I am studying for the ACE exam. Here are my ACE Personal Training Manual Chapter 7 Functional Assessments notes.
First for all, the objective of all personal training programs should be to help clients improve functionality. This will enhance a client’s ability to perform activities of daily living (ADLs). Furthermore, the key facet of functionality involves movement efficiency or learning how to stabilize the kinetic chain against reactive forces and gravity.
As a result, focus must be on posture or building a static base and alignment of body segments. Low grade isometric contractions require deeper type 1 muscle fibers. Thus, poor posture may be a reflection of muscle endurance issues in the postural muscles and/or potential imbalances in joints. This is a good indication that movement might be dysfunctional.
Static Posture Assessments
Firstly, these assessments offer valuable information about muscle imbalances at a joint and the relationship of muscles around a joint as well as altered neural action of the muscles moving and controlling the joint. Tight or shortened muscles are often overactive and dominate the movement of a joint.
Secondly, muscle imbalances and postural deviations can be contributed to: correctible factors (repetitive movements, awkward positions and movements, habitually poor posture, side dominance, lack of joint stability or mobility, imbalanced strength training programs) or non-correctible factors (congenital conditions, such as scoliosis, pathologies such as RA, structural deviations or trauma) key concept.* The initial focus of a training program should on stability and mobility.
Third, we can assess static posture through the right angle model. This is via the frontal (divide body down the middle into right and left hemispheres) and sagittal plane (divide body down the middle into anterior and posterior). We need to hang a plumb line to a fixed point overhead. Then, ask our client to remove their shoes and socks. Next, we observe for symmetry against the plumb line and right angles that the weight bearing joints make relative to the line of gravity. Observe for gross imbalances versus minor postural asymmetrical imbalances. A gross deviation is one that differs greater than or equal to 0.25 inches or 6 cms.
Plumb Line Position
To observe the plumb line in the frontal plane, first have the client stand with feet equidistant from the line. Then, the plumb line should bisect the sacrum and overlap the spinous process. Next, for the sagittal view, place the plumb line anterior to the lateral malleolus (ankle), pass through the anterior 1/3 of the knee, greater trochanter of the femur, AC joint, slightly anterior to the mastoid process, and the earlobe should be in line or just behind.
Deviation 1: Ankle Pronation/Supination and Effect on Tibial and Femoral Rotation
There are 5 postural deviations. First, lets discuss ankle pronation (arch flattening) or supination (high arches) at the subtalar joint. Pronation will lead to eversion of the foot and internal rotation of the tibia and femur. While, supination will lead to inversion of the foot and external rotation of the tibia and femur.
Deviation 2: Hip Adduction
Secondly, hip adduction or the lateral tilt of the pelvis will lead to an elevated or high hip on the other side. Also called hip hiking and happens with limb length discrepancies. For example, when the right hip is raised it means someone has right hip adduction and the left thigh, spine and center of gravity tilt left. In this case, lengthening and weakening of the right hip abductors occurs. A common cause is sleeping on your side.
Deviation 3: Pelvic Tilting
Thirdly, pelvic tilting can occur anteriorly or posteriorly. If anteriorly it is often from tight hip flexors and erector spinae muscles and lengthened hamstring and rectus abdominis muscles. Prolonged periods of sitting are often the cause. The shortened hip flexor from sitting pulls on the pelvis anteriorly when standing. The anterior and superior portion of the pelvis are moved downward.
A posterior tilt rotates the superior and posterior portion of the pelvis backward and downward. A posterior pelvic tilt is usually due to over-dominant rectus abdominis muscles coupled with tight hamstrings while the hip flexors and erector spinae are lengthened. Thus, an anterior tilt leads to increased lordosis while a posterior tilt leads to decreased lordosis.
Deviation 4: Shoulder Position and Thoracic Spine
Observation of the scapulae in all three planes provides good insight into quality of shoulder movement. The scapulothoracic joint contributes 60 degrees of shoulder movement. It has great stability with limited mobility. The glenohumoral joint contributes 120 degrees of shoulder movement. It is highly mobile but less stable. Observe a client from the posterior view for scapular position. If the vertebral (medial) and/or inferior angle of the scapulae protrudes outward this indicates and inability of scapular stabilizers. Scapular protraction is when the vertebral (medial) border protrudes outward while winged scapulae is when the vertebral (medial) border AND inferior angle protrude outward.
Deviation 5: Head Position
Finally, with good posture, the earlobe should align approximately over the acromion process. However, a forward head position is extremely common. When the earlobe is observed significantly forward of the acromioclavicular joint (AC) in the sagittal view, this indicates a forward head position. First, align the plump line with the AC joint. Then, check alignment of the earlobe with the AC, and the alignment of the cheekbone with the collarbone. Do this by putting 1 index finger on the cheekbone and 1 on the collarbone. They should be in vertical alignment. A forward head position indicates tightness in the cervical extensors and lengthening of the cervical flexors.
Faulty neural control” due to muscle tightness or imbalance often lead to compensation during movement. Observe clients performing the 5 primary movements: bend and lift (squatting), single leg movements, pushing movements (vertical/horizontal plane), pulling movements (vertical/horizontal), rotational movements.
Perform a bend and lift screen. First, observe for symmetrical upper extremity mobility and stability and lower extremity stability. Next, observe for lumbar, quadricep or gluteal dominance. Lumbar dominance indicates lack of core abdominal and gluteal muscle strength to counteract the force of hip flexors and erector spinae. Tight hip flexors may contribute to it as well. Quadricep dominance occurs when someone relies on loading their quads during the squat. This puts pressure on the client’s knees and ACL. Finally, gluteal dominance is the preferred method of squatting. It spares the lumbar spine and relieves stress on the knees. During gluteal dominance, clients activate the hamstrings and unload the ACL.
“Don’t let your knees go past your toes,” is a general que for squatting. Instead, emphasize here pushing your hips back and avoiding premature forward movement of the knees.
Hurdle Step Screen
This screening test examines the simultaneous mobility of 1 limb and the stability of the contralateral limb. Clients are to maintain hip and torso stabilization during a balance challenge of standing on 1 leg. Observe for compensation to one side during leg lift. Image on page 173.
Shoulder Push Stabilization Screen
During this test, examine stabilization of the scapulothoracic joint and core control during closed-kinetic chain pushing movements. Observe for scapular winging and lumbar hyperextension. Image on page 174.
Thoracic Spine Mobility Screen
Examine the bilateral movement of the thoracic spine. Observe for bilateral discrepancies in rotation. It is considered insignificant if it is less than 15 degrees. Image on page 175.
Flexibility and Muscle Length Testing
Thomas Test For Hip Flexion/Quadricep Length
This test is used to assess the length of the muscles involved in hip flexion or ilopsoas and rectis femorus muscles. Do not conduct this test if client has lower back pain. First, have the client lay on a table with their legs hanging off. Then, flex 1 thigh towards their chest. Ensure they keep their back on the table and observe for extension, flexion and rotation. Image page 179.
Passive Straight Leg (PSL) Raise
Assess the length of the hamstrings when a client is lying supine on the table. Have them raise 1 leg while keeping the other fully extended. Observe to see if they keep their back and sacrum flat against the table. When firm pressure is felt from their back against your hand, this indicates the end of range of motion. Image page 181.
Complete the scratch test in conjunction with the shoulder flexion-extension test and an internal-external rotation test of the humerus.
Shoulder Flexion and Extension
Perform the shoulder flexion-extension test to assess the degree of shoulder flexion and extension. To perform the extension test, first, have your client lay supine with their knees bent. Then, have the place their feet on the floor and raise their arms overhead and touch the mat. There should be no arching of the back or depression of the rib cage during movement.
To perform the extension test, first have them lay prone. Then, have them extend their arms off the mat. There should be no arching of their lower back and no lifting of the head or chest. Small extensions of the thoracic spine are acceptable. Measure the degree of movement during these tests while you observe for differences in the right or left arms. Image page 182.
Internal and External Rotation of The Humerus at the Shoulder
Have clients perform internal and external rotations of the humerus at the shoulder. First, have the client lay supine with their knees bent and second toe in line with ASIS. Then, have them abduct the arms 90 degrees with a 90 degree bend at the elbow. Their forearms should be perpendicular to the mat, upper arms aligned with their shoulder, and the back of their upper arms against the mat.
To perform the external (lateral) rotation test have them rotate their arms backwards towards the mat. This test evaluates the medial rotators. They should be able to drop the arms until the are adjacent to their head with a 90 degree bend at the elbows. They should engage their abdomen, have no lower back arching, avoid flexing the spine forward and maintain a neutral wrist.
To perform the internal (medial) rotation test have them rotate their forearms downwards towards the mat. They should maintain a 90 degree bend at the elbow, while not raising their shoulders off the table, nor flexing their spine forward. They should also maintain a neutral wrist. Observe for bilateral differences between left and right arms during both movement tests. Image page 184.
Apley’s Scratch Test for Shoulder Mobility
Use this test to assess simultaneous movement of the shoulder girdle, primarily the scapulothoracic and glenohumral joints). This test includes should extension and flexion, internal and external rotation of the humerus at the shoulder and scapular abduction and adduction. During this movement, clients should avoid arching their lower back or rotating their torso. Observe for the inability to touch the medial border of the contralateral scapulae or the inferior angle of the scapula. Note how far they can reach from top down and bottom up. Observe for bilateral differences between the right and left arms. Image on page 185.
Balance and The Core
We can evaluate the basic level of static balance using the Romberg test or the Stork-Stand Balance Test.
Sharpened Romberg Test
This test assesses static balance by having a client stand with a reduced based of support while removing sensory information. First, have your client remove their shoes and stand with one foot in front of the other, heel to toe in tandem, with arms folded over chest. Then, have them close their eyes and hold the position for 60 seconds or until they lose postural control, feet move off the floor, their eyes open, they move their arms from a folded position, or they exceed 60 seconds with good postural control. The inability of the client tor reach 30 seconds indicates inadequate static balance and postural control. Image page 186.
Stork-Stand Balance Test
This test assesses static balance by standing on one foot in a modified stork-stand position. Continue the test until their hands come of their hips, their stance or supporting foot inverts, everts or moves direction, any part of the elevated foot loses contact with the stance leg, the heel of the stance leg touches the floor or they lose balance. Image page 187.
McGill’s Torso Muscular Endurance Test Battery
Back pain and dysfunction can be reversed by having a strong core. Perform the tests individually but evaluate the results collectively. Poor endurance capacity of the torso muscles or imbalances between the 3 muscles groups is believed to contribute to lower back dysfunction and core instability.
Trunk Flexor Endurance Test
This test assesses the muscular endurance of the deep core muscles (transverse abdominis, quadratus lumborum and erector spinae. The test is contraindicated for clients with lower back pain or have had recent back surgery. First, have your client sit on the floor with their hips or knees bent to 90 degrees, arms folded over chest. Have them lean against a board at a 60 degree incline, with their head in a neutral position. Then, remove the board and have them hold the position until their are notable changes in their trunk position. Observe for deviations from neutral spine, shoulders rounding forward, lower back arches or part of their back leans against the board. Image page 188.
Trunk Lateral Endurance Test
This test assesses the muscular endurance of the lateral core muscles (transverse abdominis, obliques, quadratus lumborum, and erector spinae). It may not be suitable for clients with shoulder pain or weakness, or who suffer from back pain or have had recent back surgery. First, have the client get in a side lateral position with their feet tandem or stacked and lower arm with the elbow directly under the shoulder. Their top arm should rest alongside their body. Then, have them hold this position until their are noticeable changes in the position. Observe for deviation from neutral spine or their hips shifting forward or backward. Image page 189.
Trunk Extensor Endurance Test
This test assesses the endurance of the torso extensor muscles (erector spinae, longissimus, iliocostalis, and mulitfidi). The test may not be suitable for clients with major strength deficiencies, high body mass, or with lower back pain or recent back surgery. First, have the client lay prone on a table with their torso hanging off and arms crossed over chest. Then, have them lift or extend their torso until they are parallel with the floor. Have them hold the position until they can no longer maintain. Image page 190.
During these test evaluate their flexion: extension ratio. It should be less than 1.0. For example, if their flexion score is 120 seconds and their extension score is 150 seconds, that is a ratio of 0.8. Also, their left sided bridge should be evaluated compared to their right sided bridge. The LSB: RSB ratio should be between 0.05 and 1.0. For example, if their LSB is 92 seconds and their RSB is 88 seconds, that is a ratio of 0.96. Their side bridge extension ratio should be less than 0.75. For example, RSB score of 88 seconds and extension score of 150 seconds generates a ratio score of 0.59.