Comparing the Immediate Effects of a Total Motion Release Warm-up .

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COMPARING THE IMMEDIATE EFFECTS OF A TOTAL MOTION RELEASE WARM-UP AND A DYNAMIC WARM-UP PROTOCOL ON THE DOMINANT SHOULDER IN BASEBALL ATHLETES STEPHEN C. GAMMA,1 RUSSELL BAKER,2 JAMES MAY,2 JEFF G. SEEGMILLER,2 ALAN NASYPANY,2 AND STEVEN M. IORIO1 1

Department of Sports Medicine, Mount Saint Mary College, Newburgh, New York; and 2Department of Movement Sciences, University of Idaho, Moscow, Idaho ABSTRACT

Gamma, SC, Baker, R, May, J, Seegmiller, JG, Nasypany, A, and Iorio, SM. Comparing the immediate effects of a total motion release warm-up and a dynamic warm-up protocol on the dominant shoulder in baseball athletes. J Strength Cond Res 34(5): 1362–1368, 2020—A decrease in total range of motion (ROM) of the dominant shoulder may predispose baseball athletes to increased shoulder injury risk; the most effective technique for improving ROM is unknown. The purpose of this study was to compare the immediate effects of Total Motion Release (TMR) to a generic dynamic warm-up program in baseball athletes. Baseball athletes (n = 20) were randomly assigned to an intervention group: TMR group (TMRG; n = 10) or traditional warm-up group (TWG; n = 10). Shoulder ROM measurements were recorded for internal rotation (IR) and external rotation (ER), the intervention was applied, and postmeasurements were recorded. Each group then received the other intervention and postmeasurements were again recorded. The time main effect (p # 0.001) and the time 3 group interaction effect were significant (p # 0.001) for IR and ER. Post hoc analysis revealed that TMR produced significant increases in mean IR (p # 0.005, d = 1.52) and ER (p # 0.018, d = 1.22) of the dominant shoulder initially. When groups crossed-over, the TMRG experienced a decrease in mean IR and ER after the dynamic warm-up, whereas the TWG experienced a significant increase in mean IR (p # 0.001, d = 3.08) and ER (p # 0.001, d = 2.56) after TMR intervention. Total Motion Release increased IR and ER of the dominant shoulder more than a dynamic warm-up. Dynamic warm-up after TMR also resulted in decreased IR and ER; however, TMR after dynamic warm-up significantly improved IR and ER. Based on these reAddress correspondence to Stephen C. Gamma, Stephen.Gamma@ msmc.edu. 34(5)/1362–1368 Journal of Strength and Conditioning Research Ó 2018 National Strength and Conditioning Association

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sults, TMR is more effective than a generic dynamic warm-up for improving dominant shoulder ROM in baseball players.

KEY WORDS injury, range of motion, overhead, mobility INTRODUCTION

A

thletes have a propensity to develop patterns of muscular tightness and weakness as a result of poor technique, improper mechanics, or in response to sport specificity. This adaptive response may create suboptimal structural alignment and joint range of motion (ROM), decreasing movement efficiency and performance (14,15). One of the more common techniques to improve or maintain joint ROM and flexibility is static stretching. Although conflicting evidence exists in the literature, static stretching has been found to improve flexibility and have a positive relationship with injury reduction (18). Clinicians and strength professionals have also used other stretching techniques (e.g., proprioceptive neuromuscular facilitations [PNFs] stretching) and manual therapy techniques (e.g., band-assisted joint stretching) in conjunction with, or in place of, stretching protocols to improve ROM and flexibility (4,23). Standard static stretching, however, may not have a successful ROM carryover into active, dynamic activity. Therefore, another commonly used strategy to improve flexibility and joint ROM is a generic, or sport-specific, dynamic warm-up. Warm-up protocols are designed to reduce movement asymmetries (e.g., unilateral muscle tightness) and prepare the body for vigorous physical activity (13). A dynamic warm-up includes activities and movements of active momentum, elastic energy, and various forms of muscle contraction as opposed to placing tissue on tension while at rest, such as found with traditional static stretching (12). The primary intent of a dynamic warm-up before sport or exercise is to increase blood flow, decrease joint fluid viscosity, improve tissue extensibility, and enhance neuromuscular communication to improve performance and decrease injury risk (13). Stretching techniques are often

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TABLE 1. Traditional warm-up protocol.* Warm-up exercise Knee hugs Forward lunge w/rotation Reverse lunge w/rotation Quad stretch w/reach Lateral lunges High knees Butt kicks Power skips Sprint (50% effort) Sprint (75% effort) Sprint (100% effort) Standing arm circles Standing 90/90 IR and ER w/tubing Side-lying sleeper stretch

Repetitions 1 3 10 yards 1 3 10 yards 1 3 10 yards 1 3 10 yards 1 3 10 yards 1 3 10 yards 1 3 10 yards 1 3 10 yards 2 3 30 yards 1 3 30 yards 1 3 30 yards 1 3 15 rotations/ direction 1 3 10/direction 2 3 30 s

*IR = internal rotation; ER = external rotation.

included within the dynamic warm-up and should progress from general to more activity and sport specific. Therefore, it has been suggested that athletes complete a comprehensive, active dynamic warm-up to improve athletic performance or reduce injury risk when participating in dynamic, explosive sports (3). Frantz and Ruiz (5), for example, found that a dynamic warm-up increased both vertical jump height and long-jump distance in a group of collegiate baseball athletes, whereas Sim et al. (17) reported improved sprinting output after a dynamic warm-up. A potential concern with using a generic dynamic warmup is the potential to overlook regional interdependence (RI) and its role in decreased ROM, flexibility, or performance. Wainner et al. (20) describe RI as “a concept where seem-

Figure 1. Standing trunk twist.

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ingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint.” It is, therefore, not uncommon to observe movement dysfunction or compensation distal from pathological origin. It may be necessary to consider a movement assessment and training approach that assesses more than the area of “pathology” (e.g., needing to stretch “tight” posterior shoulder structures) or restriction to maximize ROM, flexibility, and performance. Observing the entire kinetic chain and movement pattern asymmetry may play a key role in effectively addressing dysfunction and improving performance (1,6). Total Motion Release (TMR) is an evaluation and treatment paradigm founded on the RI approach. Within TMR, the body is assessed as a unified system striving to maintain a dynamic center of gravity; therefore, pain or dysfunction in 1 area of the body may be affected by movements that take place elsewhere in the body (2). The mechanism of action when using TMR is unknown at this time, but the concept of tensegrity (i.e., the ability to maintain structural integrity through a balance of woven tensile forces) (10) and the potential influence of cross-activation to normalize muscle tone (tightness) and reduce asymmetries (7) have been proposed as explanations (1). When using TMR, subjects grade specific movements on a 0–100 scale, with 0 representing no pain, tightness, or dysfunction and 100 representing complete pain, tightness, or dysfunction (2,6). The scale is subjective and is unique to each subject, with the subject rating (e.g., range, speed, ease, level of pain, etc.) each movement compared with performing the same movement on the other side of the body, in essence searching for asymmetries. The dysfunctional side is labeled the “bad” side, whereas the side without dysfunction is labeled the “good” side. In the standard TMR screen (i.e., TMR FAB 6), 6 motions (i.e., arm raise [AR] [shoulder flexion], bent arm wall push [single-arm push-up], trunk twist [TT] [rotation], single-leg sit-to-stand, leg raise [hip flexion], and weight-bearing toereach [unilateral bent knee squat]) are compared bilaterally to determine the greatest area of dysfunction and asymmetry within the movement screen. The motion with the greatest dysfunction and asymmetry (on the 0–100 scale) is treated first (2,6). When treating with TMR, the intervention is applied to the good side (i.e., the side of ease or side perceived as normal) as opposed to the VOLUME 34 | NUMBER 5 | MAY 2020 |

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Immediate Effects of Total Motion Release to a Baseball Dynamic Warm-Up

Figure 2. Standing arm raise.

dysfunctional (e.g., tight) side, which is a departure from traditional stretching protocols (2,6). Total Motion Release treatment includes repetitions, static holds, or some combination thereof applied through the identified motion. In standard TMR, the data (i.e., progress) are evaluated after 2 sets of the motion have been completed. After evaluating patient progress, the clinician will continue the intervention by treating the same motion in the same fashion, by modifying the previously performed motion, or by moving to the next area of dysfunction/asymmetrical movement if the previous motion impairment is resolved. Treatment progresses to the second highest dysfunctional motion/score and continues until the 6 main motions are balanced (2,6). A general recommendation is to resolve at least 1 upper-body, trunk, and lower-body imbalance each session to maximize treatment effectiveness (2). Few research studies have been conducted on TMR. Baker et al. (1) used TMR to successfully treat chronic hamstring tightness. Gamma et al. (6) incorporated components of the TMR FAB 6 to improve internal and external rotational deficits of the dominant shoulder in baseball players. In this study, a single session of the TMR AR and TT significantly increased shoulder internal rotation (IR) (19.2 6 10.788 vs. 2.2 6 8.738, p = 0.03, d = 1.73) and external rotation (ER) (13.6 6 5.988 vs. 21.8 6 9.208, p = 0.01, d = 1.98) compared with a dynamic warm-up program. Interestingly enough, more than half of the participants in the TMR group did not perform the AR pattern to their dominant, throwing arm side as the authors anticipated. Additionally, the TMR protocol took less time (approximately 5 minutes) to complete compared to the traditional dynamic warm-up. side and spent over 5 minutes less time completing the TMR protocol vs. the traditional dynamic warm-up (6). The results of previous studies exploring TMR provide preliminary evidence for alternatives to traditional interventions (e.g., exclusive stretching of the throwing shoulder) being used

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for addressing baseball athletes who present with decreased IR or asymmetrical shoulder total arc of motion. More robust study is needed, however, to truly determine the acute effects of TMR compared with traditional generic dynamic warm-up programs in the baseball athletes to normalize and balance joint ROM. Thus, the purpose of this study was 2-fold: (a) to assess the effect of the previously studied TMR AR and TT protocol on improving IR and ER of the dominant shoulder compared with a generic baseball warm-up program and (b) to determine if the order of applying TMR or the warm-up program impacted IR or ER changes in the dominant shoulder.

METHODS Experimental Approach to the Problem

This study was a randomized cross-over design, including traditional joint range of motion testing in conjunction with a traditional dynamic warm-up of which the participants were physically accustomed to performing. Efforts were made to account for potential warm-up and stretching variables that may create an inaccurate representation of tissue and joint response atypical in the participant population. Order of stretching procedures were also taken into consideration to further explore a potential benefit rather than isolating one protocol versus another. Subjects

A randomized cross-over design, with a convenience sample consisting of male baseball athletes (n = 20; mean 6 SD; age = 18.45 6 1.70 years; age range = 15– 22 years; experience = 5 high school, 15 collegiate; hand dominance = 17 right handed, 3 left handed) participated in this study. All subjects had at least 5 years of previous baseball experience and were not receiving treatment for an existing or previous injury (i.e., within the past 12 months). The study was conducted during the season, in a single session for each group, and was completed before baseball/warm-up activities for the day. The study was approved by the University of Idaho’s institutional review board. All subjects provided written informed consent/ assent and parental/guardian consent was collected when appropriate. Subjects were randomly assigned to either group 1 (TW to TMR) or group 2 (TMR AR and TT to TW), with 10

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athletic trainer with 6 years of professional TABLE 2. Change in internal rotation experienced at each intervention across time.*†z experience who was blinded to the initial Time Group 1 Group 2 p 95% CI Cohen’s d measurements of the first Time 1 6.20 6 10.618 18.20 6 5.038 0.005 219.80 to 24.20 1.52 researcher and to group Time 2 17.10 6 6.008 25.40 6 9.068 0.001 15.26 to 29.72 3.08 allocation. Pilot testing *CI = confidence interval. indicated that the ath†Group 1 = Baseline to Traditional Warm-up to Total Motion Release; Group 2 = Baseline to Total letic trainer was reliable Motion Release to Traditional Warm-up. in measuring IR (intrazValues presented are mean 6 SD in degrees. class correlation coefficient [ICC3,1] = 0.988, 95% confidence interval [CI]: 0.951–0.997, SEM = 0.978, minimal detectable change subjects in each group. Group 1 was composed of 10 (MDC) = 2.688) and ER (ICC3,1 = 0.916, 95% CI: 0.464– subjects with an average (mean 6 SD) age of 18 6 1.69 0.982, SEM = 1.128, MDC = 3.108) (21). The SEM was years, height of 1.82 6 0.08 m, and mass of 77.0 6 11 kg, calculated by taking the square root of the analysis of variwhereas group 2 consisted of 10 subjects with an average age ance (ANOVA) mean square error value; the MDC was of 18.9 6 1.66 years, height of 1.82 6 0.05 m, and mass of calculated using the following formula: SEM 3 1.96 3 O2 81.0 6 10 kg. (17). The measurements taken by the second researcher, the athletic trainer, were used for analysis. Procedures After baseline measurements, group 1 members completed Goniometric assessment of shoulder IR and ER was conthe generic dynamic warm-up in 15–20 minutes. Postducted with the participants lying supine on the examination intervention (post 1) ROM measurements were then recorded table, with their shoulder abducted to 908 and their elbow for comparison (Table 1). Group 1 members then completed flexed to 908. The landmarks used for assessment were the the TMR protocol which consisted of 3 sets of a 30-second olecranon process (fulcrum), long axis of the ulna (movestanding TT to their reported side of ease, with a 30-second ment arm), and the perpendicular axis to the floor (stationrest period between each set (Figure 1). The subject was inary arm). For shoulder IR, a combination of end feel and structed to stand feet together with knees slightly bent, arms visualization of compensatory movement was used to detercrossed over the chest, and hips flexed with their chest parallel mine the end of ROM. The extremity was moved until the to the ground. Coaching cues were given throughout each set, shoulder was visualized to begin lifting off the table; motion instructing the subject to take a deep inhalation followed by was stopped when this movement occurred. The humeral deep exhalation when a new barrier (e.g., restriction) was head was not manually stabilized to avoid altering the norreached and to “unlock” the body segment that the subject mal glenohumeral arthrokinematics during measurement, perceived to be limiting motion (e.g., flex right knee if twisting but scapular stabilization was provided by the body mass to the left shoulder). After TTs, each subject completed 3 sets of of the subjects. Measurements were initially recorded by a 30-second standing AR to the “good” side, with a 30-second a Certified Strength and Conditioning Specialist (CSCS) rest between each set (Figure 2). The subject was cued to reach with 4 years of professional experience in collegiate and protoward the ceiling and back behind their head while keeping fessional baseball, who was also a student in a professional the elbow locked. When a barrier was reached, or they could graduate athletic training program at the time of the study. no longer move the arm, a cue to take a deep breath through The measurements were then repeated for validation by an the belly button was given. After the breath, the subject was asked to reach higher toward the TABLE 3. Change in external rotation experienced at each intervention across time.*†z ceiling and further behind their head in the TMR Time Group 1 Group 2 p 95% CI Cohen’s d movement pattern. The Time 1 3.50 6 7.148 10.50 6 4.678 0.018 212.67 to 21.33 1.22 entire TMR TT and AR Time 2 11.40 6 6.228 24.10 6 6.528 0.001 9.51 to 21.50 2.56 protocol was explained and demonstrated to each *CI = confidence interval. †Group 1 = Baseline to Traditional Warm-up to Total Motion Release; Group 2 = Baseline to Total subject in a 1-on-1 format Motion Release to Traditional Warm-up. before completion. The zValues presented are mean 6 SD in degrees. TT and AR we chosen from the 6 TMR motions VOLUME 34 | NUMBER 5 | MAY 2020 |

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Immediate Effects of Total Motion Release to a Baseball Dynamic Warm-Up

TABLE 4. Within-group changes in range of motion across time.*†z Change in IR Group (baseline to time 1) 6.2 6 10.618

Group 1 Group 2

18.2 6 5.038

p

Change in IR (time 1 to time 2)

p

Change in ER (baseline to time 1)

p

Change in ER (time 1 to time 2)

p

0.293

17.10 6 6.008

0.001

3.5 6 7.148

0.466

11.40 6 6.228

0.001

0.001

25.4 6 9.068

0.276

10.5 6 4.678

0.001

24.10 6 6.528

0.078

*IR = internal rotation; ER = external rotation. †Values presented are mean degree changes 6 SD. zGroup 1 = Baseline to Traditional Warm-up to Total Motion Release; Group 2 = Baseline to Total Motion Release to Traditional

Warm-up.

because of ease of application in the field. The entire TMR treatment protocol took 8–10 minutes to complete, depending on the time needed to explain the TMR procedure to the subject. After both TMR movements were completed, postintervention (post 2) ROM measurements were recorded for comparison. After baseline measurements, group 2 members performed the TMR TT and AR protocol in the same fashion described above and postintervention (post 1) ROM measurements were recorded. After ROM measurements, group 2 members then performed the same generic dynamic warmup as prescribed to group 1 (Table 1), followed by the recording of postintervention (post 2) ROM measurements for comparison.

Analysis of Internal Rotation Changes of the Dominant Shoulder

A significant difference in IR of the dominant shoulder was found between group 1 and group 2 (p = 0.034, h2 = 0.226). After initial intervention, the change in IR was significantly different (p # 0.005, CIs: 219.80 to 24.20, d = 1.522) between group 1 (mean = 6.20 6 10.618) and group 2 (mean = 18.20 6 5.038). A significant change in IR (p # 0.001, CIs: 15.26–29.72, d = 3.08) was also found between group 1 (mean = 17.10 6 6.008) and group 2 (mean = 25.40 6 9.068) after the cross-over intervention (Table 2). Analysis of External Rotation Changes of the Dominant Shoulder

Statistical Analyses

Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS, Inc., Chicago, IL, USA) version 23.0. Results are expressed as mean 6 SD. An independent sample t test was used to analyze the mean difference between groups at baseline for age, years of experience, IR, and ER. A 2 3 3, repeated-measures ANOVA was run to determine whether there were any main effect, using the multivariate criterion of Wilks’ lambda (l), or interactions on the dependent variables of IR and ER across time (baseline to postintervention 1 to postintervention 2) dependent on the group. If a significant ANOVA was found, post hoc tests were completed using independent t tests to compare the changes from baseline to postintervention 1 and from postintervention 1 to postintervention 2. All post hoc tests were corrected for type I error using the Bonferroni technique (aadjusted = 0.05/ 2), and the adjusted alpha level was set a priori at p = 0.025. Cohen’s d was calculated using the 2 independent groups formula ([mean of group 1 2 mean of group 2]/SD), and a large effect size was set a priori at d $ 0.08 (19).

RESULTS Independent t tests indicated that the groups were not statistically different in age (p = 0.247), years of experience (p = 0.773), IR (p = 0.143), or ER (p = 0.86) at initial testing.

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The time main effect (p # 0.001) and interaction effect were significant (p # 0.001), but a difference between groups was not identified (p = 0.728, h2 = 0.124) for ER. After initial intervention, the change in ER was significantly different (p # 0.018, CIs: 212.67 to 21.33, d = 1.225) between group 1 (mean = 3.50 6 7.148) and group 2 (Mean = 10.50 6 4.678). A significant change in ER (p # 0.001, CIs: 9.51– 21.50, d = 2.564) was also found between group 1 (mean = 11.40 6 6.228) and group 2 (mean = 24.10 6 6.528) after the second intervention (Table 3). Analysis of the Order of Total Motion Release Application

To assess the change in IR and ER based on the order of TMR application, the change in ROM from baseline to TMR application was compared between groups. The change in ROM for group 1 was calculated by subtracting the ROM value from time 3 (i.e., after TMR application) from their baseline measures. The change in ROM for group 2 was calculated by subtracting the ROM value at time 2 (i.e., after TMR application) from baseline measures. A significant difference was not found between groups for the change in IR (p = 0.662) or ER (p = 0.719) based on when TMR was applied. A significant change was observed, however, within each group and was dependent on the order of stretching application. Group 1 experienced a significant change in

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Journal of Strength and Conditioning Research both IR and ER after the application of TMR (p = 0.001). This change was in contrast to the results of both IR (p = 0.293) and ER (p = 0.466) from baseline to the traditional warm-up protocol. Group 2, however, demonstrated the opposite trend, again appearing to be influenced by the order of stretch application. Group 2 experienced a significant change in both IR and ER from baseline to the TMR application (p = 0.001). However, the addition of the warm-up protocol did not produce a significant improvement in IR (p = 0.276) or ER (p = 0.078). Results of the within-group analyses of changes in IR and ER across time are provided in Table 4.

DISCUSSION In this study, the application of TMR produced statistically significant and immediate increases in dominant shoulder IR and ER ROM, irrespective of whether the technique was applied before or after the dynamic warm-up. The immediate and significant improvement in IR experienced from TMR intervention compared with a generic dynamic warm-up parallels’ previous findings on the effects of TMR in this population (6); however, the increase in ER was also significant in the current study, which was not the case in the previous findings. The difference in these findings may be the result of the larger sample size in the current study, as the mean changes in ER were very similar between the studies (6). Clinically, what may be most meaningful is that group 2 produced an average total arc of motion for IR and ER of 1808 on the dominant shoulder. Despite the significant increase in ER experienced by this group, the increase in IR was so large that the group also improved their IR-toER ratio, whereas group 1 did not experience the same level of improvement. Furthermore, the resulting change in IR and ER experienced after application of the TMR protocol occurred despite taking 7–10 fewer minutes to complete the protocol and without the intervention being performed on the dominant (i.e., involved) shoulder by numerous participants. This may illustrate how a generic dynamic warm-up does not address specific ROM asymmetries and how the order of application may have a greater impact on preparing the baseball athlete for overhead activity. In this study, application of TMR after the dynamic warmup (group 1) produced a statistically significant increase in both IR and ER compared with group 2 who completed the dynamic warm-up after TMR. Clinically, the most relevant result is likely the evidence that applying the dynamic warmup protocol after TMR either impaired ROM improvements or failed to maintain the improvements, as observed by the mean decrease in IR (25.40 6 9.068) and ER (24.10 6 6.528) in group 2. Group 1, which had not previously produced a total arc of motion between IR and ER of 1808 after the dynamic warm-up, demonstrated a total arc of motion in excess of 1908 on average after TMR. Group 2, by contrast, had their total arc of motion between IR and ER decrease from over 1808 to less than 1738 on average after completing

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the dynamic warm-up protocol. Although the generic dynamic warm-up was not sport specific, it is difficult to suggest this, or a lack of TMR long-term effectiveness, was the mechanism of diminished ROM given how quickly it occurred. Therefore, based on the results, we recommend that a generic dynamic warm-up not be performed after TMR application to maximize any increase in ROM. The use of TMR in isolation will also produce equal results to completing a generic dynamic warm-up followed by TMR based on our results and previous findings (6). Although the TMR intervention produced greater ROM changes, the generic dynamic warm-up used in this study also produced acute changes in IR (mean gain of 6.28) and ER (3.58) of the dominant shoulder that is consistent with current literature in this area. Oyama et al. (11) used a passive stretch protocol (3 sets of 30-second holds for a horizontal cross-arm stretch, standing sleeper stretch with the arm at 908 of abduction, and a standing sleeper stretch with the arm at 458 abduction) to produce a mean improvement of 4.38 in IR. Sauers et al. (16) produced a statistically significant change in ER (mean gain of 7.68) and IR (mean gain of 9.28) using the Faulsmodified stretching routine. The use of clinician-assisted sleeper stretches (3 sets of 30-second holds) has also resulted in a 3.18 improvement in IR ROM and horizontal adduction ROM of the shoulder, respectively (8). By contrast, others found PNF stretching to be ineffective for improving shoulder ROM (22). Moore et al. (9) used a single application of muscle energy technique that consisted of a 5-second isometric contraction at 25% maximal against examiner provided force, followed by the examiner applying a 30-second active-assisted stretch for a total of 3 repetitions, to improve shoulder IR by an average of 4.28. Based on the literature, the generic dynamic warm-up used in this study can be viewed as comparable to other commonly used techniques, which illustrates the potential effectiveness for acute changes when using TMR. The IR and ER gains found after the TMR application exceeded all the IR and ER gains reported in these studies despite the fact that TMR was often applied to the nondominant shoulder, which means many of the participants in the TMR group experienced superior ROM improvements without any direct treatment application to their dominant shoulder.

LIMITATIONS

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FUTURE RESEARCH

As with all studies, limitations were present. The primary student examiner was not blinded to the order of interventions, creating a potential for bias in the technique-specific change in dominant shoulder ROM. As this was a student-led project, this researcher (i.e., the CSCS) recorded premeasures and postmeasures while being monitored to ensure that protocol was followed and accurate measures were collected. To reduce bias in the ROM measurements, a second clinician (i.e., the athletic trainer), who was blinded to the treatment group allocation and the values measured by the CSCS, was used to collect data for the analysis. It is possible that the repetitive measuring could have created increases in ROM; however, this VOLUME 34 | NUMBER 5 | MAY 2020 |

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Immediate Effects of Total Motion Release to a Baseball Dynamic Warm-Up effect should have been consistent across both groups as each subject completed the same number of measurements. Similarly, the subjects were not blinded to the goniometer measurements, which could introduce bias as well. Another potential limitation is the warm-up program. A “gold-standard” dynamic warm-up program for throwing sports has not been established in the literature; so, a generic overhead athlete warm-up protocol was used in this study. Although it is possible that a more throwing-specific warm-up may be able to produce larger gains in ROM, the gains produced in this study were comparable with what has been previously reported in the literature. Despite the similarities to previously published research, it may be valuable to compare the TMR protocol with more sport-specific dynamic warm-up protocols. Future studies should also be conducted to examine if using the complete standard TMR assessment and treatment protocol (i.e., TMR Fab 6) is more beneficial in correcting ROM asymmetries. In addition, future study of TMR should assess the effect across time; specifically, if the ROM improvement is retained, essentially normalizing the adaptive changes reported to occur in the throwing shoulder. Furthermore, specific research on the impact improved ROM, as a result of TMR, has on performance (e.g., throwing velocity) and injury risk should be conducted.

PRACTICAL APPLICATIONS In this study, a TMR protocol was a more effective intervention than a generic dynamic warm-up protocol for improving dominant shoulder IR and ER ROM in the baseball athlete. In addition, the final change in ROM was dependent on the order the intervention was administered, which may be clinically relevant. Subjects experienced statistically significant changes for IR and ER ROM that far exceeded the published expectations for improving shoulder ROM when using TMR. Further research is needed to determine the retention rate of the ROM improvements after TMR application protocol (e.g., 12 hours and 24 hours after treatment), along with the potential effects TMR intervention has on athletic performance (e.g., peak and average pitching velocity, etc). Based on the results of this study, strength coaches and medical professionals may want to consider a more global, full body approach to assessing and treating shoulder ROM asymmetries or deficiencies in the baseball athlete. Teams participating in sports that produce shoulder ROM asymmetries (e.g., baseball, softball, volleyball, etc.), may want to incorporate this TMR assessment and treatment protocol into their preactivity protocols.

REFERENCES 1. Baker, R, Hansberger, B, Warren, L, and Nasypany, A. A novel approach for the reversal of chronic apparent hamstring tightness: A case report. Int J Sports Phys Ther 10: 723–733, 2015. 2. Baker, TD. Total Motion Physical Therapy. TMR History. Available at: http://www.totalmotionpt.com/what-is-tmr/tmr-history/. Accessed April 24, 2014.

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