Improving Neuromuscular Function Flashcards
What does neuromuscular control involve?
the detection, perception, and utilization of relevant sensory information in order to perform specific tasks
What is neuromuscular rehabilitation (NMR)?
a method of training the enhancement of unconscious motor responses, by stimulating both the afferent signals and the central mechanisms responsible for dynamic joint control
What are the 3 aims of NMR?
- To improve the ability of the nervous system to generate a fast and optimal muscle-firing pattern
- Increase joint stability
- Decrease joint forces
- Relearn correct movement patterns and skills
What does technique or task training involve?
the performance of specific movements with an emphasis on proper technique, such as transferring from sit to stand
What is the standard progression for proprioceptive retraining?
1) Static stabilization exercises with closed-chain loading and unloading (weight shifting)
2) Transitional stabilization exercises
3) Dynamic stabilization exercises
Static stabilization exercises with closed-chain loading and unloading initially employs what?
Isometric exercise around the involved joint on even surfaces, and eventually progresses to unstable surfaces
What do transitional stabilization exercises involve?
Conscious control of motion without impact
The isometric exercises involved in static stabilization (phase 1 of proprioceptive retraining) is replaced with what?
controlled concentric and eccentric exercises that are worked throughout a progressively larger ROM
What do Dynamic stabilization exercises involve?
Unconscious control and loading of the joint, in which both ballistic and impact exercises are utilized
The neuromuscular mechanism that contributes to joint stability is mediated by what type of receptor?
articular mechanoreceptors
What do articular mechanoreceptors provide information about?
joint position sense and kinesthesia
What is the objective of NMR?
to restore proximal stability, muscle control, and flexibility through a balance of proprioceptive retraining and strengthening
When should you introduce CKCEs and OKCEs in a proprioceptive retraining program?
Initially CKCEs should be performed within the pain-free ROM and positions. Then, OKCEs, such as plyometrics, may be built upon the base of the closed-chain stabilization to allow normal control of joint mobility.
What is the neuromuscular emphasis during proprioceptive retraining CKCEs and OKCEs performance?
Emphasis is placed on functional positioning during exercise
What should proprioceptive retraining activities involve?
Sudden alterations in joint position that necessitate reflex muscular stabilization coupled with an axial load
What should be done following the treatment of any joint and why?
Retraining of the muscles to reestablish coordination (utilize PNF techniques)
What does balance retraining focus on?
The ability to maintain a position through both conscious and subconscious motor control
It is important for the clinician to determine the cause of the balance impairment. What are the 4 types of balance impairments that it could be?
- musculoskeletal
- neuromuscular
- sensory
- cognitive
What are the key elements of a comprehensive balance examination?
- a thorough history of falls
- assessments to identify sensory input and/or sensory processing deficits, abnormal biomechanical and motor alignment, poor muscle strength, poor endurance, decreased ROM and/or flexibility
- assessment of coordination, awareness of posture, awareness of the position of the body in space
- tests and observations to determine the impact of balance control system deficits on functional performance
- environmental assessments to determine fall-risk hazards in a patient’s home
What is of particular importance when performing balance training?
core strength
Balance intervention typically involves improving one or more of 6 categories, what are they?
- Static balance control
- Dynamic balance control
- Anticipatory balance control
- Reactive balance control
- Sensory reorganization
- Vestibular rehabilitation
What does the usual progression in balance retraining involve?
First narrowing of the base of support while increasing the perturbation and then changing the weight bearing surface from hard to soft or from flat to uneven
How do medications alter patient balance?
The risk of falling can be increased when the patient is prescribed sedatives and antidepressants
Other than medications what are 2 other factors that can affect balance?
low vision and sensory loss in the LE
Describe the appropriate progression to use in balance retraining adults
Begin in the short sitting position, which allows the feet to provide anterior support. Then place a wobble board or balance ball under the patient’s butt. The patient is then progressed to quadruped, through tall kneeling, and finally to the standing position.
Describe the appropriate progression to use in balance retraining children
Begin in the “W” sitting position, then progress to “Indian-style” sitting, then to the quadruped, through tall kneeling, and finally to the standing position.
Describe the progression to put a patient through when retraining balance after they are in the standing position
- Static control of the trunk with wide base of support (BOS)
- Manual perturbations to a stable trunk
- Weight shifting while maintaining postural equilibrium
- Dynamic control of trunk without extremity movement (bending at the waist)
- Dynamic control of the trunk with extremity movement (marching)
- Dynamic control of the trunk with upper extremity movement (anterior with band)
- Dynamic control of the trunk with upper extremity movement (lateral with band)
- Dynamic control of the trunk with upper extremity movement (posterior with band)
Once the patient has mastered balance training in a single plane what should you do next with them?
Progress to multiplanar exercises
Describe the progression of multiplanar exercises
- PNF movement patterns without band
- PNF movement patterns with band
- Ballistic extremity movement while maintaining trunk stability in sitting
- Ballistic extremity movement while maintaining trunk stability in standing
When should functional tasks be incorporated into balance retraining?
at the earliest opportunity
Describe a typical functional activity progression
- CKCEs initially such as squats and lunges
- OKCEs superimposed on the closed chain by adding extremity motions to the squats and lunges
- sit-stand-sit activities
- sit-to-sit transitions focusing on balance control while pivoting and changing direction
- floor to standing raises using progression of side-sit to quadruped to kneeling to half kneeling to standing
- gait activities
- lastly multidirectional drills
Describe the progression of multidirectional drills
- Jumping: 2-foot take off and landing
- Hopping: 2 foot take off with 1 foot landing
- Bounding: 1 foot take off with opposite 1 foot landing
What does BAPS stand for?
Biomechanical ankle platform systems
What does KAT stand for?
Kinesthetic ability training device
Stability typically involves the interaction of what three systems?
- Neurological control system
- Inert tissues (ligaments, capsules)
- Contractile tissues (muscular)
What does the neutral zone refer to?
A region of laxity around the neutral resting position of a joint in which minimal loading is occurring in the passive structures, and the contribution of the active system is most critical
What are the 2 primary dynamic bases or core structures in which peripheral stabilizers relay on the stabilization of?
the pelvis and the scapula
What does the pelvis act as a base for?
the whole body, especially for the spine and the lower limbs
What do the scapulae act as a base for?
for their respective upper limb
During peripheral joint movement, which muscles contract first?
The peripheral stabilizer contracts first to stabilize the core structure from which the mobilizers work, followed by mobilizer contraction resulting in a controlled movement pattern
What happens if there is injury to the stabilizer muscles?
An abnormal stabilizer recruitment pattern can develop, resulting in a dominance of the mobilizer muscles and eventual weakening of the local stabilizers
In order for stabilization training to be effective, what must the clinician ensure?
that a stable base is present from which the mobilizers can act
Once stabilizer muscles are functioning, what is the sequence of stabilization retraining?
isometric to concentric, to eccentric, and ecocentric contractions, and finally to functional movement
When does an ecocentric contraction occur?
When a 2 joint muscle shortens at one end, while lengthening at the other end
The hamstring when moving from standing to sitting for example
What are the 6 natural stabilization methods the body has?
- Muscle contraction
- Muscle spasm
- Osteophyte formation
- Scar tissue formation
- Adaptive shortening of inert tissue
- Adaptive shortening of muscle tissue
Stabilization retraining involves _ stages with __ steps
6 stages
12 steps
When does stage one of stabilization retraining occur?
in the acute phase of healing
Describe step one of stage one of stabilization retraining
The focus is to decrease pain through muscle relaxation techniques, patient education on joint resting positions and proper body mechanics, the use of electro physical agents, working in the pain-free range, and the use of medication
Describe step two of stage one of stabilization retraining
Freedom of movement and proper arthrokinematic movement of the joint movement of the joint is allowed through joint mobilization, prolonged passive stretch, muscle energy techniques (METSs), and neurodynamic techniques depending on the tissue causing the restriction
When is stage two of stabilization retraining initiated?
Once pain is under control and normal arthrokinematics are restored
Describe step one of stage two of stabilization retraining
Initial emphasis is directed toward strengthening any weak stabilizer muscles to ensure that the individual muscles will contract when and how they should, starting with isometric contractions of these muscles
Describe step two of stage two of stabilization retraining
The goal is the ensure proper muscle recruitment and reeducation so that the muscles contract in the correct order – stabilizers first, then mobilizers
Describe step three of stage two of stabilization retraining
The goal is to ensure muscle balance between groups to ensure that the various force couples work correctly and function to enable control and eliminate incoordination
When is stage three of stabilization retraining initiated?
when the patient has learned to statically control the core structures
Describe the only step of stage three of stabilization retraining
The goal is to correct endurance and strength discrepancies
Should exercises during stage 3 of stabilization retraining be high rep-low load or low rep-high load?
Focus should be on lower loads and higher repetitions to build up resistance to fatigue
When is stage four of stabilization retraining initiated?
concurrently with Stage 3
What is the goal of the only step in stage 4 of stabilization retraining?
retrain proprioception
What does stage five of stabilization retraining involve?
the integration of five different steps into the program
Describe step one of stage five of stabilization retraining
The goal is to reeducate stabilizing muscle statically by ensuring proximal stabilization of the core while allowing distal movement through the extremities
Describe step two of stage five of stabilization retraining
Advanced static stabilization exercises are taught, The patient is put in the position in which the injury occurred and asked to hold the position statically against resistance
Describe step three of stage five of stabilization retraining
Dynamic stabilization exercises are taught, which involves the use of controlled movement patterns to ensure the development of proper movement patterns and voluntary control
What do exercises during the third step of stage five of stabilization retraining include?
Movement of the core, with the control muscles typically through the full ROM
Describe step four of stage five of stabilization retraining
Advanced dynamic stabilization exercises are taught in which the added dimension of multidirectional movement is also involved
Describe step five of stage five of stabilization retraining
Functional stabilization activities are taught
Describe step one of stage six of stabilization retraining
Fitness is maintained or restored throughout
Describe step two of stage six of stabilization retraining
The patient returns to sport or heavy manual labor as appropriate
