3c - TBC Mvmt Control & Path Flashcards
what is mvmt control and what is it influenced by
way in which nervous system controls posture and mvmt to perform given motor task
influenced by:
- available mvmt of passive systems
- available mvmt of active systems
- control/timing of NM system
passive vs active system factors and examples of each
passive = no volitional control
- joint
- bone
- cartilage
- ligament
- neural structures
active = volitional, can turn on and off
- contractile structures
- endurance
what are 3 components of NM system control which ultimately impact mvmt control
ms activation
acquisition
assimilation
what are the 2 main components of mvmt control schema
local mobility
global stability
local mobility vs global stability
local mobility:
- lumbar spine and adjacent regions should (I) possess adequate neural and joint mobility and soft tissue compliance
global stability:
- ms of lumbar spine generate isolated activation can be coordinated w various joint mvmts and incorporated into ADLs
mvmt control vs motor control
mvmt control DOES NOT EQUAL motor control
- stability part of motor
- motor component of mvmt
what types of structures fall under local mobility and what are 3 examples
passive structures
- neural mobility
- joint mobility
- soft tissue
how does neural mobility impact local mobility and how can this be assessed
can nerves tolerate mechanical loading
- tension, glide, elongation, angulation
neural tension tests
- slump test, SLR, fem n. tension
how does joint mobility impact local mobility and how can this be assessed
does lumbar spine possess proper joint alignment and ability to move freely w/i physiologic limits
PPIVMS, PAIVMS, shear test
how does soft tissue impact local mobility and are examples of these tissues
can soft tissue of/around lumbar spine undergo elastic deformation when manual pressure or passive change of joint position are applied
hamstrings, quads, QL, psoas
what is the continuum of components which fall under global stability
activation
acquisition
assimilation
what is activation (component of global stability) and what are common examples of deficits in activation
ability of individual to generate isolated contraction and/or simple mvmt pattern
TrA, multifidi, scap retractors, breathing pattern
what is acquisition (component of global stability) and what are common examples of deficits in acquisition
whether mvmt is dissociated or coordinated between lumbar spine and adjacent regions
- can mvmt be maintained in higher level intensity things
active SLR, active hip ext, active hip ABD
what is assimilation (component of global stability) and what are common examples of deficits in assimilation
assesses how newly acquired skills are integrated in ADLs utilizing multiplanar mvmts under dynamic loading condition
squats, lunges, rotational mvmt
what are examples of activation interventions
training activation of hypoactive ms or isolated mvmt patterns
ex: ab hollowing, scap retraction, breathing pattern
what are examples of acquisition interventions
training to acquire skill of dissociated or coordinating mvmts of lumbar spine and adjacent regions
ex: single plane co-contraction exercises, balance, and coordination exercises
what are examples of assimilation interventions
training to assimilate loaded multiplanar mvmts into ADLs
step up/down progression
STS progression
multi-planar progression
is motor control different in those with LBP
trunk ms activity
trunk alignment, posture, and mvmt
how is trunk ms activity different in those w LBP, why and what is the problem with this?
deeper ms like TrA and multifidi more consistently inhibited
superficial ms inc
when in pain, body adaptively tenses up to protect you
- results that superficial ms are often first to engage since easiest -> creates cycle of not activated deep stabilizing structure
problem bc deep ms line of pull is best for stability w/o too much compression or shear
- superficial ms line of pull is different bc meant to move spine, not stabilize
how is trunk alignment, posture, and mvmt different in people w LBP
tend to find larger postural sway
dynamic mvmt tasks are typically performed slower
stronger coupling of thoracic and pelvic mvmts and dec variability of trunk mvmt
what are the 3 main ms targeted for activation interventions
TrA
multifidi
pelvic floor
screening vs clinical vs diagnostic assessments for TrA activation
screening:
- abdominal draw in supine
- palpation
clinical:
- abdominal drawing in prone w PBU
diagnostic:
- measure of deep ms function w fine wire EMG, real time US
cues for teaching action of TrA and what are considerations
relax abs
draw up and in
slow and controlled, hold for 10sec
avoid trunk, pelvis mvmt
dissociate breathing
- count outloud if trouble dissociating
what is the ab draw in test prone w PBU and why doesn’t Mr. Steve like to do this
PBU inflated to 70mmHg
breath out and hold
draw in slowly
hold 10sec x10reps
norm: dec of 6-10mmHg
he doesn’t do this much bc he wants them out of activation phase so don’t want to train them in activation phase
what are compensatory patterns for a weak TrA to watch for (7)
breath holding
oblique activation
inc rectus ab activity
trunk forward flex
inc WBing thru feet
post pelvic tilt
mvmt of pelvis, trunk, or LEs
how can you tell if there is oblique activation compensating for TrA
if ms pops out
- should feel ms flatten and draw out w activation
where is the easiest spot to palpate multifidi
off PSIS and move slightly in and up
what is a cue for multifidi activation in prone and what do you look for when palpating multifidi in standing
“swell out into my fingers”
activation, activity w mvmt, feedforward mechanism
- can they maintain engagement
most people will have problems actively engaging their multifidi, what is a cue that can help
draw in TrA
how can you teach pts to turn on multifidi themselves
utilize feed forward mechanism
- have them shift forward, left to right, chop arm up
- have them palpate the ms activation –> after feel the contraction w mvmt, try to have them do an isometric contraction
*don’t let them get frustrated, just try again later
what are cues for pelvic tilts
PT place hand under lower back
- have them apply pressure onto hand (post tilt)
have them put their hands on hips in C shape
- passively rock hips back and forth and pay attention to way hands move
—> external cue that can transition from supine to standing
at what point do we determine someone is ready to move on from activation to acquisition
once they have achieved TrA, pelvic tilt, and multifidi
what are 6 acquisition interventions
active SLR
dead bug w PBU
bent knee fall outs w laser
hooklying flies/OH abs w laser
anti-rotational punch (palloff)
ball sitting
what is the major ms are we targetting in PBU dead bugs in mvmt acquisition
psoas
- if unable to dissociate and hip comes up, see lumbar spine enter ext as psoas pulls eccentrically on it
what is a consideration w external cues like a laser being used in mvmt acquisition interventions
people get good at compensating
- make sure not drawing in and using rectus
what mvmt acquisition intervention assesses a higher level of endurance and control
double leg lower and isometric hold
- can they maintain a neutral pelvis
what are 6 mvmt assimilation interventions
HKE
back facing rotation
squatting w pelvic neutral
lunging w pelvic neutral
step ups
jumping
what is the issue w squatting w your chest out
stability is coming from passive structures and as a result are putting more stress on them
what is the bridge between TBC mvmt control and functional optimization
endurance
what is the bridge between TBC sx modulation and mvmt control
mobility
what are components to complete a higher level clinical eval of spinal control
lateral ms test
extensor endurance test
flexor endurance test
the the ratio from lateral ms endurance testing isn’t 1:1, what is this a predictor of
recurrent back pain
what is the lateral ms endurance test
side plank test
pt maintains position as long a possible w proper form
time length should be a 1:1 ratio b/w sides
who is not appropriate for an extensor endurance test
someone just out of sx modulation stage or w a lot of pain
- not ready and tissues not ready for it
what is the extensor endurance test
prone w lower body on table and torso off table
- pt hold in neutral as long as possible w proper form
what is the flexion endurance test and what is a common compensation seen
back is at 60deg from horizontal w hips and knees in 90deg alignment
- pt holds for as long as possible w proper form
ex: excessive flexion of spine
what is the flexion to extensor strength endurance ratio and why
flexor:extensor should be <0.75
extensors should be stronger than flexors bc often fighting gravity
- gravity is often on side of flexors w bending over, etc.
what does OPTIMAL stand for in the OPTIMAL Theory of Motor Performance
Optimizing
Performance
Through
Intrinsic
Motivation and
Attention for
Learning
what are the common theories for motor performance and what does Mr. Steve have qualms about their use
blocked vs random
variable vs constant
factors approach learner as a computer-like processor of info and not taking into account motivational factors
cultural vs social context to behavior
cultural:
- norms and stereotypes ab appropriate or expected activities for a certain age, gender, or ethnic group
social:
- motor behavior observable and often performed in public
- the presence of another person may provide reassurance or additional pressure
how does cognitive context impact motor learning
can slow or speed
- focus on coordination or intended mvmt effects respectively
what are the 3 main things to think about when setting up exercises that will facilitate motivation
- enhance expectancies
- autonomy support
- external focus of support
what is the concept of enhanced expectancies
idea of improving the learner’s forward directed anticipatory or predictive cognitions or beliefs ab what is to occur
- building their confidence and self-efficacy
self-efficacy vs confidence
confidence
- past successful experiences or lack thereof
- primary theoretical determinant of self-efficacy
self-efficacy
- individual’s situation-specific confidence or prospective sense that he or she will be able to affect actions that bring about task outcomes
what are strategies to enhance expectancies in pts
positive feedback
challenge them but not too much
- perceived task difficulty
- conceptions of ability
positive affect
extrinsic reward (happy in environment)
self-modeling
social comparative feedback
what is autonomy support and what is a strategy to facilitate this
allowing individuals to exercise control over environment
give learners choices even if incidental
- existence of inherent reward w exercise of control
what pt population will benefit from encouraged autonomy support as a strategy
chronic pain
external vs internal focus of attention and which is more effective
external focus on intended mvmt effect
- ex: on an implement
internal focus on body mvmt
- ex: squeeze your glute ms
what is the result of learners adopting an external focus
mvmt kinetics start to resemble those typically seen at later stages of learning (experts)
what are directions to give to facilitate an external focus of attention
instructions directing attention away from one’s body parts or self and to intended mvmt effect
age demographic of isolated acute HNP vs disc degeneration
isolated acute HNP = younger pts
degen = 40s-50s
what are 4 types disc dysfunction seen
protrusion (bulge)
herniation/extrusion
- disruption of annular lig / PLL
sequestration (free floating)
derangement
- breakdown of integrity of annulus but no bulging
where in the spine are disc prolapses most common
L4/5
L5/S1
L3/4
what is a consideration of disc prolapses picked up on imaging
they can often be asymptomatic
how can the location of disc herniation affect the presentation and what are examples
post lateral - nerve root
most common
post central (large)
- cauda equina syndrome
- (B) sx
far lateral
- nerve root variations (ie IVF)
what is a consideration for a lateral disc herniation impacting the nerve root at the IVF
might not see all changes in the LQ scan
- but for true radiculopathy, have to see changes in all
what TBC classification categories are disc dysfunction associated with
SM: traction/ active rest
SM: direction preference ext
SM: direction preference flex
SM: direction preference lateral shift
mvmt control
functional optimization
L3-4 disc (L4 NRCS): strength, sensation, reflexes, pain
strength: quads, tib ant
sensation: med first toe, ant-med calf
reflexes: patellar
pain: ant thigh
L4-5 disc (L5 NRCS): strength, sensation, reflexes, pain
strength: ext of big toe
sensation: lat calf
reflex: none
pain: back of thigh, lat calf
L5-S1 disc (S1 NRCS): strength, sensation, reflexes, pain
strength: gastroc plantar flex
sensation: lat foot and heel
reflexes: achilles
pain: back of thigh and calf
what is spinal stenosis and what is it on the continuum of
can be anything that narrows the spinal canal or intervertebral foramen
continuum of DJD/OA
why and how can the presentation of spinal stenosis vary
if more lateral = nerve root
more central = spinal canal
spinal stenosis: demographics
> 50yo
spinal stenosis: MOI
insidious in older individuals (>50yo)
spinal stenosis: aggravating factors
extension based activity
- walking, standing, standing from a chair
spinal stenosis: relieving factors
sitting, leaning forward, grocery cart
- similar to flex directional preference
spinal stenosis: ROM, joint play
limited/painful ext
hypomobile lumbar/thoracic spine
hypomobile fem acetabular joint
spinal stenosis: ms strength/control/endurance, flexibility and ms length
weak glut max/med
poor pelvic control
poor TrA, multifidi activation
stiff psoas and/or rectus fem
spinal stenosis: neuro exam
may have myotomal weakness
may have sensory deficits
depends on location of stenosis (lat)
spinal stenosis: significant special tests
(+) two-stage treadmill test
possible signs of neurogenic claudication
possible signs of NRCS
- dependent on location of stenosis (lat)
neurogenic claudication vs vascular claudication
neurogenic:
- intermittent pressure on the SC
vascular:
- insufficient blood supply d/t PVD
two-stage treadmill test and how can it be used to differentiate
begin walking on treadmill normally, record time to sx
rest 5min
walk on treadmill w incline until sx
uphill facilitates lumbar flex
- as you flex opens up foraminal areas
- can walk longer than if PVD on incline
- early onset w no incline significant correlation to spinal stenosis
vascular
- uphill requires more work and more effort placing higher stress load on CV system
- shorter walking time on incline associated w PVD
what are the 4 areas of intervention for stenosis
pain control
centralization/specific exercise and traction
mobility/manip
conditioning/stabilization
what are 6 specific interventions for stenosis
traction/joint mobs
flex specific exercise (based on direction preference)
aerobic exercise (bike)
posture (neutral to flex bias)
body mechanics - post pelvic tilt
education on provocative positions
what is the prognosis/natural course of stenosis
majority do not progress
- this is the stenosis itself, sx can get much better
what are medical interventions for stenosis
pain control via rest & analgesics
epidural/cortisone injections
surgery
- decompression (ie laminectomy)
- discectomy for lumbar disc prolapse
what are surgical indications for spinal stenosis
cauda equina syndrome
- (B) leg pain, saddle anesthesia
- urinary retention/incontinence, loss of rectal tone
pain persistent at least 6wks of non-op treatment
- leg pain >back pain at least 12wks
- (+) neuro signs, progressing
- evidence of path corresponding w levels of sx
decompression vs laminectomy
decompression - shave bone out
laminectomy
- remove lamina and give more room for SC
what spinal stenosis surgical procedure had the best outcome and what is the caveat to that
discectomy
- faster relief than conservative management
doesn’t appear to be a long term difference, same functional outcomes to conservative care
what are 3 common precautions after a spinal stenosis surgical procedure
avoid excessive bending, lifting, twisting - 6wks
corset - prevents excessive strain across site
avoid sitting prolonged intervals (compression)
**read the post-op note!
what types of exercises might you emphasis post surgery in spinal stenosis
flexion biased exercises
what are education points for individuals post op for spinal stenosis
protect, ms control, body mechanics
what TBC categories does spinal stenosis fit into
SM: mob/manip
SM: traction / active rest
SM: direction preference flex
mvmt control
spondylolysis vs spondylolisthesis
spondylolysis
- defect in pars articularis
spondylolisthesis
- ant slippage of vertebra
spondylolisthesis: demographics
adolescents (women)
gymnasts/ volleyball/swimming - ext based
spondylolisthesis: pain patterns
pain d/t affected structures
- typically back pain
spondylolisthesis: aggravating and relieving factors
aggravating:
- jumping (landing), running, twisting, ext motions
relieving: flex biased motions
spondylolisthesis: posture
excessive lordosis
lumbosacral step
spondylolisthesis: joint signs/mobility
hypermobile PA
(+) shear
spondylolisthesis: muscle function
ms imbalance b/w hip flex and ABD
what are 4 categories of interventions for spondylolisthesis
pain control
centralization / specific exercise and traction
mobility / manipulation
conditioning / stabilization
what is a thought about pts w spondylolisthesis in the TBC sx modulation group
moves to mvmt control quickly
likely sx as a result of having trouble finding neutral
what are specific conservative interventions for spondylolisthesis
restore posture and quality of ROM
flex biased exercise (TBC SM DP flex)
stabilization (neutral spine) –> TBC mvmt control
education
when are surgical interventions indicated for spondylolisthesis and what are 2 examples of interventions
w neural compromise
fusion
decompression
what TBC groups do spondylolisthesis fit into
mvmt control
SM DP: flex
facet dysfunction: demographic
age 20-40yo
- all ages possible
facet dysfunction: MOI
quick twist, SB
- “threw my back out”
facet dysfunction: sx description
sharp localized pain
may relieve as day goes on
described feelings of stuck
facet dysfunction: aggravating factors
ext pattern / quadrant
prolonged standing / positions
facet dysfunction: relieving factors
sitting
flexion
w mvmt
facet dysfunction: exam findings
+/- list (lateral shift)
para-vertebral tenderness
(+) quadrant / compensated mvmts
(+) unilateral PPIVMS/PAIVMS
if someone has facet dysfunction what do you have to decide in order to proceed w interventions
if d/t:
- hypomobility
- hypermobility
facet dysfunction d/t hypomobility interventions
pain control (earlier on if reactive)
mobility/manips - restore ROM
education
facet dysfunction d/t hypermobility interventions
mobility/manip - restore ROM
conditioning/stabilization
- prevention
- trunk stabilization
- motor control
- aerobic exercise
what TBC categories does facet dysfunction fit into
SM: manip/mob
SM: traction/active rest
mvmt control
SM DP: lat shift
what is the pathophys of spondylosis (DJD, OA)
result of new bone formation in areas where structures of spine are sressed
typical clinical findings of lumbar spondylosis
usually no sx
- usually no findings unless complication ensues
spondylosis: subjective demographics and c/o
older person
60+ insidious
arthritic complaints
- worse in morning, better w mvmt, worse w too much mvmt
spondylosis: exam findings
loss ROM ext and ipsi SB and rot
- one side more than the other
(+) joint signs multiple levels
spondylosis interventions
pain control
mobility/manip
- joint mobs, ROM, flexibility
conditioning/stabilization
- aerobic program
- posture
what is hypermobility and what can this lead to
loss of spinal stiffness
can result in spondylothesis
hypermobility: demographic and pain pattern
age <40
recurrent pattern, switches sides, unstable
hypermobility: aggravating factors
walking
STS
prolonged positions
changing positions
hypermobility: (+) exam findings
thigh climbing, catch pain thru motion, reverse lumbar lordosis
(+) shear, (+) PA testing, protective spasm
poor ms patterning, dec tone
SLR >91deg
(+) prone instability test
aberrant motion present
what TBC category does hypermobility fit in
mvmt control
- sx often not severe
- if severe sx, figure out direction preference and then move to mvmt control
