Exercise Prescription Flashcards
Postural Relationship to Gravity
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
Gravitational Strain Pathophysiology (GPS) and Postural Decompensation
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
INTRINSIC GPS
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)
EXTRINSIC GPS
Surgeries
Traumas
Increased Gravitational stress (like a G6)
Tensegrity
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
Structural Lesions
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.
Functional Lesions –
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
FOCUS ON …
THE CAUSE OF THE PROBLEM RATHER THAN FOCUS ON THE PATHOLOGY
Structural Lesions on Imaging
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
In patients with chronic musculoskeletal pain,
the source of the pain is rarely the actual cause of the pain.”
Nociception is telling you that there is
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
Three major pathways for innervation to the lumbosacral region-
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
- 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
- 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
Vertical & Horizontal Generalization
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.
Vertical programming-
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
Horizontal adaptation
recognizes that an injury at one joint is going to affect other joints around it.
Let’s use the example of an ankle sprain
with vertical and horizontal programming/ adaptation
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
Gravitational Strain and Postural Decompensation affects:
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
Response of Tissues to Gravitational Strain and Postural Decompensation: Skeletal-Arthroidial Response
Wolffe’s Law
- Bone remodels according to stress
Spurs, wedging, and degenerative changes
Response of Tissues to Gravitational Strain and Postural Decompensation: Ligamentous Response
Stabilizing ligaments become stressed
- Iliolumbar
- Sacrotuberous
- Long dorsal sacroiliac ligaments
Can become Tender
Calcified
Sclerotomal pain pattern
Let’s look at the knee
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
Response of Tissues to Gravitational Strain and Postural Decompensation: Muscular Response
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
different issues with muscular response
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
Response of Tissues to Gravitational Strain and Postural Decompensation: Neural, Vascular, Lymphatic and Visceral Element response
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
Chronic postural changes can also lead to
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
If you don’t treat the cause,
you may end up chasing the symptoms…
All that radiates is not nerve
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
So How Can We Complete Assessment and Evaluation Looking for GPS and Postural Decompensation?
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!!!!!
Even minor changes in one body region
may affect significant biomechanical, tensile and ergonomic changes elsewhere”
Muscle Response to impaired afference is not a random occurrence
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
Vladimir Janda, DMed, DSc
- 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
The sensorimotor system
- key to proper function of the motor stystem
- clinicians must consider the whole body in sensorimotor dysfunction
3 Key areas of proprioception for posture
- Foot
- SI Joint
- 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
Sensory system- motor system- must function together. To check patient:
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
Proprioceptive deficits lead to
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
Muscle Imbalance Description
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
Agonist/ Antagonist Reflex
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
How Does Muscle Imbalance happen?
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
muscle imbalance happens Through neuroreflexive loops
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
Muscle Imbalance- Neuroreflexive Component
“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.
Theoretical Causes of Muscle Imbalances
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
Lifestyle can contribute to muscle imbalance
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
Muscle Imbalance
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
Dynamic/Phasic Muscles
Smaller Muscle Groups
Respond by
- Inhibition
- Hypotonicity
- Weakness (Psuedoparesis)
Postural/Tonic Muscles
Large Muscle Groups
Respond by
- Facilitation
- Hypertonicity
- Shortening
LOWER CROSSED SYNDROME : Posture
spinal curves
Leg lengths
Tilt of the pelvis
Gait
Lower extremity muscle hypertrophy or atrophy
Postural Changes that Affect Muscle Imbalance: Upper Crossed
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
Anterior head posture
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
Think about upper crossed in
patients with TMJ and headache complaints
Long dural strains from tipped pelvis
But also malalignment of bite
Brachial plexus restriction
anterior and middle scalene
between the clavicle and the first rib
pectoralis minor
TONIC/POSTURAL
in the lower extremity
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
RECTUS FEMORIS vs quads
usually tight, rest of the quads usually weak.
PHASIC
Lower extremity
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
Upper extremity: TONIC/ Postural muscles
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
Upper Extremity PHASIC MUSCLES
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 *
Muscle imbalance in Shoulder impingement
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
Review
“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”
The Janda ‘Recipe’
- Sensorimotor balance training
- Stretch before strengthen
- Re-educate movement pattern
- Quality of movement emphasized.
Restore Length, strength and control of muscle function
GOALS OF TREATMENT OF MUSCLE IMBALANCES
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
STEP 1 PROPRIOCEPTIVE BALANCE
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
Afferent information helps with
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.
Step 2 Stretch Tonic/Facilitated Muscles
Stretching to * alleviate myofascial * hypertonicity of tonic and facilitated muscles
Stretching to * relieve pseudoparesis of the phasic muscles
Step 3 Muscle re-education/ strengthening
Teaching * correct muscle firing patterns to weak muscles
- Strengthen weak muscles
Treat the CAUSE of the Muscle Imbalance
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!
Treatment of the dysfunctional postural alignment yields
more lasting results than treatment of the secondary recurrent somatic dysfunction (myofascial trigger points, isolated muscle imbalances)”
