pounds; neck extensorsD. 40 pounds; thoracic extensors

19. During a Bent-Over-Row, it is important to have complete shoulder _______.

A. AdductionB. AbductionC. FlexionD. Extension

20. According to Janda, the _________________ muscle(s) is the most common site of muscle imbal-ances in the body.

A. RhomboidB. PsoasC. Erector spinaeD. Abdominal

21. �e �rst _______ degrees of load, going from standing to bending, is primarily controlled by the _______ system.

A. 35; ligamentousB. 45; muscularC. 25; ligamentousD. 55; muscular

22. It is best to use a rounded back lifting posture when the load is light enough that you can lift it _______ times.

A. 10B. 15C. 20D. 30

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23. �e knee needs to bend _______ % to recruit the _______.

A. 45; HamstringsB. 20; Gluteus maximusC. 10; Gluteus minimusD. 35; Piriformis

24. �e Inner Unit is composed of the _______ muscles.

A. External obliques, diaphragm, multi�dus, pelvic �oor, transversus abdominis.B. External obliques, diaphragm, erector spinae, posterior �bers of the internal obliques, pelvic �oor,

transversus abdominis.C. External obliques, psoas, multi�dus, posterior �bers of the internal obliques, pelvic �oor, transver-

sus abdominis.D. Diaphragm, multi�dus, posterior �bers of the internal obliques, pelvic �oor, transversus abdomi-

nis.

25. �e thoracolumbar fascia is a bu�ering system to control the transfer of forces from _______ to _______ and vice versa.

A. Nerves; tendonsB. Muscles; ligamentsC. Nerves; musclesD. Ligaments; tendons

26. If a client draws his belly button in, without any load, and it creates pain, he has a _______.

A. Compression pathologyB. Neurological issueC. Sciatic nerve painD. Stenosis

27. Which exercise below would be the best choice for working the posterior oblique system?

A. Bench press on a Swiss ballB. Lateral lunge pull with cableC. Standing shrugs on a wall crackD. Horizontal cable push split stance


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28. Pain in the right adductor may shut down the _______.

A. Left external obliqueB. Right external obliqueC. Lower abdominalsD. Left abductors

29. �e lateral system is made up of the _______.

A. Gluteus maximus, piriformis, ipsilateral adductors and opposite quadratus lumborum, external and internal obliques.

B. Gluteus Medius, gluteus minimus, contralateral adductors, gracilis, quadratus lumborum, external obliques.

C. Gluteus medius, gluteus minimus, ipsilateral adductors and opposite quadratus lumborum, exter-nal and internal obliques.

D. Gluteus medius, gluteus minimus, ipsilateral abductors and opposite latissimus dorsi, external and internal obliques.

30. Which system stabilizes the stance leg in gait?

A. Posterior obliqueB. Deep longitudinalC. LateralD. Anterior oblique

31. �e _______ system is designed to support the body and bu�er shock away from the joints.

A. Deep longitudinal B. LateralC. Anterior obliqueD. Posterior oblique

32. When you bend over, functional abdominals cause _______ in the _______.

A. Force closure; pelvisB. Strain; QuadricepsC. Lengthening; External obliquesD. Strains; Hamstrings

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33. When you bend forward, the lower abdominals rotate the pelvis _______ and this tightens the _______.

A. Anteriorly; sacrotuberous, sacrospinous and facet capsulary ligamentsB. Posteriorly; , introspinous, sacrospinous and sacroiliac ligamentsC. Posteriorly; sacrotuberous, sacrospinous and sacroiliac ligamentsD. Anteriorly; sacrotuberous, �avum and sacroiliac ligaments

34. When a child is born, the �rst spinal curve he develops is the _______.

A. �oracicB. LumbarC. CoccyxD. Cervical

35. Walking too soon as an infant/toddler forces the child to skip the _______ phase of crawling.

A. ReptilianB. MammalianC. StereognosisD. Embryonic

36. Inhalation is coupled with __________.

A. InversionB. SupinationC. EversionD. Pronation

37. Which exercise would be the best choice for training the vestibular system?

A. Front squat in squat rackB. Single leg Swiss ball lungeC. Lateral lunge pullD. Horse stance vertical

38. Which system controls righting and tilting re�exes?

A. MasticationB. RespiratoryC. VisualD. Vestibular


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39. �e most common dysfunction you see from an atlas subluxation is a _______.

A. Shoulder impingementB. Severe pronationC. �oracic KyphosisD. Lumbo-pelvic dysfunction

40. �e _______ system has the power to override the entire system.

A. RespiratoryB. Limbic/EmotionalC. VisualD. Vestibular

41. You need to place a _______ degrees or larger bend in the knee during the ankle dorsi�exion test to �nd the end range of the _______.

A. 15; SoleusB. 10; GastrocnemiusC. 5; SoleusD. 12; Gastrocnemius

42. During the hamstring �exibility test at the knee it is important to place your �nger on the _______ vertebra.

A. L1B. L3C. L2D. L5

43. During the Sit Reach Test you are looking at _______.

A. Lumbar extensionB. Hamstring lengthC. Lumbar �exionD. �oracic �exion

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44. More than a _______ % di�erence from left to right in comparative range of motion testing is a cause for concern.

A. 2B. 7C. 10D. 5

45. �e Hip Adduction Test is assessing the _______.

A. Hip abductorsB. Hip adductorsC. Hip �exorsD. Hip extensors

46. When you see striation in the _______ (wash boarding) it usually means the vertebra are sliding _______.

A. Quadratus lumborum; leftB. Multi�dus; forwardC. Erector spinae; backwardD. Spinalis; right

47. If the trunk cannot rotate at least 90 degrees during a swinging motion, such as a tennis racket swing, it will most likely place torque on the ________.

A. AnkleB. ShoulderC. KneeD. Wrist

48. For the Internal and External Hip Rotation Test, direction of rotation is indicated by the _______.

A. FootB. KneeC. HipD. Ankle


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49. �e Standing Side Flexion Test is assessing the �exibility of the _______.

A. Multi�dusB. Lower trapeziusC. Erector spinaeD. Quadratus lumborum

50. During the Forward Bend Test, structural scoliosis is identi�ed when the client has _______.

A. A relatively �at backB. A rib hump on one sideC. Uneven gluteal skylineD. A rounded thoracic spine

51. When a client’s right hip is higher than the left it causes a side bend _______ which is coupled with ________.

A. Left; reduced lumbar curveB. Right; right rotation of lumbar spineC. Left; increased lumbar curveD. Right; left rotation of the lumbar spine

52. �e Lumbopelvic Rhythm Test assesses _______.

A. �e relationship between the sacroiliac joint and the pelvis with regard to forward bendingB. �e relationship between the lumbar spine and the sacroiliac joint with regard to forward bendingC. �e relationship between the lumbar spine and the pelvis with regard to forward bendingD. �e relationship between the thoracic spine and the lumbar spine with regard to forward bending

53. Which mobilization is best for integrating the pelvis with the rest of the body?

A. McKenzie Press-upB. Feldenkrais Hip and Pelvis IntegratorC. Feldenkrais Shoulder and Spine IntegratorD. Foam Roller Longitudinal Mobilization

54. Feldenkrais mobilizations help _______.

A. Build strength in the lamina grooveB. Decrease nerve stimulationC. Reestablish motor controlD. Increase muscle tone in the calves

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55. Which mobilization is best for clients with disc injuries?

A. McKenzie Press-upB. Feldenkrais Hip and Pelvis IntegratorC. Feldenkrais Shoulder and Spine IntegratorD. Foam Roller Longitudinal Mobilization

56. During the foam roller segmental mobilization you should mobilize the spine _______.

A. Above the segment where the client has di�culty extendingB. Below the segment where the client has di�culty extendingC. Right on the segment where the client has di�culty extendingD. Above and below the segment where the client has di�culty extending

57. �e Dynamic Horse Stance mimics the _______ position.

A. Reptilian crawlB. Mammalian crawlC. Cross crawlD. Brachiation crawl

58. Holding the arm at a _______ degree angle during the horse stance exercise helps activate the __________.

A. 45; Lower trapeziusB. 90; Latissimus dorsiC. 20; Posterior deltoidD. 10; Middle trapezius

59. �e Supine Hip Extension Feet on Ball exercise is excellent for training the strength and coordina-tion of the _______ of the body.

A. Flexor mechanismB. Posterior oblique systemC. Anterior oblique systemD. Extensor mechanism


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60. Over pronation in the Supine Hip Extension Back on Ball exercise indicates the client has ________.

A. Weak hamstringsB. Weak external hip rotatorsC. Tight erector spinaeD. Weak internal hip rotators

61. Which exercise would be best for back pain clients that have pain when they bend forward?

A. Parallel back extensionB. Swiss ball back extensionC. Incline back extensionD. Reverse hyperextension

62. Which exercise is best for working the stabilizers in the frontal plane?

A. Supine hip extension back on ballB. Swiss ball side �exionC. Reverse hyperextensionD. Prone cobra

63. �e Supine Lateral Ball Roll works which slings of the body?

A. Anterior oblique; Posterior oblique, LateralB. Anterior oblique; Posterior oblique, Lateral, Deep longitudinalC. Anterior oblique; Lateral, Deep longitudinalD. Lateral, Deep Longitudinal

64. During the Forward Ball Roll, the contribution from the hips and shoulders should be as follows:

A. Shoulders move �rst and farthestB. Hips move �rst and farthestC. Hips and shoulders move equally the sameD. Hips should remain �xed at all times

65. �e best exercise to integrate the core with the lower extremities is the ________.

A. Prone jack knifeB. Forward ball rollC. Supine lateral ball rollD. Horse stance vertical

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66. Phase two exercises are done predominantly _________.

A. Standing with axial loadingB. Supine and proneC. Standing without axial loadingD. Kneeling and standing

67. Which exercise is safest for introducing a rotational load to the spine?

A. Kneeling back extensionB. Reverse hyperextensionC. 3-Point single arm rowD. Bent over row

68. �e single-arm bicep curl activates the _______ on the _______ side of the body.

A. Biceps; same B. Triceps; same C. Triceps; oppositeD. Stabilizers; opposite

69. Which type of exercises help people move from Phase one to Phase two exercises?

A. PrimaryB. Non-compressiveC. Axial loadingD. Secondary

70. A Lat Pull Down with a client who has an injured spine, should be performed in which position?

A. SittingB. StandingC. KneelingD. Single leg

71. When the pelvis tips forward during the Straight Arm Lat Pull Down it is an indication that the _______ is/are not working properly.

A. Hip �exorsB. CoreC. Hip extensorsD. Erector spinae


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72. �e sequence of any cable push or pull exercise is:

A. Twist to 90 degrees, weight shift, push or pull naturally, reciprocityB. Push or pull naturally, reciprocity, weight shift, twist to 90 degrees C. Weight shift, twist to 90 degrees, push or pull naturally, reciprocityD. Weight shift, push or pull naturally, reciprocity, twist to 90 degrees

73. Adding a reciprocity movement in a pushing or pulling exercise does what to the spine?

A. Reduces rotational torqueB. Increases sagittal plane movementC. Increases stress to the spineD. Reduces neurological input

74. Which exercise is the best choice for preparing someone for the dead lift?

A. High cable pullB. Lat pull downC. Low rowD. Lat pull over

75. Before someone can perform a reverse wood chop safely, they need to be able to pass the __________ test.

A. Waiter’s bowB. �oracic arm raiseC. Side bendD. Lumbopelvic rhythm

76. During the wood chop exercise, the _______ works with the _______.

A. lat; ipsilateral gluteB. Glutes; ipsilateral adductorsC. External obliques; contralateral latD. Glutes; contralateral lat

77. If a client, such as a golfer, has rotational challenges you could have them do the _______ in the op-posite direction.

A. Single arm cable pushesB. High cable pushesC. Single arm low rowD. Reverse wood chop

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78. During the squat assessment, you are looking for when a client switches from a _______ lifting pos-ture to a ________ lifting posture.

A. Lordotic; kyphoticB. Sumo; closed stanceC. Kyphotic; lordoticD. Kyphotic; sumo

79. Phase three exercises introduce _________.

A. Axial loadingB. Axial loading beyond body weightC. Supine exercisesD. Prone exercises

80. When coming through the sticking point of the squat, it is important to _______.

A. Let the air out quicklyB. Let the air out through pursed lipsC. Hold the airD. Let the air out for 5 seconds

81. When the pelvis tips forward during a squat, it causes _______.

A. Hallux valgusB. Hallux varusC. Femoral retroversionD. Femoral anteversion

82. During a back squat, the bar should rest _______.

A. Just behind the neckB. Just above T1 and T2C. Low on the back near T5D. Balanced on C7

83. �e rack height of the bar in a squat should be _______.

A. Between the chin and the clavicleB. Between the nipple line and collar boneC. Between the xyphoid process and nipple lineD. Between the nose and chin


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84. During the squat, the eyes should be _______.

A. Level with the horizonB. Looking 3 feet in front of youC. Looking 15 degrees above the horizonD. Looking up to the ceiling

85. It is important to initiate the squat with the _______.

A. HipsB. AnklesC. TrunkD. Knees

86. If the abdominal wall is not activating on command, you could also tell the client to tighten the _______.

A. RectumB. Multi�dusC. External obliqueD. Erector spinae

87. A plumb line dropped between the cheeks of the squatting athlete’s gluteus maximus should _______.

A. Always deviate toward the strong legB. Always deviate toward the weak legC. Always fall an equal distance between the feet at any point in the squatD. Swing slowly

88. A Front Squat puts a tremendous amount of work at the _______.

A. Lumbar spine L3 levelB. Apex of the thoracic curvatureC. Sacroiliac jointD. T12 level of the spine

89. During the Sumo Dead Lift, the bar and the _______ should touch.

A. ShinsB. KneesC. HipsD. Ankles

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90. Conventional dead lifts tend to put excessive _______ on the body, causing tremendous stress to the _______.

A. Forward lean; SI JointB. �oracic extension; PatellaC. Lumbar lordosis; Acetabulofemoral jointD. �oracic rotation; Achilles tendon

91. During the sumo squat, the hips are _______.

A. AdductedB. Internally rotatedC. AbductedD. Externally rotated

92. Which assessment do you use to determine if a client needs blocks for a dead lift?

A. Sit and reachB. Lumbopelvic rhythmC. Hamstring �exibility at the hipD. Waiters bow

93. When lunging forward, it is important to take a _______ step.

A. Short B. Big C. ½D. Natural position

94. During the bent-over row, the trunk should be at a _______ degree angle.

A. 35-40B. 20-30C. 45-60D. 10-20

95. During the Bent-Over Row, the knees should be bent _______ degrees to activate the _______.

A. 10; hamstringsB. 30; IliopsoasC. 25; IT BandD. 20; glutes


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96. Spindle cells are responsible for telling the brain about the _______.

A. Length of the muscleB. Tightness of the tendonsC. Elasticity of the muscleD. Golgi tendon organ response

97. The _______ is known as the abdominal brain.

A. External obliqueB. TVAC. Solar plexusD. Iliacus ligament

98. The nervous system remembers the last _______ rep(s) of an exercise set.

A. 3B. 4C. 1D. 2

99. Which types of muscles are postural in nature?

A. PhasicB. TonicC. IntrinsicD. Extrinsic

100. Most lumbar disc bulges are _______.

A. AnteriorB. LateralC. MedialD. Posterior

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1. A B C D 9. A B C D 17. A B C D 25. A B C D








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Paul Chek HHP is a prominent expert in the �eld of holistic health and corrective and high-performance exercise. For over twenty-six years, Paul’s unique, holistic approach to clinical assessment, intervention, treatment rehabilitation and education has changed the lives of countless individuals worldwide. By treating the body as a whole system and �nding the root cause of a problem, Paul has successfully coached clients toward complete resolution of their health and performance challenges, where traditional approaches have consistently failed.

Paul is the founder of the C.H.E.K (Corrective Holistic Exercise Kinesiology) Institute and the PPS Success Mastery Program based in San Diego, California.

He developed the C.H.E.K Advanced Training Programs in 1995, which currently have over 6000 C.H.E.K Institute Trained Professionals worldwide.

For over twenty-six years, Paul’s unique, holistic approach to clinical intervention, treatment and education has changed the lives of countless individuals worldwide. As a walking, talking de�nition of success, Paul is above all an educator: teaching and applying his methods to bene�t others. His programs are not only cutting-edge, students leave his courses and trainings with practical information that can be applied to achieve successful results right away.

Paul is a sought after presenter and has consulted for organizations such as the Chicago Bulls, Australia’s Canberra Raiders, New Zealand’s Canterbury Crusader’s and the US Air Force Academy. Paul was the keynote speaker for the NZ Musculoskeletal Conference in 1998 and was rated number one speaker by participants at the 1998 IHRSA conference.

From 1992 to present, Paul has produced over 50 videos and advanced level home study courses designed for the �tness and clinical professional, such as his Scienti�c Core Conditioning and Scienti�c Back Training series. He is a regular contributor to several publications and websites. His book, �e Golf Biomechanics Manual and course are PGA approved, and has been adopted for use by professional golf schools, as well as featured on the Golf Channel in 2000.

Certi�cations: Holistic Health Practitioner (California), Certi�ed Neuromuscular �erapist, Clinical Exercise Specialist (ACE), Massage �erapist (CAMTC)

Testimonials From Peers

“Paul Chek’s courses will give you a greater understanding and appreciation of the role that core strength and stability play in the development of an athlete”

-Al Vermeil, Strength Coach, Chicago Bulls

“Paul’s workshops and videos are easily understood and provide excellent tips on proper biomechanics. �ese programs are a must for anyone in the rehabilitative or exercise �elds." -Darryl Curl, D.D.S., D.C.

“Paul’s approach re�ects a unique synthesis of scienti�c principles and clinical experience that the practitioner can immediately apply.” -Jay Smith, MD

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