Exercise Prescription

Question 1

Postural Relationship to Gravity

Answer 1

Gravity- constant stressor

Posture- distribution of body mass in relation to gravity over a base of support

Muscle balance continually adapts to the body’s posture- mechanical responses and adaptations

Chronic postural functional demands will accelerate breakdown

Question 2

Gravitational Strain Pathophysiology (GPS) and Postural Decompensation

Answer 2

Posture

• Any compensation will require counterbalancing
• Muscles must adapt

Gravitational Strain Pathophysiology

• Strain from the body’s attempts to stave off the effects of gravity
• Leads to altered postural alignment and recurrent somatic dysfunction
• Intrinsic and Extrinsic factors

Postural Decompensation

• Homeostatic mechanisms are overwhelmed
• Pathological change becomes structurally incapable of resisting gravitational forces

Question 3

INTRINSIC GPS

Answer 3

Age (muscle weakness, fascial elasticity, bone mass)
Altered integrity of soft tissue (hypermobility, CT disorder)
Incompetent bony structures (spondylolysis, spondylolisthesis)
Poor Tissue Health (disease, poor nutrition, smoking)
Altered base of support (flat feet, high heels, short leg, altered gait after injury or surgery)
Change in body habitus (pregnancy, weight gain)
Ergonomic factors (how to people sit/stand/walk)

Question 4

EXTRINSIC GPS

Answer 4

Surgeries
Traumas
Increased Gravitational stress (like a G6)

Question 5

Tensegrity

Answer 5

elements of tensegrity include compression and stress- light- mobile- efficient- one aspect of the structure effects the others.
We have found that we aren’t so much pulley’s and slings so much as tensegrity units.
One aspect affects the other so that if we let an area collapse the whole thing collapses.

We have to stop defining anatomy as origin and insertion and start defining it according to
the functional muscle groups that work together
The fascial sleeves that link us from head to toe
And the neuromuscular innervation that is critical to how we move

Question 6

Structural Lesions

Answer 6

rooted in anatomy and biomechanics- structural approach to pathology
relying in imaging- damages to physical structures- this approach is foundational to medical education and practice
Diagnostic tests may be inconclusive- more than likely there is a functional cause.

Question 7

Functional Lesions –

Answer 7

impairment in the ability of a structure or system to perform it’s task
impairment manifests as reflexive changes
much more difficult to diagnose and treat- you have to understand complex interactions within the system
Shifts our focus from structure to function

Question 8

FOCUS ON …

Answer 8

THE CAUSE OF THE PROBLEM RATHER THAN FOCUS ON THE PATHOLOGY

Question 9

Structural Lesions on Imaging

Answer 9

Disc herniations are seen in 22-67% of asymptomatic adults and spinal stenosis in 21%, of asymptomatic adults over age 60

One systematic review showed 90% over 60 had a disc herniation or bulge that was asymptomatic

Osteoarthritis often seen but poorly correlates with symptoms

Study of 188 people age 40-80- 60% males & 67% females had facet joint OA on lumbar CT- no correlation with back pain

Even if the structure is causing the problem- unclear if it correlates to the clinical severity and outcome

Question 10

In patients with chronic musculoskeletal pain,

Answer 10

the source of the pain is rarely the actual cause of the pain.”

Question 11

Nociception is telling you that there is

Answer 11

inflammation or injury- but it can be very misleading- innervation from multiple areas- referral pain- so you can’t chase the pain- you need to look for the dysfunction in the function system to find the source

Question 12

Three major pathways for innervation to the lumbosacral region-

Answer 12

dorsal rami of spinal nerves, sinu vertebral nerve or somatosympathetic nerves from the sympathetic trunk
1. Irritation of these dorsal rami can lead to the perception of pain and the pain can refer to the corresponding ventral ramus- this is how SIJ pain could have a referral pattern to that of sciatica

2. Sinu vertebral or recurrent menengial branch is off the spinal nerve- PLL, periosteum, vertebral body, intervertebral discs, spinal dura- the problem with theis nerve is that it can travel up or down segments, it can cross and re-enter- therby referring pain to the contralateral side as well as segments above or below the affected segment- makes identifying the source of the pain very difficult
3. Finally the somatosympathetic nerves- penetrate the ALL and anterior outer layers of the intervertebral discs- pain in the lowest levels of lumbar and sacrum will ascend in the sympathetic trunk presenting to the spinal cord at the thoracolumbar junction –the region of the lowest white rami- this leads to referral pain and facilitation in the lower thoracics and upper lumbar region

Question 13

Vertical & Horizontal Generalization

Answer 13

No biomechanical lesion remains localized. Its effect can be on other muscles and joint dysfunctions above or below the original site.

Vertical Adaptation- motor programming

Horizontal adaptation- one joint problem leads to joint problems in the next joint up

• The more distal the injury the greater the proximal trunk disorganization.

Question 14

Vertical programming-

Answer 14

affects the way the muscles fire- so the actual innervation patterns of the muscles- then they become programmed that way and this affects the system globally

Question 15

Horizontal adaptation

Answer 15

recognizes that an injury at one joint is going to affect other joints around it.

Question 16

Let’s use the example of an ankle sprain

with vertical and horizontal programming/ adaptation

Answer 16

Horizontal adaptation shows us how our abnormal gait will affect the knee the hip and the low back as we attempt to compensate for this issue

Vertical adaptation shows us that because we have altered our gait for so long- we will now have a new neuromuscular firing patter around this injury- we have rewired our neuromuscular system- not just at the ankle but for the whole compensatory pattern- so the injury affects us globally

Question 17

Gravitational Strain and Postural Decompensation affects:

Answer 17

Bones, Muscles, Ligaments, Fascia, Vasculature, Connective Tissue, and Organs

not just a musculoskeletal thing- but our posture affects our circulation and lymphatic flow as well as the way our organs are situated and able to function in our bodies

Question 18

Response of Tissues to Gravitational Strain and Postural Decompensation: Skeletal-Arthroidial Response

Answer 18

Wolffe’s Law
- Bone remodels according to stress

Spurs, wedging, and degenerative changes

Question 19

Response of Tissues to Gravitational Strain and Postural Decompensation: Ligamentous Response

Answer 19

Stabilizing ligaments become stressed

• Iliolumbar
• Sacrotuberous
• Long dorsal sacroiliac ligaments

Can become Tender

Calcified

Sclerotomal pain pattern

Question 20

Let’s look at the knee

Answer 20

So often we try to fix a structural problem- a spur here- floating meniscus piece there
But what caused it?

Unbalanced biomechanical joint stresses from muscle imbalance can lead to joint damage (balance between agonists and antagonists) for shock absorption with each step helping to prevent unnatural loading
But what if tendons pull unevenly
This leads to inflammation
This affects proprioception and the afferent system which adapts a new motor program to adapt.

The FUNCTIONAL cause is muscle imbalance
The SYMPTOM is pain and inflammation from a structural lesion- start thinking of structural lesions as symptoms of a bigger problem

Question 21

Response of Tissues to Gravitational Strain and Postural Decompensation: Muscular Response

Answer 21

Elastic component: Transient functional change in connective tissue length

Plastic component: More permanent structural deformatino in response to static postural change

• shortening not resonsive to muscle spindle resetting (ie. counterstrain)
• fibrosis
• fatty replacement
• myofascial remodelling along vectors of postural tress
• Trigger points and tendonitis- develop in muscles that tend to be weak and inhibited
• Tears and ruptures develop in muscles that tend to tightness
• Avulsion fractures and apophysitis common at attachments of muscles that tend to tightness
• Sacroiliitis and osteitis pubis not likely primary inflammatory but *imbalance from wear and tear

Question 22

different issues with muscular response

Answer 22

Loss of elastic component- ability to flex- increasing stiffness
And then the plastic component which is more permanent
Shortening and hypertonicity- “tight and weak”
Fibrosis- altering joint ROM
Fatty replacement- multifidis- lots of studies look at the fatty involution in multifidis and it is actually highly correlated with low back pain- more so than other anatomic structures- why do we do nothing about it? Because we can’t surgerize it- retraining multifidis takes time and energy- and the patient has to play a role- they have to be active and engaged in their musculoskeletal health.
Bones aren’t the only thing that remodels along stress lines- fascia and muscles do too- creating areas of chronic tightness that can lead to other things

Question 23

Response of Tissues to Gravitational Strain and Postural Decompensation: Neural, Vascular, Lymphatic and Visceral Element response

Answer 23

Transitional zones in the body related to transverse diaphragms
- dysfunction leads to decreased lymphatic venous return

Posture can relate to *autonomics and facilitated segments affecting organs

Question 24

Chronic postural changes can also lead to

Answer 24

increased sympathetic tone in organ systems via
Somatovisceral reflexes

Lots of input from the musculoskeletal system into the spinal segment that innervates it- facilitation- leads to increased sympathetic output or lowered firing thresholds in ventral rami and sympathetic innervation

Question 25

If you don’t treat the cause,

Answer 25

you may end up chasing the symptoms…

Question 26

All that radiates is not nerve

Answer 26

Muscular radiation
Ligamentous/tendinous radiation
Somatosympathetic radiation
Trigger points

And a lot of these radiation patterns can mimick serious patholody

RF- deep ache in the knee
SI joint- sciatica
Piriformis- pelvic floor dysfunction

Question 27

So How Can We Complete Assessment and Evaluation Looking for GPS and Postural Decompensation?

Answer 27

Remembering back to the tensegrity lecture- Buckminster fuller and tensegrity concepts
We remember that muscles are not just origin and insertion- having one role of flexion or extension

But other roles of stabilization through connectivity and fascial ligamentous stockings
Muscular slings providing movement and stabilization across multiple joints- transferring forces
Functional anatomy- how these things move together

Let’s look at the sacrum- you can have SI joint pathology- but why? Due to loss of form and force closure mechanisms- so the problem may lie elsewhere

So how can we begin to look for this or identify this? It seems like the pain could be coming from anywhere!!!!!

Question 28

Even minor changes in one body region

Answer 28

may affect significant biomechanical, tensile and ergonomic changes elsewhere”

Question 29

Muscle Response to impaired afference is not a random occurrence

Answer 29

Sensorimotor System
Responds in a predictable way based on structure and function
Biomechanical changes vs neurological changes
One of the 1st to suggest a biopsychosocial approach

Question 30

Vladimir Janda, DMed, DSc

Answer 30

• Viewed the muscles as a WINDOW into the sensorimotor system
• Muscles are at a corssroads- because they respond to the CNS as well as react to joints and PNS
• Changes in one system are reflected by adaptive changes elsewhere
  He noticed that people with low back pain exhibited the same patterns of muscular tightness and weakness as those with upper motor neuron lesions such as cerebral palsy- but just to a smaller degree
• Pattern does not differ among individuals- only the degree of imbalance
• Patterns of muscle imbalance to be systematic and predictable because of the innate function of the sensorimotor system
• He noticed that alteration in proprioception led muscles to either tighten or weaken- over time this leads to a changed motor program in the cord
  And there is often a systemic response (through the neuromuscular system) involving the whole body
• Sensorimotor systems- our bodies rely on proprioceptive information to tell our muscles how forcefully to contract- what information is coming into my hand to tell me how hard to squeeze the clicker so I don’t either break it or drop it- that’s proprioceptive input and it’s critical to our muscular system.
• What we are going to look at is what happens when we have injury or alteration of the proprioceptive input from poor posture- how does that hinder our muscles from firing properly?
• He was also one of the first to suggest a biopsychosocial approach

Question 31

The sensorimotor system

Answer 31

• key to proper function of the motor stystem
• clinicians must consider the whole body in sensorimotor dysfunction

3 Key areas of proprioception for posture

1. Foot
2. SI Joint
3. Cervical Spin

Pain is the strongest stimulus of this system

Altered proprioception–> altered afferent information–> altered CNS functioning–> affects motor output–> affects local joint–> affects global musculoskeletal responses

Question 32

Sensory system- motor system- must function together. To check patient:

Answer 32

have them stand on one leg- balance is a three legged stool
Relate standing on one foot to over pronation or over supination
One legged standing tests have been found to accurately predict who has low back pain

Single leg balance can discriminate patients with chronic back pain from those without pain

Link between reduced proprioceptive input and altered slow motor unit recruitment- and the development of chronic pain states
Deep segmental instability and poor control of the neutral joint position

Altered length and recruitment of muscles that can over or under pull the joint, bone, tendon they attach to.
No proprioception- also recruit harder even if there is a low load

Question 33

Proprioceptive deficits lead to

Answer 33

LOCAL and GLOBAL dysfunction- affects CNS output and motor and joint function
If you have less proprioception you will recruit harder even with a lower load
Think about all the proprioceptors in every joint in your low back- ALL, PLL, facet capusles, supraspinous/interspinous ligament, TLF- all recruiting

Question 34

Muscle Imbalance Description

Answer 34

Alteration in Length, Strength and Motor Control

Balance needed for opposing muscle groups to be coordinated

Length or strength changes of agonist and antagonist muscle prevents normal function

• Muscle Length
• – Facilitation/tightness/shortening of postural/tonic muscles
• Muscle Strength
• – Inhibition/pseudoparesis/weakness of phasic muscles
• Motor Control
• – Loss of integrated coordinated neurologic function
• ———- Incorrect sequence of muscle firing patterns

Question 35

Agonist/ Antagonist Reflex

Answer 35

Co-Contraction: Stimulation to both flexor and extensor muscles to stabilize a joint

Joint Flexion: Flexor contracts, then via reciprocal inhibition extensor muscle group relaxes

Joint Extension: Extensor group contracts, then reciprocal inhibition flexor muscle group relaxes

• The harder a muscle contracts the more it inhibits its antagonist
  *** Occurs ipsilaterally and contralaterally
  (This is why when we have you stretch muscles we have you treat both sides)
• Short/Facilitated muscles can inhibit their antagonist
• ** Pseudoparesis

Question 36

How Does Muscle Imbalance happen?

Answer 36

Disturbance of muscular function- mechanoreceptors/nociceptors stimulated (altered posture and attempt to return to homeostasis)–>

Afferent neural activity goes to the cord, brainstem and cortex–>

Final common efferent pathway is the alpha motor neuron which causes the muscle fibers to contract (descending cortical signals have to be modified from sensory input)–>

Then through the gamma system muscle spindles adapt leading to alteration in muscle tone–>

Perpetuation of this loop leads to ongoing aberrant muscle tone

Question 37

muscle imbalance happens Through neuroreflexive loops

Answer 37

Alpha motor neurons relay voluntary motor commands
Gamma motor neurons unconscious length

Descending cortical signals have to be modified b the sensory input from proprioceptive nerve endings- proprioceptive feedback critical to recruiting muscle fiber type and amount

Think about holding a coffee cup- how hard, how heavy

And there are different strategies for keeping us upright
Ankle strategy
Hip strategy
Step strategy

Joint instability may be caused by proprioceptive abnormalities- not just ligamentous laxity

Question 38

Muscle Imbalance- Neuroreflexive Component

Answer 38

“Faulty posture results in alteration of the center of gravity, which initiates mechanical responses requiring muscle adaptation.”

“Change in a joint’s mechanical behavior causes neuroreflexive alteration in muscle function through aberrant afferent mechanoreceptor stimulation of articular reflexes. “

“Long term activation of abnormal articular reflexes causes change in cord memory from a normal to an abnormal adaptive program resulting in muscle imbalance.”

In brief: altered proprioception–> altered joint position–> joint position becomes embedded in CNS as a motor pattern–> wicked bummer.

Question 39

Theoretical Causes of Muscle Imbalances

Answer 39

Postural adaptation to gravity
- Faulty posture shifts center of gravity and body tries to compensate

Neuro-reflexive due to joint blockage
- Dysfunction of normal articular reflexes

Central nervous system mal-regulation

• Limbic system
• Loss of reciprocal Agonist/antagonist interplay

Response to painful or noxious stimuli.

• Spinal cord level- facilitation
• Higher centers- central sensitization

Response to physical demands
- Fatigue

Habitual movement patterns

• Repetitive stress, insufficient movement,
• Repetitive movement

Psychological influences
- Mood, somatization of stress, fatigue, pain

Question 40

Lifestyle can contribute to muscle imbalance

Answer 40

Stress

Fatigue

Insufficient movement

Lack of variety of movement
- Most repetitive movements activate the postural system neglecting the phasic system leading to imbalance

Bracing and anticipation of pain
- Yoga and exercise retraining connection

Question 41

Muscle Imbalance

Answer 41

Begin by observing posture

Occur in two major body regions

• Pelvic girdle (lower crossed)
• Shoulder girdle (upper crossed)

Alteration in firing pattern in principle muscle movements

• Hip extension
• Hip abduction
• Shoulder abduction

Question 42

Dynamic/Phasic Muscles

Answer 42

Smaller Muscle Groups

Respond by

• Inhibition
• Hypotonicity
• Weakness (Psuedoparesis)

Question 43

Postural/Tonic Muscles

Answer 43

Large Muscle Groups

Respond by

• Facilitation
• Hypertonicity
• Shortening

Question 44

LOWER CROSSED SYNDROME : Posture

Answer 44

spinal curves

Leg lengths

Tilt of the pelvis

Gait

Lower extremity muscle hypertrophy or atrophy

Question 45

Postural Changes that Affect Muscle Imbalance: Upper Crossed

Answer 45

Forward Head Posture
Extension of the OA and upper C-spine
Increased kyphosis of the C/T junction (Hump at base of the neck)
Protracted and internally rotated shoulders

Question 46

Anterior head posture

Answer 46

2-4 hours each day with neck bent at unnatural angle- shooting off emails or texts.

• loss of normal spinal curve
• increase of stresses
• leads to earlier wear, tear and degeneration

Question 47

Think about upper crossed in

Answer 47

patients with TMJ and headache complaints
Long dural strains from tipped pelvis
But also malalignment of bite

Question 48

Brachial plexus restriction

Answer 48

anterior and middle scalene

between the clavicle and the first rib

pectoralis minor

Question 49

TONIC/POSTURAL

in the lower extremity

Answer 49

Slow Twitch

• Oxidative
• – More capillaries-Red fibers
• Phylogenetically older
• Flexor or postural muscles
• Typically one joint muscles

Hip/Pelvis
- Hamstrings, Iliopsoas, rectus femoris, TFL, Thigh Adductors, piriformis,

Lspine

• Erector spinae group
• QL

Lower extremity
- Gastrocnemius and soleus

**SHORT, TIGHT ,FACILITATED with repetitive stress

Question 50

RECTUS FEMORIS vs quads

Answer 50

usually tight, rest of the quads usually weak.

Question 51

PHASIC

Lower extremity

Answer 51

Fast Twitch

• Glycolytic pathway
• – Low capillaries-White fibers
• Phylogenetically younger
• Generally extensors
• Typically two-joint muscles

Hip/ Pelvis
- Vastus medialis, intermedialis, lateralis, gluteus medius, maximus and minimus, rectus abdominus, obliques, transversus abdominus

Lower extremity
- Tibialis anterior, peroneal muscles

*** WEAK HYPOTONIC, INHIBITED or WEAK with repetitive stretch

Question 52

Upper extremity: TONIC/ Postural muscles

Answer 52

Tonic- typically become TIGHT and Hypertonic and Facilityated

slow twitch: oxidative, more capillaries- red fibers

Neurodevelopmentally: typically flexion, though not exclusively

Scalenes
Lat
Subscap
Flexors of the UE
Levator scap
Upper Trap
SCM
Pectorals
Suboccipitals
Cervical Erector Spinae

Question 53

Upper Extremity PHASIC MUSCLES

Answer 53

Phasic muscles typically respond with WEAKNESS, INHIBITION and HYPOTONICITY

• stretch weakness
• allows for inappropriate joint motion and excessive wear/ tear

Fast Twitch- glycolytic pathway
— low capillaries- white fibers

Neurodevelopmentally- typically extensors

Infraspinatus
Delt
Deep cervical flexors
Extensors of the UE
Middle and lower trap
serratus anterior
Rhomboids
Supraspinatus
Lat Dorsi *

Question 54

Muscle imbalance in Shoulder impingement

Answer 54

Pec minor hypertonicity- limits scapular upward rotation, posterior tilt; decreases SAS

Patients with impingement EMG: increased upper trap, decreased lower trap, serratus anterior

Lower Trap; important stabilizer. Decreased lower Trapz activity or increased upper Trapz. –> altered scapular rotation, upward migration of the glenohumeral joint, less SAS

Question 55

Review

Answer 55

“when the manipulative intervention has achieved maximum mobility, the question remains, how is it maintained?”
* “the obvious answer is an appropriate exercise program”

Why?
“A disturbance of musculoskeletal function initiates a series of events beginning with stimulation to mechanoreceptors and nociceptors resulting in afferent neural activity initiating a variety of reflexes at the cord, brainstem and cortical levels. The final common pathway is the alpha motor neuron that stimulates the muscle fiber to contract and through the gamma system, the muscle spindle to adapt, resulting in the alteration in muscle tone”

• “Interruption and reprogramming of this vicious cycle contributes to improvement of overall muscle tone and maintenance of balance”

Question 56

The Janda ‘Recipe’

Answer 56

• Sensorimotor balance training
• Stretch before strengthen
• Re-educate movement pattern
• • Quality of movement emphasized.

Restore Length, strength and control of muscle function

Question 57

GOALS OF TREATMENT OF MUSCLE IMBALANCES

Answer 57

Goal of an exercise program is to
“maintain the enhanced functional capacity of the musculoskeletal system that has been achieved by appropriate manual medicine intervention”

• Restoration of normal posture & movement patterns
• Alleviation of pain & dysfunction
• Protection of the osteoarticular system
• Reduction of strain placed on joint capsules & ligaments
• – Appropriate muscle balance of agonists and antagonists provides shock absorption

Question 58

STEP 1 PROPRIOCEPTIVE BALANCE

Answer 58

Proprioceptive balance is a key component to muscle firing pattern sequencing

Our orientation in space is dependent on three systems, the vestibular, visual, and our stance (our only contact with the ground)

Restoration of proprioceptive balance is the first stage of an exercise program.

Should look at not only if they can do it or not- but amount of pre-shift and excessive activity of knee, tibialis anterior or toes indicating poor proprioception

Proprioception may also be a pain gate

Question 59

Afferent information helps with

Answer 59

Reflex response
programming the parameters of normal voluntary responses
Integrating feedback

This is how we can tap into the feedback loops

Proprioception may also be a pain gate that blocks or inhibits nociceptor transmission

Changes the sensorimotor system from the ground up.

Question 60

Step 2 Stretch Tonic/Facilitated Muscles

Answer 60

Stretching to * alleviate myofascial * hypertonicity of tonic and facilitated muscles

Stretching to * relieve pseudoparesis of the phasic muscles

Question 61

Step 3 Muscle re-education/ strengthening

Answer 61

Teaching * correct muscle firing patterns to weak muscles

• Strengthen weak muscles

Question 62

Treat the CAUSE of the Muscle Imbalance

Answer 62

Etiology and treatment involves:

• Neuro-reflexive spinal cord component
• – Tight muscles need to be relaxed
• – Inhibited muscles need to be neurologically stimulated

A Viscoelastic component
– Tight muscles must be manually lengthened

OMT should address both components- ME does!

Question 63

Treatment of the dysfunctional postural alignment yields

Answer 63

more lasting results than treatment of the secondary recurrent somatic dysfunction (myofascial trigger points, isolated muscle imbalances)”