ARTICLE IN PRESS

Physical Therapy in Sport 9 (2008) 4051 www.elsevier.com/locate/yptsp

Masterclass

A new perspective on risk assessment

Sarah Mottram, Mark Comerford
Performance Stability, Lower Mill Street, Ludlow, Shropshire SY8 1BH, UK Received 12 July 2007; received in revised form 4 November 2007; accepted 9 November 2007

Abstract Pre-season screening is routinely promoted as part of either an injury risk management strategy or as a performance enhancement strategy. Many of these processes focus on testing joint range, muscle strength (both power and endurance) and testing muscle extensibility. Although some functional tests based on work specic tasks and sport specic skills are applied they are specic to one task or a sport specic skill. It seems that the clinical outcomes of asymptomatic function, normal range of joint motion (isolated testing) and normal muscle strength (isolated testing) are not adequate rehabilitation end points to prevent recurrence. This Masterclass explores assessment and retraining from a new perspective in an attempt to address multiple muscle interactions acting on multiple joints in functionally orientated tasks. The assessment is based on the specic assessment of the site and direction of uncontrolled movement, under low and high threshold loading at different joint systems within functionally orientated tasks. From this assessment, a specic retraining programme can be developed and implemented. r 2007 Elsevier Ltd. All rights reserved.
Keywords: Risk assessment; Performance; Core Stability

1. Background Pre-season screening of athletes is now common place in elite and professional sport and in competitive sport even at junior levels. This screening is promoted as part of either an injury risk management strategy or as a performance enhancement strategy. The development of risk assessment and screening processes and subsequent training packages for sport is of interest to therapists involved in sport (Bahr & Holme, 2003; Fuller & Drawer, 2004; MacAuley, 2000; McKeag & Sallis, 2000). Until now, the focus has been on testing joint range, muscle strength (both power and endurance) and testing muscle extensibility (Bennell, Tully, & Harvey, 1999; Bennell, Wajswelner, Lew, Schall-Riaucour, Leslie, & Cirone, 1998; Gabbe, Finch, Bennell, & Wajswelner, 2005; Garrick, 2004; Kibler, Press, & Sciascia, 2006; Leetun, Ireland, Willson, Ballantyne, & McClay Davis, 2004). Assessing these
Corresponding author. Tel.: +44 1584 877987.

E-mail address: sarah@performance-stability.com (S. Mottram). 1466-853X/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ptsp.2007.11.003

parameters invariably tends to isolate the individual joints or muscles in non-functional standard situations. Some attempts have focused on developing functional tests based on work specic tasks and sport specic skills. When functionally orientated tests are used they tend to be highly specic to one task or sport specic skill (Bennell et al., 1999; Chek, 2004; Hewett, Myer, Ford, & Slauterbeck, 2006; McGill, Childs, & Lieberman, 1999; Myer, Ford, Hewett, & Slauterbeck, 2004; Nadler, Malanga, Feinberg, Bubanni, Moley, & Foye, 2002; Parkkari, Kujala, & Kannus, 2001). All these parameters have been relatively unsuccessful at predicting risk of injury. There is almost no reliable evidence base to support the use of screening for physical factors to either predict risk of injury to prevent injury in the systematic review or meta-analysis databases (Chalmers, 2002; Wingeld, Matheson, & Meeuwisse, 2004). Currently, the research evidence points to a history of previous injury being the most consistent and reliable predictor of high risk of re-injury (Fuller & Drawer, 2004; Joy, Paisley, Price, Rassner, & Thiese, 2004; Locke, 2003; Reed, 2004; Van Mechelen, Hlobil,

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& Kemper, 1992; Van Mechelen, Twisk, Molendijk, Blom, Snel, & Kemper, 1996; Watson, 2001). If this is the case, then clearly there is a problem in the way that we are managing the previous injury. It seems that the clinical outcomes of asymptomatic function, normal range of joint motion (isolated testing) and normal muscle strength (isolated testing) are not adequate rehabilitation end points to prevent recurrence. Screening questionnaires currently include some or all of the following factors: health questionnaire including medical conditions and history of previous injury and management, lifestyle questionnaire including occupational, recreational and personal variables, nutritional evaluation, physical assessment and psychological prole (Emery, 2005; Galambos, Terry, Moyle, & Locke, 2005; Junge, 2000; Locke, 2003; Peltz, Haskell, & Matheson, 1999; SMA, 2005). Physical assessment recommendations are currently advocated by authors of many screening programmes. These include movement based parameters such as quick functional screening e.g. Gray CooksFunctional Movement Screen (Cook, 2002), baseline measures of strength in the primary power muscle groups, joint range, exibility, power and elastic potential (Hewett et al., 2006). Physiology based parameters include cardiovascular tness and recovery and sport specic protocols (Parkkari et al., 2001). Assessment of real function, that is, the inuence of the multiple muscle interactions acting on multiple joints in functionally orientated tasks has yet to be undertaken. This Masterclass explores assessment and retraining from a new perspective in an attempt to address real function. The assessment is based on the specic assessment of the site and direction of uncontrolled movement, under low and high threshold loading at different joint systems within functionally orientated tasks. It utilises multi-joint tasks that are generic (not task or sport specic) and are related to both low and high load movement functions. The testing does not focus excessively on testing individual muscles or joints. This testing process identies a specic joint system as a weak link demonstrating uncontrolled movement, within a chain of linked joints in functional multi-joint tasks.

1.1. Evidence of uncontrolled movement In the pain-free state, normal postural control and non-fatiguing functional movements demonstrate efcient recruitment of the deep segmental muscles that provide a stability role. While high load or high speed activities demonstrate dominance of supercial multijoint muscles that provide a mobility (high load, large range or high speed) role (Hodges, 2003; Hodges & Moseley, 2003). There is evidence in the literature that chronicity/ recurrence of symptoms is linked with dysfunction in control of movement (Dankaerts, OSullivan, Straker, Burnett, & Skouen, 2006; Hodges & Moseley, 2003; Hungerford, Gilleard, & Hodges, 2003; OSullivan, 2005). There is strong evidence linking motor control deciencies in deep (force inefcient) local stability muscles, which control inter-segmental movement, to pain and recurrence (Hodges & Moseley, 2003; Jull, 2000; Moseley & Hodges, 2006; Richardson, Hodges, & Hides, 2004; Sterling, Jull, Vicenzino, Kenardy, & Darnell, 2005). However, the evidence to support assessing local stability muscles as part of routine screening is poor unless there is a previous history of pain in that region (Hodges & Moseley, 2003; Moseley & Hodges, 2006). Many authors have proposed that there is a link between pain being provoked by a particular direction of movement (e.g. low back pain

Table 1 Key features of the Performance Matrix

 Tests motor control efciency of movement (site and direction of    

uncontrolled movement) rather than just individual strength or exibility parameters Uses functional multi-joint tasks and identies any uncontrolled joint in the chain rather than testing individual joints or muscles isolated from functional situations Functionally orientated tasks that are generic rather than sport skill or task specic and can be applied to any sport or work screening process Screens for both motor control (low threshold) and strength and speed (high threshold) deciencies to identify weak links Identies performance assets that can be progressed more rapidly or fast tracked in training

Fig. 1. Relative exibility of the lumbar spine compensation into extension. (a) Prone Knee Flexion(adapted Sahrmann 2002). Ideally, there should be approximately 1200 knee exion without signicant lumbo-pelvic motion. (b) Lumbar extension weak link (Prone Knee Flexion) (adapted Woolsey et al 1988): The relatively more exible abdominals compensate for relatively stiffer hip exors (rectus femoris resists knee exion), producing excessive anterior tilt and lumbar extension (reproduced with permission from KC International).

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provoked by forward bending) and motor control deciencies of the muscles that control that movement (Comerford & Mottram, 2001b; Dankaerts, OSullivan, Burnett, & Straker, 2006; Falla, Jull, & Hodges, 2004; Janda, 1996; OSullivan, 2005; OSullivan et al., 2006; Sahrmann, 2002). Studies looking at the patterns of recruitment between 1 joint (stabiliser) and multi-joint (mobiliser) synergists

Low

THRESHOLD OLD

High T H R E S H D I R E C T I O N UN Adduction LN SB SITE SJ Sidebend Rotation

in non-symptomatic subjects have observed that the one joint stabiliser synergists are dominant in non fatiguing functional movement and postural control tasks (Hodges & Moseley, 2003; Jull, 2000; OSullivan et al., 2006; Sterling, Jull, & Wright, 2001). In the presence of chronic or recurrent musculo-skeletal pain subjects employ strategies or patterns of muscle recruitment that are normally reserved for high load function (multi-joint mobiliser muscle dominance) to perform low load postural control and normal non-fatiguing functional movements (Dankaerts, OSullivan, Burnett et al., 2006; Falla, Bilenkij, & Jull, 2004; Falla, Jull, & Hodges, 2004; Hodges, 2003; Hodges & Moseley, 2003; Jull, 2000; Lee, 1999; Moseley & Hodges, 2006; OSullivan, 2005; OSullivan et al., 2006; Richardson et al., 2004; Sahrmann, 2002; Sterling et al., 2001, 2005). There is

Flexion Extension
Table 2 Low load multi-joint function testing categories in the Performance Matrix reproduced with permission from Performance Stability Low load testing categories 1. Standing small knee bend control 2. Sitting spinal dissociation Identies low load failure

Abduction

LB/P

LL

Fig. 2. The Performance Matrix reproduced with permission from Performance Stability. The Performance Matrix tests for

1. The site of the weak link, where the performance decit is:

       

upper neck (UN) lower neck (LN) upper back (UB) shoulder blade (SB) shoulder joint (SJ) low back/pelvis (LB/P) hip (H) lower leg (LL)

3. Standing arm control 4. Crook lying limb control 5. Hands and knees limb control

Weak links associated with spinal, girdle and lower limb during bilateral and single leg stance Weak links associated with spinal control during lumbar thoracic and cervical movements Weak links associated shoulder girdle control during arm movement Weak links associated with lumbo-pelvic control during limb movements Weak links associated with spinal, pelvic and shoulder girdle control during limb movements

Table 3 High load multi-joint function testing categories in the Performance Matrix reproduced with permission from Performance Stability High load testing categories 6. Crook lying limb loading 7. Modied pushup 8. Standing shoulder loading 9. Lunge loading Identies high load failure

2.

The direction of uncontrolled movement at the weak link. which direction (3 cardinal planes) of loading is poorly dissociated that is, the direction that is difcult to prevent or resist movement into:  axial plane J rotation (spine, limbs and scapula), winging (scapula) sagittal plane: J exion and extension (limbs and spine), posterior tilt and anterior tilt (pelvis), elevated and forward tilt (scapula), forward glide (hip and gleno-humeral translation)  coronal plane: J sidebend (spine), lateral tilt (pelvis), abduction and adduction (limbs), depression and retraction (scapula) The threshold of loading failure  whether the weak link is related to a motor control decit or to a strength decit: J low threshold motor control failure (low load and slow) J high threshold weakness (high load or fast)

3.

10. Explosive propulsion

Weak links associated with spinal, pelvic and shoulder girdle control during limb movements Weak links associated with spinal control and girdle control during upper and lower limb weight transfer Weak links associated spinal and girdle control during high force and high speed arm movement Weak links associated spinal girdle and lower limb control during high force and high speed leg movement Weak links associated spinal girdle and lower limb control during high force and high speed leg movement

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little objective evidence for the measurement of uncontrolled movement under high load testing. This is partially due to the observation that to lift or push a maximal load or weight proximal spinal or girdle movement normally increases to improve the mechanical efciency of lifting or pushing heavy weights. The point or threshold at which normal movement becomes uncontrolled movement under high load testing has not yet been determined. 1.2. Altered control strategies These altered strategies or patterns have been described in the research and clinical literature as substitution strategies, compensatory movements, muscle imbalance between inhibited/lengthened stabilisers and shortened/overactive mobilisers, faulty movements, abnormal dominance of the mobiliser synergists, co-contraction rigidity and control impairments. Making the link between altered control strategies and pain is not new but the concept of linking it to injury prevention is (Schwellnus, 2004). This is of particularly interest as in the presence of chronic or recurrent musculo-skeletal pain these altered strategies have been shown to be reversible (OSullivan, 2005). 1.3. Relative exibility These altered control strategies have been linked with the concept of relative exibility (Comerford & Mottram, 2001b; Janda, 1996; Sahrmann, 1987, 2002). It is frequently observed that a loss of range of movement at

one or more motion segments is matched by the development of compensatory movement at an adjacent segment. This has been described as relative stiffness and relative exibility (Sahrmann, 2002). The relative stiffness is commonly observed in the dominant multi-joint mobility muscle synergists and the relative exibility in the inefcient one joint stability muscle synergists. During multi-joint movements, a relatively stiffer segment tends to resist movement, but function is maintained by developing compensatory movement at the less stiff (relatively exible) segment. The concept of relative exibility has been linked to uncontrolled movement and pain and pathology by causing direction related stress and strain (Comerford & Mottram, 2001b; Sahrmann, 2002). The ability to compensate for restrictions to keep function is normal adaptive behaviour in the movement system. This is not abnormal as long as motor control strategies within the central nervous system can control this movement when required. Compensation for restriction (relative exibility) should be considered to be maladaptive behaviour when the central nervous system lacks the ability to control or prevent the compensation when required. The assessment of this uncontrolled movement can be described in terms of the site and direction of uncontrolled compensatory movement (Comerford & Mottram, 2001a; Mottram, 2003). Fig. 1 demonstrates relative exibility at the lumbar spine relative to hip and knee. Other examples of how relatively more exible structures compensate for relatively stiffer structures in function include; the relatively more exible back extensors compensating for relatively stiffer hip extensors producing excessive

Fig. 3. Test 1F: Single leg small knee bend+lunge & lean (see scoring Table 4) (reproduced with permission of Performance Stability).

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lumbar exion (Esola, McClure, Fitzgerald, & Siegler, 1996a, 1996b; Sahrmann, 2002) and relatively more exible scapulothoracic stabilisers compensating for relatively stiffer scapulohumeral muscles producing excessive scapular forward tilt or gleno-humeral translation (Babyar, 1999; Mottram, 2003; Sahrmann, 2002). A lack of ability to actively control or prevent a compensatory movement when required or instructed to do so is considered to be uncontrolled motion. This uncontrolled motion is dened as a weak link or give (Comerford & Mottram, 2001b).

plane only. However, everybody should have the ability to perform patterns of movement that are not habitually used in normal function. Performance of these unfamiliar movements is a test of control of movement
Table 5 Score sheet for test 1F demonstrating low back extension weak link under low load (reproduced with permission of Performance Stability) 1F Single leg small knee bend+lunge & lean Results Fail Direction Flexion Extension Rotation Sidebend Flexion Rotation (medial) Rotation (lateral) L & & & & & & R & & & & & &

Weak link Load Site Low back

2. Functional testing for uncontrolled movement the weak link During functional movements muscles co-activate in integrated patterns to control movement. Normal function rarely eliminates movement from one joint system while moving at another and rarely moves in one

Low

Hip (NWB) Hip (WB) Lower leg (WB)

Table 4 Example of a low threshold test evaluation: 1F see Fig. 3 (reproduced with permission of Performance Stability) Test 1F Start position Single leg small knee bend+lunge & lean
J J J J J J J J

Stand with one foot forward and one foot back Front foot is 3 foot lengths in front of rear foot (one foot length between front and rear feet) Inside edge of the front foot aligned straight ahead Keeping heel down, bend the knee to lunge forward onto the front foot (the rear heel can lift) Keep the thigh out over the second toe The back should be straight and vertical as if sliding down a wall The pelvis should be facing straight ahead (not rotated away from the front foot) Keep the spine straight (dont let it round out or over arch) Shift the full weight onto the front foot by bending forward at the hips to 451 forward leaning Keep the pelvis facing straight ahead Keep the knee and thigh over the second toe Keeping the rear leg straight lift the rear toe clear of the oor There should be a straight line from the point of the shoulder through the trunk and down the rear leg Hold the position for 5 s Weak link L R Yes & No Yes & No Yes & No Yes & No Yes & No Yes & No Yes & No Load Low Low Low Low Low Low Low Site Low back (lumbo-pelvic) Hip (WB) Low back (WB) (knee) Low back (lumbo-pelvic) Low back (lumbo-pelvic) (lumbo-pelvic) Hip (NWB) Direction Rotation Rotation (medial) Rotation (lateral) Flexion Extension Sidebend Flexion

Test movement

      

Performance Matrix analysis

Can you prevent rotation of the pelvis? (pelvis staysfacing straight ahead) Can you prevent turning in of the weight-bearing (WB) front knee or rolling down of the arch? Can you prevent the foot turning out or heel pulling in? (arch rolling down 7 toe clawing) Can you prevent the back from rounding out (exing)? Can you prevent the back from over arching (extending)? Can you prevent sidebending of the trunk or tilting or side shifting of the pelvis? Can you prevent the non weight-bearing (NWB) rear leg dropping from the straight line?

Yes & No Yes & No Yes & No Yes & No Yes & No Yes & No Yes & No

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(Comerford & Mottram, 2003). The ability to activate muscles to isometrically hold position or prevent motion at one segment, while concurrently actively producing a movement at another joint segment is a test of control and known as dissociation. A clinically applicable method of determining uncontrolled movement is based on the concept of dissociation (Hamilton & Richardson, 1998; Sahrmann, 2002; Woolsey, Sahrmann, & Dixon, 1988). The subject is instructed to actively prevent movement at one joint region while concurrently moving at an adjacent region. For example, the subject is instructed to prevent anterior pelvic tilt with lumbar extension while exing the knee to 1201 against the passive resistance of rectus femoris which attempts to anteriorly tilt the pelvis (Woolsey et al., 1988) (Fig. 1). The abdominals should be able to efciently resist this movement. 2.1. The weak link The weak link may present as uncontrolled dissociation movements under non-fatiguing functional movement or postural control load (low load) or as uncontrolled dissociation movements under high force or high speed (high load) testing. The site and direction of uncontrolled motion (weak link) is of particular interest to therapists as it usually relates to the direction of movement in which pain sensitive structures are provoked by abnormal compression or stretch. Identifying the site and direction of uncontrolled motion may determine a mechanical subgroup of movement or control dysfunction and helps direct the assessment and retraining of control of movement (Comerford & Mottram, 2001b; Dankaerts, OSullivan, Straker et al., 2006; Sahrmann, 2002). A decrease in exibility is not a predictor of injury risk (Bennell et al., 1998, 1999; Thacker, Gilchrist, Stroup, & Kimsey, 2004). Likewise, stretching does not prevent injury (Pope, Herbert, Kirwan, & Graham, 1999; Thacker et al., 2004; Weldon & Hill, 2003). Muscle imbalance, lax or hypermobile movement is considered to be an important factor in predicting injury (Cameron, Adams, & Maher, 2003; Nadler et al., 2002; Nadler, Wu, Galski, & Feinberg, 1998; Stewart & Burdon, 2004). Since a loss of extensibility or recovery of exibility does not appear to be a signicant factor in screening for injury prediction or prevention it would seem that identifying the compensations for restricted motion might be more relevant. Identifying uncontrolled movement could be a more useful component of screening and a priority in retraining in risk management strategies. Identifying the weak link is of value to the sports therapist and other professionals working in the eld as it is possible to identify uncontrolled movement before symptoms become apparent. The

correction of these faults may prevent occurrence of pain and injury (Comerford, 2004, 2006; Comerford & Mottram, 2001b). 3. The Performance Matrix The most signicant and reliable predictor of injury risk in sport is a history of previous injury (Allen & Locke, 1989; Locke, 2003; Locke & Allen, 1992; Parkkari et al., 2001; Schwellnus, 2004; Watson, 2001). It seems clear then that there is a problem in the way the previous injury is being managed. It is common (and considered good management) for a sports person to return to sport after an injury having achieved the outcomes measures of asymptomatic function, normal range of joint motion on isolated joint testing and normal muscle strength on isolated muscle testing. These outcome measures are not adequate to return to sport. There must be some other factors that are not being measured or managed in the rehab process. The authors would suggest that assessing the control of real

Fig. 4. Test 7B: Elbows push up+twist to side support (see scoring Table 6) (reproduced with permission of Performance Stability).

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function must consider the inuence of multiple muscle interactions; multiple linked in functional movement; functionally orientated tasks and low and high threshold loading challenges. With increasing evidence supporting the need to identify uncontrolled motion in multi-joint tasks as part of screening processes, an innovative new screening tool has been developed. It has been designed to identify altered control strategies in terms of the site and direction of uncontrolled movement within a chain of

linked joints. It has also been designed to assess the threshold of decit. This tool, the Performance Matrix, also assesses multiple muscle interactions acting on multiple joints in functionally orientated tasks (Comerford, 2006). The key features are described in Table 1. The Performance Matrix is a three-dimensional assessment system to identify performance related weak links in the movement system. It is represented by a cube made up of smaller blocks (Fig. 2).

Table 6 Example of a high threshold test 7B: (reproduced with permission of Performance Stability) Test 7B Start position Elbows push up+twist to side support
J J J J J

Lie face down propped on elbows with hands pointing to opposite elbow Knees and feet together Shoulders midway between hitched and dropped Taking weight through the arms, lift hips and knees off oor pushing off the toes Make a straight line with legs and trunk and head

Test movement

 Keeping the pelvis neutral in a straight line with the legs and trunk, shift the upper body weight
onto one elbow

 As the weight shifts, turn the whole body 900 from the shoulder so that the whole body is side
on with the pelvis and knees unsupported and in a straight line with the legs and trunk

 The forearm and feet are the only contact points  The weight bearing upper arm should be vertical
Performance Matrix analysis L Can you prevent the back from side bending as the turn is initiated? Can you prevent the pelvis from leading the twist? (keep the back and pelvis turning together) Can you prevent the back from arching? Can you prevent the pelvis and bottom hip from dropping towards the oor in the side position? Can you prevent the hips from exing? (keep the legs and trunk in a straight line) Can you prevent the weight-bearing (WB) shoulder blade winging? Can you prevent the weight-bearing (WB) shoulder blade hitching? Can you prevent the weight-bearing (WB) shoulder blade dropping? Can you prevent forward protrusion of the head of the weight-bearing (WB) shoulder joint? Can you prevent the weight-bearing (WB) forearm from turning towards the feet (medial rotation) as the body twists? Can you prevent the head from turning or tilting? Yes & No Yes & No R Yes & No Yes & No Weak link Load High High Site Low back (lumbo-pelvic) Low back (lumbo-pelvic) Low back (lumbo-pelvic) Hip (bottom leg) Direction Sidebend Rotation

Yes & No Yes & No

Yes & No Yes & No

High High

Extension Adduction

Yes & No

Yes & No

High

Hip

Flexion

Yes & No Yes & No Yes & No Yes & No

Yes & No Yes & No Yes & No Yes & No

High High High High

Shoulder blade (WB) (scapula) Shoulder blade (WB) (scapula) Shoulder blade (WB) (scapula) Shoulder Joint (gleno-humeral)

Winging Hitch (elevation) Drop (downward rotation/depression) Forward glide

Yes & No

Yes & No

Low

Shoulder joint (WB) (glenohumeral) Neck

Rotation (medial)

Yes & No

Yes & No

High

Rotation

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The Performance Matrix uses 10 testing categories to identify any weak link in the chain within multi-joint function. It identies the weak link in terms of site, direction and threshold of uncontrolled movement. There are ve low threshold motor control testing categories and ve high threshold strength testing categories. The testing categories are based on multijoint functional tasks. Table 2 describes the low load testing categories and illustrates the low load failures, i.e. weak links. Table 3 describes the high load testing categories and illustrates the high load

Table 7 Test results demonstrating low back extension weak link under high load (reproduced with permission of Performance Stability) 7B Elbows push up+twist to side support Results Fail Direction Rotation Hitch Drop Winging Forward glide Rotation (medial) Extension Rotation Sidebend Flexion Adduction L & & & & & & & & & & R & & & & & & & & & &

failures, i.e. weak links. Each testing category has several sub-tests that are functionally related to each other. An example of a low threshold test is illustrated in Fig. 3 and Tables 4 and 5. An example of a high threshold test is illustrated in Fig. 4 and Tables 6 and 7. Each element of the testing system has a pass or fail question? Can [test movement] be prevented or controlled during the test action: yes or no ? Yes is checked ( ), if the control is good. This indicates that there is no weak link at that particular site in that particular direction under that particular load threshold. However, if no is checked as the test result ( ), then there is a weak link present for the site, direction and load tested. 3.1. Retraining the weak links Following the Performance Matrix Assessment, a performance prole is produced (Comerford, 2006) highlighting performance assets and weak links. Identication of an individuals Performance Assets can allow training programmes to be modied to fast track or challenge some processes and skills with less risk of injury. With an individuals performance weak links identied, a prescriptive retraining programme can be developed and implemented. This retraining programme includes strategies to regain control of the site and direction of performance failure and retrain at the appropriate threshold of loading. These are priority risk factors.

Weak link Load High Site Neck Shoulder blade (WB)

Shoulder joint (WB) Low back

Hip (WB)

Fig. 5. Series of photos, motor control retraining of low threshold lumbar extension. The principle is to prevent lumbar extension while extending the hip below or the thoracic spine above.

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48 S. Mottram, M. Comerford / Physical Therapy in Sport 9 (2008) 4051 Table 9 Guidelines for low threshold control of the site and direction of uncontrolled motion

3.2. Core Stability The term Core Stability is a term used loosely to describe stability retraining but its denition can be confusing. The term Core Stability is now used to describe exercises that range from an almost imperceptible activation of the deep abdominal muscles to lifting weights overhead while balancing on a physio ball. The term motor control stability may be an appropriate new label for low threshold stability concepts and is best dened as central nervous system modulation of efcient integration and low threshold recruitment of local and global muscles systems. Strengthening is a term more appropriate for high load or high speed training of symmetrical limb loading (traditional strengthening) and asymmetrical trunk loading (core strengthening). There are some dening differences between motor control stability and strengthening (Table 8). Core Stability now encompasses a large range of exercise processes. These processes include: local muscle system motor control, global muscle system motor control, asymmetrical trunk loading or symmetrical limb loading (Comerford, 2004, 2006). Based on the evidence to date, high threshold retraining (traditional strengthening and core strengthening) does not appear to correct motor control dysfunction in the local stability system (Moseley & Hodges, 2006; OSullivan, Twomey, & Allison, 1997; Tsao & Hodges, 2007). However, specic low threshold training does appear to correct local and global motor control stability dysfunction (Hides, Jull, & Richardson, 2001; Jull et al., 2002; OSullivan, 2000; Tsao & Hodges, 2007). Low load training does not appear to correct high threshold dysfunction or atrophy (Danneels, Vanderstraeten, Cambier, & Witvrouw, 2001). Both

 Employ a dissociation motor control training strategy. That is,

prevent movement at the site of the weak link (e.g. lumbar extension) while moving at an adjacent region (e.g. extend the hip) as illustrated in Test 1F Non-fatiguing low load exercise Slow or static Unilateral or asymmetrical limb or trunk load Trunk does not move out of neutral Dissociate all three directions: rotation, exion and extension Emphasise rotation control at trunk and girdles Trunk may move out of neutral with control Shortened range hold for postural control for girdle and trunk muscles Discourage core rigidity or bracing

        

the local or global muscle systems must integrate together for efcient normal function (Comerford & Mottram, 2001b; Hodges, 2003). Both low threshold motor control and high threshold strength training are required for return to manual work or sport (Comerford, 2004, 2006). 3.3. Training guidelines Once the weak link has been identied in terms of site, direction and load a specic exercise programme can be prescribed using guidelines to train one element of Core Stability (Comerford, 2004, 2006). Guidelines for retraining low threshold weak links are detailed in Table 9. Guidelines for retraining high threshold weak links are detailed in Table 10. Examples can be used to illustrate the application of these concepts and guidelines. Motor control retraining of low threshold lumbar extension is illustrated in the series of photos (Fig. 5). The principle is to prevent lumbar extension while extending the hip below or the thoracic spine above. High threshold strength training of lumbo-pelvic rotation is illustrated in series of photos (Fig. 6). The principle is to prevent lumbo-pelvic rotation while creating a rotation challenge to the lumbo-pelvic region with a high load or high speed unilateral limb movement or rotation of the thorax.

Table 8 Dening differences between motor control and strengthening Motor control Muscle specic: Training can be biased for either a local stability muscle role or a global stability muscle role depending on the cuing and facilitation used. Stability strengthening

Muscle non-specic: During high load resistance or endurance overload training to the point of fatigue all relevant synergists are signicantly activated. There is cocontraction of the local stability muscle system, global stabiliser and global mobiliser muscle roles. Recruitment specic: Because all Recruitment non-specic: Again, these exercises use low load or because of overload, both slow and functional normal loads then slow fast motor units are strongly motor units are predominately recruited. recruited. Central nervous system modulated: Adaptation to load and demand: Afferent spindle input inuences Muscle hypertrophy is a response CNS processes and tonic motor to overload training (hardware output (software upgrade). upgrade).

4. Conclusion A new system for screening for injury risk management or performance enhancement has been presented. This system can be used as a risk analysis system and can be used to develop a training package where therapists and exercise professionals can implement the tests and identify the weak links. Therapists have many reasons for screening (Table 11) and identifying specic

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weak links in terms of site, direction and threshold can help with the reasoning process of addressing some of these issues. Different individuals pass or fail different aspects of the testing process so that the individuals performance risks and assets can be determined. These risks and assets are used to develop

Table 10 Guidelines for high threshold control of the site and direction of uncontrolled motion (reproduced with permission of Performance Stability) Symmetrical limb loading traditional strengthening Asymmetrical trunk loading core strengthening

a client specic Performance Prole. With an individuals performance assets and weak links identied, a specic retraining programme can be developed and implemented. This is a critical missing piece of the screening and risk management puzzle. However, further research is needed to explore unanswered questions, e.g. is it best to start with low load or high load retraining. Conict of Interest Statement: None.

Table 11 Indications for screening (reproduced with permission of Performance Stability)

Employ a dissociation motor control training strategy. That is, prevent movement at the site of the weak link (e.g. lumbo-pelvic rotation) while moving at an adjacent region (e.g. rotate at the shoulder) as illustrated in Test 7B  Fatiguing high load exercise  Fatiguing high load exercise  +/ speed  +/ speed  Bilateral or symmetrical limb  Unilateral or asymmetrical load limb or trunk load  No rotation challenge  High load rotation challenge  Limb or trunk lifting in the  Emphasise rotation control at exion extension plane trunk and girdles  Allow global mobiliser  Resist rotation force at trunk dominance  Dissociate rotation, exion  Encourage core rigidity if and extension isometric core  Rotate trunk against resistance  Discourage global mobiliser dominance

            

Unexplained performance decits Eliminate intrinsic faults prior to coaching technique changes Prevention of injury risk Technique/fault correction that is resistant to coaching correction and advice Pain associated with performance Assess for performance assets and weak links in multi-joint tasks Low threshold tests may identify risk of: Injury associated with a minor incident or unguarded movements Overuse injury associated with repetitious low load activity or static positioning Injury recurrence Inconsistency in repetitive performance tasks High threshold tests may identify risk of: Injury associated with fatiguing loads Overuse injury associated with repeated high load activity Loss of power/consistency with high load or high speed performance

Fig. 6. Series of photos, high threshold strength training of lumbo-pelvic rotation. The principle is to prevent lumbo-pelvic rotation while creating a rotation challenge to the lumbo-pelvic region with a high load or high speed unilateral limb movement or rotation of the thorax.

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