Intro To Func Rest Flashcards
Two approaches for locomotor system pain and dysfunction
Structural
Functional
Rooted in anatomy, biomechanics
Visualized with imagery or surgery
Diagnosed by clinical tests
Structural approach
Structural approach repaired through
Immobilization, surgery, rehabilitation
Basis for most medically-oriented education and practice
Structural approach
Lesions cannot be observed directly with structural tools
Must be visualized virtually by understanding interactions of structures and systems
Functional approach
Everything must work together - the sensory motor system - muscles
Recognizes the funciton of all processes and systems within the body, rather than focusing on a single site of pathology
Functional approach
Janda’s theory
Joints, muscles, nervous system functionally integrated
Sensory and motor systems function together as sensorimotor system
Muscular system often reflects status of sensorimotor system
Kinetic chain is made up of
The soft tissue system (muscle, ligament, tendon, and FASCIA), neural system and articular system
Overuse injuries may be traced to improper technique that puts too much stress
Somewhwere on the kinetic chain
Relationship between kinetic chain structure and function
Each component system within the kinetic chain works interdependently to allow structural and functional efficiency
If any systme does not work efficiently compensation adn adaptations occur in the other systems
Compensations and adaptations lead to
Tissue overload, decreased performance, predictable patterns of injury
3 subsystems in stabilizing the spine
Passive musculoskeletal subsystem
Active musculoskeletal subsystem
Neural and feedback subsystem
Need all to have good spinal stability
Passive musculoskeletal subsystem
Spinal column
Active musculoskeletal subsystem
Spinal muscles
Neural and feedcback subsystem
Neuromuscular control unit
**Basic biomechanical functions of the spinal system
To allow movements between body parts
To carry loads
To protect the spinal cord and nerve roots
Normal function of the spinal stabilizing system
Provide sufficient spinal stability to match instantaneously varying demands due to
Postural changes, static loads, dynamic loads
Degradation of spinal stabilizing system results from dysfunction in any of 3 subsystems
Injury
Degeneration
Disease
Any abnormal loading conditions including overload and immobilization can produce
Tissue trauma and/or adaptive changes that may result in disc degeneration
Adverse mechanical conditions can be due to
External forces or may result from impaired neuromuscular control of the paraspinal and abdominal muscles
If and when pain is on board your body
Is unable to respond in a timely fashion due to loading you won’t have appropriate muscle timing/sequencing
Movement of arm in patients with neck pain indicates
Significant deficit in teh automatic feedforward control of the cervical spine
People with recurrent LBP respond differently to trunk loading despite
Remission from symptoms
Neuromuscular function in athletes following recovery from a recent acute low back injury
Objective measures of neuromuscular function indicated altered muscle response pattern to sudden trunk loading in athlets following recovery
Asymptomatic athletes with a recent history of LBP were slower during performance of teh timed 20 m shuttle run than atheletes wihtout
Athletes with resolved LBP were
Slower than a matched group of normal atheltes without LBP
Athletes with history of lower extremity injury
Significantly slower response time
Kinetic chain deficits may exist long after symptomatic recovery from injury resulting in functional deficits which may be missed on a
Standard physical assessment
Believed that muscles are at functional crossroad between CNS and PNS
Janda theory
Motor system acts as window into
CNS function
Reflexes influence
Muscle balance and function
Chronic musculoskeletal pain and dysfunction is functional pathology mediated by
CNS
Janda’s muscle imbalanace paradigm
Impaired relationship between muscles prone to tightness vs inhibition/weakness
Muscles predominantly static, tonic, postural have tendency to become
Tight
Muscles predominantly dynamic, phasic have tendency toward
Weakness, inhibition
If patient has upper and lower crossed syndrome
Layer syndrome
7 muscles prone to hypertonicity (tightness) when the iliopsoas is tight and the gluteals have become inhibited
Quadratus lumborum Thoracolumbar fascia Piriformis Hamstrings Iliotibial band/tensor fascia lata Adductors Gastroc/soleus
Mobility and stability joint by joint
Foot should be stable Ankel mobile Knee stable Hip mobile Lumbar stable Thoracic mobile Cervical stable C0-C2 mobile Hand stable Wrist mobile Elbow stable Shoulder mobile Clavicle stable
Pronation distortion syndrome weak muscles
Posterior tibialis Anterior tibialis Vastus medialis oblique Biceps femoris Gluteus medius
Pronation distortion syndrome tight muscles
Peroneals Adductors Medial hamstrings TFL/ITB Psoas
Pronation distortion syndrome arhtrokinematic dysfunctions
1st MTP
Subtalar joint
Tibiotalar joint
SI joint/ISjoint/PS joint
Pronation distortion syndrome neuromuscular dysfunction
Decreased pronation control of the foot and ankle
Decreased frontal and transverse plane control at the knee
Increased compensation in the lumbopelvic hip complex
The force transmission between muscle and its surroundings, passing via the outer limits of muscle-tendon complexes (epimysium)
Epimuscular myofascial force transmission
The effects of myofascial force transmission have a major impact of our understanding of
In vivo muscle function
Integrative approach for myofascial force transmission
To combine knowledge of functional properties of isolated elements of the locomotor system with the knowledge of effects of nearby structures belonging to a higher level of organization and their interactions
Myer’s myofascial meridians: the lateral line
Myofascial tracks Peroneal muscles Anterior ligament of fibular head Iliotibial tract TFL Gluteus maximus Abdominal obliques Intercostals Splenius capitis/SCM
Myer’s myofascial meridians: the spiral line
Splenius capitis, cervicis Rhomboids Serratus anterior External oblique Abdominal aponeurosis, linea alba Internal oblique TFL, iliotibial tract Tibialis anterior Peroneus longus Biceps femoris Sacrotuberous ligament TLF, erector spinae
Back chain
Tuberosity of tibia Subpatellar tendon/patella Vastus lateralis Shaft of femur Gluteus maximus Sacrum Sacral fascia, lumbodorsal fascia, lat dorsi Shaft of humerus
Front chain
Linea aspera of femur Adductor longus Pubic tubercle and symphysis Lateral sheath rectus abdominus 5th rib and 6th rib cartilage Lower edge pec maj Shaft of humerus
Model for chiro
Macroinjury, microinjury, hypomobility, hypermobility, chronic stress - inflammation - connective tissue fibrosis - abnormal mechanical and nociceptive afferent input to CNS - altered motor patterns - abnormal tissue stress - more abnormal mechanical and nociceptive input to CNS and fibrosis - chiro specific adjusting, soft tissue mobilization and anti-inflammatory protocols - remodeling of connective tissue fibrosis - improvement of tissue mechanical function and improvemnt of mechanical and nociceptive neurological afferentation to CNS
Assessment for kinetic chain dysfunction
Myofascial balance assessment
Sensorimotor system assessment
Spinal stabilization assessment
Functional approach to treatment
Restore/improve proprioceptive input
Restore myofascial balance
Facilitation of afferent system and sensorimotor training
Rehabilitation efforts that attempt to maximize the extent of cortical neuroplastic changes stand to provide the greatest potential for
Rehabilitation success
Assessment of muscle length and movement patterns
Postural muscles
Phasic muscles
Postural muscles
Responsible for maintaining posture esp during gait
Type I slow twitch
Tend to become short and tight - not necessarily weak
Stabilizers
Phasic muscles
Antagonistic to postural muslces
Type II
Tend to become weak/inhibited
Mobilizers
Upper crossed syndrome weak muscles
Rhomboids Medial/lower trapezius Serratus anterior Teres minor/infraspinatus Posterior deltoid Longus colli/capitis
Upper crossed syndrome tight muscles
Pec major/minor Levator scapulae Upper trapezius Latissimus dorsi Subscapularis SCM Rectus capitus/scalenes
Upper crossed syndrome arthrokinematic
C0-C1 Cervico-thoracic Thoracic/rib AC joint SC joint
Upper crossed syndrome neuromuscular dysfunction
Excessive cervical protraction
Scapular winging
Early/excessive scapular elevation
Lower crossed syndrome weak muscles
Lower abdominals Multifidus Deep erector spinae Gluteus maximus Biceps femoris
Lower crossed syndrome tight muscles
Psoas
Superficial erector spinae
Rectus femoris
Adductors
Lower crossed syndrome arhtrokinematic dysfunctions
SI joint Iliosacral joint Iliofemoral joint Proximal tibio-fibular joint Subtalar joint
Lower crossed syndrome neuromuscular dysfunctions
Altered hip extension
Decreased frontal plane stabilization
Increased lumbar extension
Muscle length assessment of tightness-prone muscles
Triceps surae Hip flexors Hip adductors Hamstrings Piriformis Pec major Upper trapezius Levator scapula
Triceps surae
Make hook with 5th MCP and hold calcaneus between hook and thenar eminence
Distract calcaneus distally until reach barrier to fix inserion of triceps surae
Apply pressure to sole of foot to passively dorsiflex ankle without inversion/eversion
Normal is 90 degrees dorsiflexion
Ankle dorsiflexion test - triceps surae differentiation
Flex pt knee while maintaining calcaneal distraction and dorsiflexion
Increase in dorsiflexion following kene flexion indicates tight gastrocnemius
No increase in dorsiflexion following knee flexion indicates tight soleus
Muscle length assessment of tightness-prone muscles: hip flexors and adductors
Pt contacts table with ischial tuberosities and pulls knee on non-tested side to chest, hold and rolls back to lie supine on table
Examiner stablizes the patinet non-tested leg and observe position of tested leg
Normal = thigh on tested side should lie horizontal with leg vertical
Pec major lower sternal
150
Pec major mid sternal/clavicular
90
Functional screening sequence
Assessment of quality of stereotypical movements
Obsrevation with light palpation
Look for alterations in muscle firing - selection, timing, intensity
Functional screening sequence muscles
Hip extension Hip abudction Trunk curl-up Cervical felxion Shoulder abduction Wall angel Apley’s Stright leg raise Deep squat SFMA
Hip extension screen indicators
Decreased gluteus maximus bulk
Increased hamstring bulk
Observation of spinal horizontal grooves or creases
Anterior pelvic tilt
Increased or asymmetrical paraspinal bulk
Decreased trailing limb posture at terminal stance during gait
Hip Abduction screen indicators
Lateral shift or rotation of pelvis
Asymmetrical height of iliac crest
Adducted hips or varus position
Positive result on single-leg stance test
Trendelenburg sign or increased lateral pelvic shift during loading response during gait
The SFMA top tier movements
Cervical movement patterns UE movement patterns Multi-segmental flexion Multi-segmental extension Multi-segmental rotation Single leg stance Squatting pattern
Cervical movement patterns
Flexion, extension - feet together teeth together
UE movment patterns
Apley’s
Inf shouldn’t get winging
Multi-segmental flexion
Patient should be able to touch her toes, should have uniform spinal curve and sacral base angle of 70 at least
Multi-segmental extension
Feet together, ASIS should clear the toes, spine of scapula should clear heels, uniform spinal curve, GH joint should maintain at least 70-90 of humeral flexion
Multi-segmental rotation
50 deg hips,
50 deg torso
Single leg stance
10 sec eyes open
10 sec eyes closed
Leg raised should be to 90 degrees and no loss in height when doing this
Top Tier movements are categorized by functional or dysfunctional and then non-painful or painful
FN, DN, FP, DP
Dysfunctional non-painful movments
Are further broken down
How do you break down a test
Fully loaded with full influence of gravity (dys due to mobility, stability, and/or motor control)
Partially loaded with partial influence of gravity (dys could be due to mobility, stability, and/or motor control)
Unloaded, PROM (dys most likely due to mobility)
Mechanics of breathign
Abdomen expands outward during inspiration and inward during expiration
Not anterior-posterior plane movement
Cylindrical like filling a balloon
Belly breathing often encourages movement in 1 plane
What constitutes good breathing
Nasal breathing pattern - rest tongue in roof of your mouth
Increase in intra-abdominal pressure especially on left side and without moving into spine extension
Should be authentic
Relaxed inhalation followed by LONG exhalation (2-4x as long as inhalation) with a pause between breaths
Try to keep xiphoid and pubic bone in approximation during exhale
Get out of your neck!!!!
Ability of body to control the whole range of motion of a joint so that there is no major deformity, neurological deficit or incapacitating pain
Spinal stability
Spinal stability
Neural control subsystem - neural
Passive subsystem - spinal column
Active subsystem - spinal muscles
Osteo-ligamentous cervical spine shown to buckle with
10.5N of applied axial compression
1/5 to 1/4 the weight of the average head
Osteo-ligamentous lumbar spine shown to buckle with
90N of applied axial compression
Normal loads in standing 2-3x body weight
Muscles provide
Support and stiffness necessary at intervertebral level to sustain forces commonly encountered in life
Requirement of spinal stability in neutral posture estimated to be 5-10% MVC co-contraction of
Abdominal and paraspinal
Endurance is more important than strength to maintain spinal stability
Strength reserve necessary for unpredictable activities
Segments damaged by ligamentous laxity or disc disease require greater muscle activation
Results in greater compressive force
Coordination of muscle activity to respond to both
Expected and unexpected forces
Must activate correct muscles in the right amount at the right time in order to
Protect spine from injury
Loss of both feedforward and feedback motor control seen in
Lumbar and cervical injury (pain) patients
Motor control shown to become dysfunctional post neck and low back injury
Changes also seen in muscle structure
Transverse abdominis
Multifidus
Longus capitis
Longus colli
Goal of assessing spinal stability is
To identify loss of stability, motor control and aberrent recruitment patterns
Results for assess spinal stability
Provide data for reeducation of faulty motor patterns
Creating dynamic stability in the presence of mechanical compromise
Spinal stabilization assessment
LPHC muscle imbalances Abdominal bracing Shear/prone instability Neuromuscular control (NMC) Endurance Force transfer from lower to upper extremities
Abdominal bracing
Contracting the muscles of the trunk in a hoop-like fashion without drawing the abdominal wall inward
The level of contraction should be low = 10% of maximum
Continue to breathe!
Lumbar shear stability positive
Pain with resting position that diminishes in active position
Sahrmann core stability test - level 1
Begin in supine, crook-lying position while abdominal bracing
Slowly raise 1 leg to 100degree of hip flexion with comfortable knee flexion
Opposite leg brought up to same position
Sahrmann level 2
From hip-felxed position, slowly lower 1 leg until heel contacts ground
Slide out leg to fully extend the knee
Return to starting flexed position
Sahrmann level 3
From hip-flexed position slowly lower 1 leg until heel is 12 cm above ground
Slide out leg to fully extend the knee
Return to starting flexed position
Sahrmann level 4
From hip-flexed position, slowly lower both legs until heel contacts ground
Slide out legs to fully extend the knees
Return to starting flexed position
Sahrmann core stability test level 5
From hip-flexed position, slowly lower both legs until heels 12 cm above ground
Slide out legs to fully extend the knees
Return to starting flexed position
In order to attain next level of stabilization must maintain pressure change +/-mm pressure
In order to attain next level of stabilization must maintain pressure change
+/- 10mm pressure
Sahrmann core stability test explanation
Pt braces, needle can move 10 mmHg either way but shouldn’t move at all. Pt is able to abdominal brace and not change pressure of biofeedback unit under lumbar spine. Then take pt through various positions, can pt hold their own legs without abherrent movement in the needle.
Pressure biofeedback placed under the spine with the subject in sidelyihgn position and inflated until the lumbar curve was straight to determine target pressure
Hip abduction test
Hip abduction test, pressure changes of 5 mmHg from the target pressure are allowed to accomodate
Changes induced by breathing
Hip abduction test explanation
Bladder between iliac crest and ribs in love handle region. This time bladder is pumped up so pt is now in spine neutral then ask patient to abduct the leg. Should not see any chnges in the needle moving.
Pressure biofeedback device folded in 3, fastened and placed behind the neck at the occiput.
Inflated until pressure is stabilized on the baseline of 20 mmHg
Pt attempts to nod the head to inc cushion pressure by 2mm and hold 6-10 sec
Progressive inc attempted up to 30mm
Craniocervical flexion test
Craniocervical flexion test positive
Inability to achieve deesired pressure change
Craniocervical flexion test indicates
Decreased activation of deep segmental cervical stabilizing musculature
Craniocervical flexion test corrective action
Reactivation of deep neck flexors via craniocervical flexion exercise training
Assessment for deep neck flexor endurance
Pt supine, tuck chin, lift head 2 cm and hold
Test terminated when chin tuck no longer maintained
Mean endurance capacity for deep neck flexors
Males = 18.2 sec Females = 14.5 sec
Modified biering sorenson test
Turnk extensor endurance time
Trunk flexor endurance time
Trunk lateral flexor endurance time
Normal modified biering-sorenson test
Trunk extensor endurance greater than flexor and/or lateral flexor endurance
Modified biering-sorenson Test extensor endurance time
Pt prone with lower body fixed to table at ankles, knees, and hips upper body on floor or stool
Exertion
Beginning of exertion, upper limbs held across chest with hands resting on the opposite shoulders
Upper body lifted off teh floor until upper torso horizontal
Pt instructed to maintain horizontal position as long as possible
Endurance time recorded in seconds from point at which pt assumes horizontal position until upper body comes in contact with support surface
Modified Biering-Sorenson Test Flexor Endurance Time
Pt sits on table with upper body against a support with an angle of 60degrees and knees and hips flexed to 90.
Pt arms folded across the chest with the hands placed on the opposite shoulder and teos were placed under toe straps.
Pt instucted to maintain the body posiiton while supporting wedge pulled back 10cm
Test terminated when the upper body fell below 60d angle
Modified Biering-Sorenson Test Lateral Flexor Endurance Time
Pt sidelying on a table with legs extended
Top foot placed in front of lower foot support
Pt instructed to lift hips off table to maintin a straight line over their full body length supported on one elbow and both feet.
Uninvolved arm held across the chest with hand placed on the opposite shoulder
Test ended when the hips returned to the table.
Modified Biering-Sorenson Test
Extensor
Norm time male = 146 sec Norm time female = 189 sec Norm ratio male = 1.0 sec Norm ratio female = 1.0 sec NWNL ratio = N/A
Modified Biering-Sorenson Test flexor
Norm time male = 144 sec Norm time female = 149 sec Norm ratio male = .99 sec Norm ratio female = .79 sec NWNL = >1.0
Modified Biering-Sorenson Test Side Bridge, Right
Norm time male = 94 sec Norm time female = 72 sec Norm ratio male = .64 sec Norm ratio female = .38 sec NWNL ratio = >0.75 or side-to-side difference >0.05
Modified Biering-Sorenson Test Side Bridge, Left
Norm time male = 97 sec Norm time female = 77 sec Norm ratio male = .66 sec Norm ratio female = .40 sec NWNL = >0.75 or side-to-side difference >0.05
Corrective action for NWNL ratio =
Spinal stabilization exercise training to improve balance in endurance times
Form closure
Cut out of white boxes can easily hold black on like a shelf
Force closure
Pick up niece or nephew by ears - hands cupping either side and lift them off the ground
We are a combination of form and force closure
SI joints cut at an angle and sacrum sits in that. Muscles force that together
Myofascial slings contributing to SI joint force closure: posterior oblique system
Glute with opposite latissimus
Myofascial slings contributing to sI joint force closure: anterior oblique system
Anterior oblique with piriformis
Supine active leg raise (ASLR)
Assesses force transfer from lower extremities to upper extremities through pelvic girdle
Pt supine, flex hip and elevate leg off table noting degree possible right versus left; ease of performance (subjective and objective); compensatory pelvic or trunk rotations
Corrective for ASLR form ligamentous
Greater trochanteric belt
Form closure augmentation in ASLR
Passive compression of SI joints with medially-directed force applied to lateral innominate as patient attempts ASLR
ASLR form vs force dysfunction improvement in any assessment criteria indicates
Positive test
Corrective action form vs force closure dysfunction in ASLR
Temporary applicaiton of pelvic (trochanteric) belt
Core stabilization training with emphasis on anterior oblique system
Force closure augmentation ASLR
Activation of anterior oblique sling with patient reaching UE toward opposite knee against tester resistance as patient attempt ASLR
Corrective action ASLR force closure
Core stabilization training with emphasis on anterior oblique system
Prone active straight leg raise (ASLR)
Assesses force transfer from lower extremities to upper extremities thorugh pelvic girdle
Prone active straight leg raise (aSLR)
Pt prone, extend hip and elevate leg off table noting
Degree possible right vs left
Ease of performance (subjective and objective)
Compensatory pelvic or trunk rotations
Form vs force closure: posterior sling
Raise leg as high as can while keeping stright, then other leg
Check form closure first, greater trochanters squeeze then have raise legs same as before
Improved height = less abherrant problems = form closure problem = greater trochanteric belt and corrective exercises - lats and glutes
Check force closure put one arm by side, extends and hold 45 away from body, push down on arm while she holds, raise leg if does better = force closure = lats and glutes exercises
Focusing on posterior oblique ssytem
Form vs force closure: anterior oblique sling
Pt lies supine - looking at ant oblique chain
Raise leg, then other one with foot flexed
Form = passive
Force = active
Check form - use your muscles to push SI together as hard as can have pt raise both legs - if SLR improves when pushing SI joint together = form closure problem = greater trochanteric belt
Check force - pt hand on opposite shoulder, 1/2 sit up, then raise leg - if improves = hyperactivating obliques = need to focus on corrective exercises specifically the obliques
Lumbar shear stability test
ASIS laid on table, hanging on to table, feet still on ground
Start at L1, pincer grip press in PA - any pain? Go down level by level asking if pain
If says yes - then have pt raise legs - press in again - if now says no = turns on extensors = positive test = corrective exercises for extensor group
Apley’s (FMS)
Looking for quality of movement
Measure hand from distal wrist crease to tip of chiro finger
1.5 hand length total = ok
Feet together, arms out, thumbs in palms, measure
Look to see if have scapular winging or loss of height from jutting head forward, no spinal deviation
Asymmetry from L to R is predictor of future injury - depending on what she has going on as a pt might tease that out - need abduction, external rotation and elbow flexion superior - GH extension, internal rotation, and elbow flexion for inferior
If pt does not have good thoracic extension, won’t be able to get into this apley’s position
To gain thoracic extension - chiro adjustment
Wall angel test
Feet 4-6 inches from the wall, spine leaning against the wall, get rid of lumbar space - shoulders should be able to be against wall without moving.
EOP should be against wall too.
Don’t let patient extend neck to get against wall - tight SCM, suboccipital in addition with problem with anterior head carriage
Pt stuck in ant flexion pulls head off the wall as well - they’re gonna tilt back again.
Pt abducts shoulders to 90 degrees - double check to make sure stays against wall - really tight = terrible thoracic extension
Ask pt to ext rotate both hands - if can’t get to full ext rotation = tightness in the subscap
Janda’s trunk flexion test
Not common test done often
Pt hands on thighs, does crunch, shoulder blades up off the table. Doc stands near feet with hands underneath heels
If heels comes off table that’s not good - should be able to move trunk without heels moving - positive test
Cervical flexion test
C0-C1 neck flexion - hold for 10 sec - watch to see if have any abherrant movment patterns
Let go slowly and have pt maintain that position, if they break position and starts to chin jut toward ceiling that’s tightness in suboccipital or SCM - pt shaking = fail.
Pt head shifts to one side or another or rotate = maybe levator scap issues
Should be able to hold for whole 10 seconds
Muscle length assessment upper trap and levator scap
Pt supine, bring her into FULL cervical flexion - we’re assessing the left upper trap, lateral flex away and rotate her toward the upper trap you’re assessing - hand goes on AC articulation and give some muscle play
For levator scap on left - bring pt to FULL cervical flexion, go lateral flex away from levator and cervical rotate away from levator checking - go to AC articulation and give SI pressure to see if have spring
If doesn’t have spring have tightness in levator scap and/or upper trap
Muscle length assessment hamstring: passive and active
Passive first - start with opposite knee flexed in hookline position - 45 hip flexion, 90 knee flexion - try to raise other leg should be 70-90 degrees passive hip flexion
Ask pt feet together, toes to nose, raise leg as high as can go, now bend other knee which will put that iliopsoas in slack and have them actively raise again. If now can do it - need to maybe look at putting some length on the opposite iliopsoas
Pt bend elbows to 90 degrees and drive them into the table, feet together toes to nose, raise leg
If get length gain = hyperactive core
Muscle length assessment piriformis
Pt supine bring them into little knee flexion and int rotation and look for a little springy feel
Alternative way - prone - bring legs into 90 degrees and let legs fall outward - feel tighter than the other one?
Should be able to see which is not rotating as well - this means you’re able to see active ROM easier
Muscle length assessment pec major: clavicular vs sternal division
Elbo flexed at 90, abduct GH to 90 and ext rotate - your hand tractioning sternum pointing toward shoulder - should drop below or be parallel to the floor - clavicular division
Sternal = abduct to 150 deg - should drop below table again with humerus or parallel to floor
Pec major is like a chinese fan - fanning out - by doing this both clavicular and sternal you’re getting all the fibers
Muscle length assessment adductors: 1 vs 2 joint
Doc in between pt’s legs
Should be able to abduct leg into 45 deg
If get stuck before that, differentiate between 1 or 2 joint adductors
Now bend knee and abduct more - problem tightness is in 2 joint adductor
If meet resistance and then bend knee but no more abduciton = 1 joint adductors are tight
Modified thomas: iliotibial band and adductors
Ischial tube is barely on edge of table, bring one knee to chest then lay back - brace foot of bent knee on oblique of you, if thigh is already in abduction = IT band might already be tight. Try to pull into adduciton, if not good springiness = tightness in IT band/TFL
Adductors - push into abduction - if already in adduction could already have adductors tight. If don’t have length won’t move nicely in abduction.
Modified thomas: iliopsoas and rectus femoris
Ischial tubes barely on table - one knee to chest then lie straight back, brace as in above
Looking for thigh to be parallel or closer to floor - if high then tight iliopsoas
If doesn’t have springiness = tight iliopsoas
Rectus femoris - tibia should be 90 deg relative to femur - if doesn’t meet that then come in and see
If have springiness = tight rectus femoris (attaches AIIS to tibial tuberosity)
Half kneeling ankle dorsiflexion
Proposal position - looking for knee to come over toe by 4 inches or 10 cm - normally shoes off - keep heel on ground
Janda’s hip abduction
Side lying - straighten them out, bend bottom knee so they’re more stable, bottom arm cups head for stability - raise top leg towards ceiling - looking for at least 45 deg of hip abduction - if when raising leg she hip hikes first it’s dominance of quad lumborum. If as raises leg abducts and sneaks into hip flexion that’s tight TFL. If raises up and starts to ext rotate = tight piriformis. Looking for firing pattern of glutes, quad lumborum, TFL, pure hip motion into abduction
Janda’s hip extention
Pt prone
Keep one leg stright and raise to ceiling while doc has one hadn on glutes and one on mid lumbar region - looking for glutes or hamstrings to go first and erectors to go 3rd or 4th - if not then that’s a problem
If we get knee flexion - adding in hamstring - don’t want that
Goes into lumbar lordosis before raising that’s a problem
Progressive model for rehabilitation of physically active individuals
Physical exam
Control swelling, control pain, restore integrity of injured tissue
Restore ROM, restore control of volitional contractions
Restore strength and endurance, restore reflex reactions
Restore control of complex functional movements
Return to functional activities
4 principles of functional rehabilitation
Discovery of type of injury present
Determination of method of presentation of injury
Complete and accurate diagnosis of injury
Plan of treatment of injury: short term goals, long term goals, progression and return-to-play criteria
Framework for funcitonal rehabilitation
Type of injury
Method of presentation
How to rehabilitate
Knowledge of injury type and presentation method determine what needs to be rehabilitated
Macrotrauma
Due to spcific event
Time, place mechanism of injury (MOI) usually clear
Single event resulting in previously normal anatomical structures becoming suddenly and distinctly abnormal after injury
Microtrauma
Chronic, repetitive injuries
Usually a process resulting from failure of homeostasis of cellular mechanisms and tissue constituents to maintain integrity of structures subjected to demand of physical activity over time
Fairly long process
Clinically evident adaptive changes in flexibility, balance, strength, biomechanics, performance occur with continued sports participation
Acute
Injury episode easily recalled
Activity halted or curtailed
Chronic
Usually microtrauma with gradual symptom onset
Pain may be widespread
Activity still ongoing although at reduced performance level
Acute exacerbation of chronic injury
Previous injury apparently successfully treated; symptom resolution does not equal normal function
Acute exacerbation occurs with return to acitivity
History of previous injury and rehab plan give clues to remaining underlying deficits: inflexibiilities, strength deficits/imbalances, biomechanical faults
Subclinical adaptations to athletic activity
Maladaptations to training
Asymptomatic strength, flexibility, biomechanical changes that predispose to future injury
Need to screen for kinetic chain dysfucntion prior to implementing strength and conditioning program
Clinical alteration
Clinical symptom complex
Anatomic alteration
Tissue injury complex
Tissue overload complex
Physiologica na dmechanicl alteration
Functional biomechanical deficit complex
Subclinical adaptation complex
Framework for functional rehab clnical alteraltion
Frequently occurs in presence of subclinical alterations
May be present with acute injury or may be produced as a result of acute injury
Clinical symptom complex
Clinical symptom complex
Pain, swelling, decreased ROM
Tissue injury complex
Actual tissue that has been damaged
Tissue overload complex
Tissues that have been stress/overloaded
Contribute to or exacerbate injury
Functional biomechanical deficit complex
Alterations in activity performance mechanics: caused by abnormalities in strength, strength/muscle balance, flexibility
Subclinical maladaptation complex
Substitute motions
Altered recruitment patterns
Synergistic dominance
Dec pain and restor normal joint motion
Restore balance in muscle system - length, strength, endurance
Improve proprioceptive input - local facilitation, peripheral stimulation
Re-educate movement patterns and posture on an automatic basis
Good quality good control of motion and posture
Philosophy of exercise design
Training for health versus performance
Integration of prevention and rehabilitation strategies
Continuous improvement in function/pain reduction
ADL journal
Ensuring the progressive positive slope
Patient lifestyle changes
Training for health vs performance
Emphasizes muscle endurance, motor control perfection, maintenance of spine stability during ADLs
Integration of prevention and rehabilitation strategies
Must reduce source that exacerbates tissue overload
Exercise enhances prevention and rehabilitation outcomes
Continuous improvement in function/pain reduction
Return of function and reduction of pain can be slow process
Patients have good and bad days during reconditioning process
ADL journal
Documenting back pain/stiffness essential in identifying link with mechanical stresses
Ensuring the progressive positive slope
Initiate reconditioning process with limited number of exercise
Add new exercises one at a time after positive slope established
Add/remove exercises based on positive slope changes
Patient lifestyle changes
Must change patterns that result in tissue loading in excess of threshold
Guidelines for core stabilization training
Develop sound basis for exercise prescription
Basic issues core stabiliztion training
Flexibility
Strength
Endurance
Flexibility
Generally spine flexibility should not be emphasized until spine has stabilized and undergone endurance and strength conditioning
Lumbar problem = hypermobile lumbar.
Hypomobile thoracics or hips
Strength
Appears to have little relationship with spine health
Perturbed ration of flexor-to-extensor strength ration may have effect on low back health
Endurance
Diminished trunk extensor endurance linked to low back injury
Aerobic exercise
Appears to enhance effects of spine-specific exercise
Order of exercises within a session
Prior activity can modulate biomechnicas of spine in subsequent activity
Motion exercises performed first to reduce spinal tissue viscosity
Breathing
Must learn to maintain spinal muscle stiffness during torque demands adn breathing patterns
Time of day for exercise
No forward bending exercise in first 1-2 hours after rising with low back pain
Our discs rehydrate
Overnight
Stage 1 of patient progression
Awareness of psine position and muscle contraction
Awareness of spine position and muscle contraction
Distinguishing hip flexion from lumbar flexion
Maintaining mild abdominal contraction
Learning abdominal bracing
Stage 2 patient progression
Stabilization exercises to groove stabilizing motor patterns and build endurance
Stabilization exercises to groove stabilizing motor patterns and build endurance
Key is to determine optimum starting level
For chronic patients may want to undershoot
Once positive improvement slope estabilished can increase rehab challenge
Stage 3 of patient progression
Ensuring stabilizing motion patterns and muscle activation during ADLs
Ensuring stabilizng motion patterns and muscle activation during ADLs
Clinician must identify range of ADLs for which patient must prepare
Rehearse spine-sparing strategies and appropriate motor patterns related to ADLs
Methodology of sensorimotor training
Establish key postural stability points
Key postural stability points
Foot
SI joint
Cervical spine
Stages of progression
Static
Dynamic
Functional
Static phase senosrimotor training
Emphasis on stable core
Maintenance of postural stability on progressively unstable surfaces
Progression methods - weight shift, eyes closed, adding head moevment
Dynamic phase sensorimotor training
Addition of arm and leg movements
Use of progressively unstable surfaces
External resistance applications - manual, elastic, isotonic
Functional phase sensorimotor training
Performance of functional movements - squats, lunges
Integrate use of unstable surfaces and external resistance - resisted lunges on labile surfaces
Active self-care and functional reactivation
Spine-sparing strategies: Hip hinge Safe squatting ADL modification Slump posture self-care Micro-breaks
Active self care hip hinge
Pole/broomstick behind back, hold above head and behind near butt and hip hinge with back stragith against pole
Sit to stand using hpi hinge
Practice from chair
Wall squat
Hands against wall above head, squat while keeping hands on wall
Ball squat
Ball behind back, sit down like in wall sit
ADL modification brushing teeth
Use stool and put one foot up
Slump posture self-care
Bruegger relief position - sit on very edge, hands against chair
Wall lean - sit on very edge of setat arms against wall
Wall slides - stands against wall feet about 6 inches forward hands in ext rotation 90 degrees, slide down wall
Postures of development
Supine Prone Quadraped Sitting Kneeling Vertical stance
4-6 months old before can
Sit and diaphragm starts to act as spinal stabilizer
Super important how we originally develop some of our stability and moviblity movements from
When we were a child
We crawl, then push up, then pull up
Patterns of developemnt
First thing when baby is born = takes a breath Breathign and gripping is our first pattern of development Reaching Head movement Rolling and crawling Hinging and rocking Squatting Pulling up/pushing down Gait
Flexibility
Ability of soft tissue structures to elongate through available joint ROM
Often single structure is cause of movement restriction
Not uncommon to have concurrent limitations from more than 1 structure
Flexibility
Limitation from structural involvement can be caused by trauma, surgery or lack of stretching or lack of general appreciation of what we’re supposed to be able to do
Flexibility
Pain associated with disruption to tissue or joint swelling may inhibit ability to
Actively and passively generate joint movement
types of muscle hypertonicity**
Limbic system dysfunction Interneuron dysfunction MTrPs Reflex spasm Muscle tightness
Limbic system dysfunction
Caused by psychological stress
Inc muscle tone in cervico-thoracic-shoulder complex, low back, pelvic floor muscles
Headache, LBP, dysmenorrhea, dyspaneuria, urinary frequency
Caused by aberrant afferent info sent by spinal or peripheral joint dysfunction (subluxation) - like when you get adjusted, walk in tight and then feel less tight
Interneuron dysfunction
Hypertonicity in segmentally-related muscles that can spread beyond involved segments
Interneuron dysfunction
Interneuron dysfunction prone to
Form MTrPs
Muscle imbalance including reciprocal inhibition, synergistic dominance
Faulty movement patterns established and perpetuated
MTrPs
Myofascial trigger points
Hyperirritable spot usually within taut band of skeletal muscle or in the muscle’s fascia, that is painful upon compression and can give rise to characteristic referred pain, tenderness and autonomic phenomena
Myofascial trigger points
MTrPs formed as a result of dysfunction
Sustained shortened position Sustained lengthened position Acute overload (muscle strain)
Zone of intense pain in a hardened muscle band that refers (triggers) pain distantly when stimulated
Myofascial trigger points
Central TrPs
Develop in muscle belly at endplate zone (motor point)
Primary
Attachment TrPs
Enthesopathy that develops at each end of involved fibers
Secondary due to sustained tension
Active TrPs
Causes clinical pain complaint
Always tender
Latent TrPs
More common than active TrPs
Pain free unless palpated
Alter muscle activation patterns
Sensory abnormality characterized by primarily by pain
Can be local to site of taut band and distant (referred) to another part of body
Autonomic dysfucntions - abnormal sweating, lacrimation, salivation, pilomotor activity
Clinical attributes of TrPs
Clinical attributes of TrPs
Proprioceptive dysfunctions
Imbalance, dizziness, baragnosis
Motor dysfunction characterized by constant, discrete hardness within muscle
Motor dysfunction characterized by constant, discrete hardness within muscel
Taut band or nodule within belly of muscle
Constant feature of active TrP
Can be present in absence of pain
Primary abnormality that develops in response to stressors that activate TrP
Development of TrPs
Acute overload
Unaccustomed eccentric exercise or eccentric overload (muscle strain)
Eccentric exercise in unconditioned muscle
Maximal or submaximal concentric exercise leading to muscle fiber damage adn hypercontraction within muscle fiber
Like going to the gym at the start of january
Chronic overload devleopment of TrPs
Sustained or repetitive postures and/or movements - us sitting all day long or doing the same movment all day long like a hairstylist
We should not stretch myofascial trigger points,
It won’t fix them, might just make them
Scalene MTrPs
Medial border of scapula over shoulder lateral arm doewn lateral forearm into first and second digit on dorsum of hand, 2 points above nipple on same side
Trapezius MTrPs
TrP1 = behind ear down neck, angle of mandible, behind eye
TrP2/3 = top of shoulder, back of occiput on either side of time
TrP 4/5/6 = top of GH joint, medial border of scapula, T3-6 on side of spine
This patient with sinus infections with ear pain
SCM or suboccipital MTrPs
SCM trigger points
Behind ear, top of head, in EAM, path from in front of EAM up over eyebrow, below end of SCM, forehead above eye from one side to teh other
Suboccipital MTrPs
Behind ear up to behind eye
Quadratus Lumborum MTrPs
Top of iliac crest and near greater trochanter, sacrum and ischial tube, front lower ab next to iliac crest
Iliopsoas MTrPs
Next to lumbar spine, anterior thigh
Gluteus minimus MTrPs
Anterior portion: butt lateral side of thigh through pes anserine through to back of calf
Posterior portion: butt into iliac crest, back of thigh, popliteal fossa, back of calf
Reflex spasm
Muscle spasm in response to nociception
Reflex spasm frequently acts as
Splinting mechanism
Once underlying pain process resolves
Hypertonicity often remains
If left uncorrected reflex spasm leads to
MTrP formation and faulty movement patterns
Myopathological and neuropathological state where muscle becomes hyperactive and shortened
Muscle tightness
Most commonly from overuse esepcially in postural function
Results in reciprocal inhibition, synergistic dominance
Muscle tightness
Over time muscle tightness leads to formation of
Joint dysfunction (Subluxation), MTrP formation, aberrant movement pattern
Techniques to restore flexibility
Ballistic (dynamic) stretching Static stretching Proprioceptive neuromuscular facilitation (PNF) Self-myofascial release (SMFR) Neurodynamic stretching
Ballistic (dynamic) stretching
Bouncing movement in which repetitive contractions of agonist work to stretch antagonist muscle
Static stretching
Stretch to point of discomfort and hold at that point for period of time
Proprioceptive neuromuscular facilitation (PNF)
Involves alternating contractions and stretches
Self-myofascial release (SMFR)
Gentle force application to adhesion or knot within the fascial ssytem in the body
Neurodynamic stretching
Gentle technique to release adhesions within nervous system fascia
Muscle relaxation techniques (MRT) basis in
Proprioceptive neuromuscular facilitation (PNF)
Used to relax overactive muscles and associated fascia
Involve manual resistance of patient’s isometric or isotonic muscular effort
Muscle relaxation techniques
Utilize post-contraction inhibition and reciprocal inhibition (RI)
Sometimes referred to as postisometric relaxation (PIR) and neuromuscular stretching
Muscle relaxation techniques
Neurophysiology of MRT
2 aspects to MRT
Ability to relax overactive muscle
Ability to inc extensibility of shortened muscle or fascia when connective tissue changes are present
Ability to relax overactive muscle
Increased neuromuscular tension
Spasm
Myofascial trigger points
Post contraction inhibition
After a muscle contracts it is a brief latent/inhibitory states - 25-30 seconds with agonist or antagonist contraction vs 10 seconds with static stretching
Reciprocal inhibition
Sherington’s law of reciprocal inhibition
When a muscle contracts its antagonist is automatically relaxed
Essential to relax neuromuscular component of a muscle prior to attempting forceful stretching
Inhibits stretch reflex
Prevents sarcomere damage adn reduces patient pain in the presence of MTrPs
Muscle length changes can be caused by
Neuromuscular factors
Connective tissue factors
Both
If a muscle lengthens spontaneously after application of MRT then probably a
Primary neuromuscular cause
If not porobably primary connective tissue
Clinical application of PIR
Bridge between passive adn active care
Complementatry to chiro adjustment
Main application is in directly treating muscular component to enhance efficacy of adjustment
May be used to relax tension in muscles before adjustment
May be used to stretch chronically shortened muscle or fascia after adjustment
require patient participation and are less likely to result in dependency
can be used in place of deep massage in areas with hypersensitivity to pressure
Easily tolerated in all phases of healing
MRT
Engaging the barrier
Muscle elongated to extent that full resting length attained
Wind-up muscle taking out slack in all planes
Barrier is point at which further lengthening would cause initiation of stretch reflex
Must engage barrier but not go past
Use of isometric contraction
Least amount of force necessary is used
Gentler contraction tried first in order to isolate TrP
Duration usually 4-10 seconds, can be as long as 30-60 seconds
Use of breathing and eye movements
Most muscles facilitated with inhalation and inhibited with exhalation
Some muscle facilitated with eye movement in certain direction and inhibited with opposite eye movment
Feeling the release
After isometric contraction released wait for tension to release
Not a stretch
Guide muscle until new barrier is reached and repeat process
Hamstring PIR
Pt supine, straight leg raise up
Push above knee toward feet and at ankle toward head
Iliopsoas PIR
Pt on edge of table, knee up to chest, lean back push knee down into chest and down into floor
OR
Side lying - one knee bent, other pulled back
Quadratus lumborum PIR
Pt side lying, have them hip hike, then relax you lean on above iliac crest
Erector spinae PIR
Pt side/back lying, top leg off table behind them, bottom leg bent, pull shoulder forward and push iliac crest back
Upper trapezius PIR
Pt supine, lat flex head to one side, push shoulder toward feet on other side
Levator scapula PIR
Head lat flex push it forward while pushing shoulder down
Scalene PIR
Anterior scalene middle scalene: head off table, laterally flex over
Pec Minor PIR
Arm off table push down on GH joint
Self-myofascial release (SMFR) focuses on
The fascial system in the body
Gentle force application to the adhesion or knot
Elastic collagenous fibers are manipulated from a bundled position (that causes the adhesion) into an alignment that is straighter with the direction of the muscle and/or fascia
SMFR
SMFR
Self-myofascial release
Also assist in releasing the knot by stimulating the golgi tnedon organ and thus create autogenic inhibition
SMFR
Find the tender spot (this indicates an adhestion) and sustain pressure on that spot for a minimum of 20-30 seconds to activate the autogenic response
SMFR
Possibly stimulates fascial Ruffini end-organs creating gel-to-sol effect
SMFR
Helps restore the body back to an optimal level of function and performance by resetting teh soft tissue proprioceptive mechanisms
SMFR
Use prior to static stretchign for postural distortion patterns and/or activity as well as a useful cool-down
SMFR
Mechanism of myofascial release
Practitioner’s manipulation stimulates intrafascial mechanoreceptors
CNS repsonse includes change in tonus of related striated muscle fibers and autonomic nervous system effects: altered global muscle tonus, change in local vasodilation and tissue viscosity, lowered tonus of intrafascial smooth muscle cells
Resotring myofascial balance
Foam roller self-myofascial release
PIR
25% effort
4-10 seconds
Adductor PIR
Looking for inferior ilium or IT band - inc bulk at upper 1/3 of medial thigh, genu valgus stress in midstance, femoral acetabular discomfort - lower crossed syndrome,
High ilium side is
Tight quadratus lumborum
High ilium
Diffuse pain
Janda’s abduction test will hip hike then abduct
Treatment is PIR quad lumborum
Quad lumborum
Femoral acetabular joint falls anterior to malleoli, butt is flat
Hamstrings PIR option
Pt gets headache crawling up the side of the neck
Upper trapezius PIR
Do some of this before cervical adjustment, could make adjustment go easier
Levator scapula PIR
Posterior scalene
Lateral flexion and rotation away
Anterior scalene
Lat flex away, rotation towards. Shoulder elevate and reflex
Middle scalene
Hook left occiput area, shoulder shrug
Suboccipital PIR
Take head and make occiput go away from atlas like on a stick when cooking a pig. He looks backwards with his head and eyeballs. Pt has sensation of a double chin
Thoracic clean-up move. Person in VP area has bump
Cross their hands, put them on EOP, bring elbows together. Inferior hand goes on elbow, superior hand on his crossed fingers. Pt looks backwards with ehad and eyes
Pec Minor PIR
Shoulder protraction. Grab shoulder joint and move it like on an axel. If coracoid process is coming closer to the ribs, want to take shoulder like roll it back. Grab inferior angle of scapula, other hand is on GH area. Pt will rotate into your top hand, then when he relaxes you’ll push back up and around.
Self-myofascial release (SMFR) focuses on
The fascial system in the body
Gentle force application to the adhesion or knot
Elastic collagenous fibers are manipulated from a bundled position (that causes adhesion) into alignment that is straighter with the direction of the muscle and/or fascia
SMFR - self-myofascial release
Assist in releasing the knot by stimulating the golgi tendon organ and thus create autogenic inhibition
Possibly stimulates fascial ruffini end-organs creating gel-to-sol effect
SMFR
SMFR how to
Find tender spot (indicates adhesion) and sustain pressure on that spot for a minimum of 20-30 seconds to activate the autogenic response
Helps restore the body back to an optimal level of function and performance by resetting the soft tissue proprioceptive mechanisms
SMFR
Use prior to static stretchign for postural distortion patterns and/or activity as well as a useful cool-down
SMFR
Practitioner’s manipulation stimulates intrafascial mechanoreceptors
Mechanism of myofascial release
CNS response includes change in striated muscle fibers and autonomic nervous system effects - mechanism of myofascial release
Altered global muscle tonus
Change in local vasodilation and tissue viscosity
Lowered tonus of intrafascial smooth muscle cells
Functional anatomy of core musculature
Lumbar spine muscles
Abdominals
Hip muscles
Cervical spine muscles
Transversospinalis group parts
Rotatores Interspinales Semispinalis Intertransversarii Multifidus
Poor mechanical advantage relative to movement production
Primarily type 1 muscle fibers with high degree of muscle spindles (2-6x normal)
Designed for stabilization and proprioception
Multifidus
Primarily responsible for providing proprioceptive information to CNS
Inter/intra-segmental stabilization
Transversospinalis group
Segmental deceleration of flexion and rotation of spine during functional movements
Must be trained to allow dynamic stabilization
Transversospinalis group
___ may be most important part of transversospinalis group
Provides intersegmental stabilization in all positions
Multifidus
Erector spinae
Thoracic longissimus and iliocostalis
Long extension moment arm with minimal compression
Most efficient lumbar extensors
Erector spinae
Lumbar longissimus and iliocostalis
Create posterior shear with lumbar flexion
Quadratus lumborum
Stabilizer in wide variety of tasks involving flexion, extension and lateral bending
Latissimus Dorsi
Largest moment arm of all back muscles therefore great effect on LPHC
Any UE rehab has to pay attention to it and its impact on LPHC
Bridge between upper and lower extremities
Latissimus dorsi
Operate as a functional unit to help maintain optimal spinal kinematics
Abdominal musculature
Provide sagittal, frontal and transverse plane stabilization by controlling forces reaching LPHC
Abdominal musculature
Abdominal musculature
Rectus abdominis
External oblique
Internal oblique
Attaches to posterior layer of thoracolumbar fascia
Internal oblique
Contraction of TrA and internal oblique create traction and tension forces on
TL fascia
Enhances regional inter-segmental stability in LPHC
Abdominal musculature
Provide dynamic stabilization against rotational and translational stress
Provide optimal neuromuscular control to entire LPHC
Transverse abdominis (TrA)
Contraction precedes activation of other abdominal muscles regardless of direction of reactive foreces
Transverse abdominis
Important for dynamic stabilization during all trunk movements
Transverse abdominis
Active during all trunk movements
Transverse abdominis and multifidus
Contributes to stability of lumbar spine during inspiration and expiration
Involved in the control of postural stability during sudden voluntray movement of the limbs
Diaphragm
Normally in horizontal position in adults
Cephalad posiition is inhibitory of normal function
Diaphragm
Posterior intersegmental cervical spine muscles
Multifidi and suboccipitalis
Deep cervical flexors
Longus capitis and colli
Primary segmental stabilizer
Feedforward contraction with arm movment
Lower cervical/upper thoracic extensors
Semispinalis cervicis and longissimus cervicis
Scapular mobilizers and stabilizers
Upper, middle, lower trapezius
Levator scapula
Pectoralis minor
Serratus anterior
Injury mechanics in the lumbar spine
Too many repetitions of force and motion and/or prolonged postures/loads
Cumulative loading
Compression, shear, or extensor moment
Injury mechanics in the lumbar spine
Axial torque with flexion or extension loading
Cumulative exposure to unchanging work
Injury mechanics in the lumbar spine
Any abnormal loading conditions (including overload and immobilization) can produce
Tissue trauma and/or adaptive changes that may result in disc degeneration
Adverse mechanical conditions can be due to
External forces, or may result from impaired neuromuscular control of the paraspinal and abdominal muscles
Most important modifiable mediating factor for primary OA
Muscle dysfunction
Gute med exercise
Clam shells
Side plank from knees - downside is getting glute med, you’re getting closed kinetic chain closed shoulder, neurodevelopmental
Reducing tissue damage
Reduce peak and cumulative spinal compressive loads
Reduce repeated spine motion to full flexion
Reduce repeated full-range flexion to full-range extension
Reduce peak and cumulative shear forces
Reduce slips and falls
Reduce length of time in prolonged sitting especially exposure to seated vibration
Name one way to teduce repeated spine full motion to flexion
Hip hinge
Abdominal bracing
Tightening in a hoop like fashion - uses multiple muscles and we want that!
Ab hollowing is using one muscle
Transverse abdominus - suck belly button into spine as much as you can
Stiffening or tightening muscles of the midsection as if someone was about to strike you in the trunk
Abdominal bracing
Abdominal bracing
The level of contraction should be low about 10% maximum
Train core stabilizaing musculature without focus on any 1 muscle
Minimize shear and compression
McGills Big 3
Shown to train core stabilizing musculature with relatively low compressive loads
McGill’s big 3
Curl-up
Side bridge
Birddog
High level of rectus abdominis activation with posterior pelvic tilt
High level of compression
Hanging knee-up
High compressive load (6000N)
Extension load of posterior elements
Potential damage to interspinous ligaments
Superman
High compressive load (4000N)
Extension load of posterior elements
Lumbar extensors not designed for powerful extenstion movements
Roman Chair Back Extension
Phases
Corrective
Functional
Performance
Corrective phases
Stability training
Functional phases
Functionally integrated training
Performance phases
Strength and power training
Corrective exercise training goals focus on
Postural control, muscle balance, pain reduction/centralization
Train coordination and endurance with
Safe, low-load exercises
Progress to complex activites and functional exercises once patient learns to
Move and position spine in fundamental ways
Program corrective design
At least 1 session a day!!
Longer than 8 seconds could cause muscle trigger points in muscles
Cat camel
Warmup
Leg loading with
Biofeedback device
Dead bug progression
Back, knees at 30d
One leg lifted
Both legs lifted
Both lifted, one at 90, one straight, one arm above head, one toward ceiling
Quadraped birddog
All fours
One hand out
One leg out
One hand and opposite leg out
Sidelyign bridge beginner
Knees down, one or two hands
Sidelying bridge advanced
On feet only…then one leg lifted
Rotational bridge
Side plank, plank, other side plank, plank…etc
Abdominal curl up
One knee up, hands behind back
Lift head and shoulders
Supine bridge progression
Supine bridge
Then one leg in air, one on mat
Clamshell
On side, top knee up and down
Cranio-cervical flexion
Feet on table, kenes up, flex head
Stability ball hamstring training hip extension
Feet on exercise ball, lying on back, do supine glute bridge
Stability ball double leg curl
Feet on exercise ball, spine bridge, bring knees in while rolling ball
Stability ball hamstring training single leg curl
One leg on ball, supine bridge, one knee in air, bring other knee in
Stability ball bridge ball braidge
Supine bridge with feet on ball
Stability ball abdominal curl up
Back over ball, crunch
Core stability trained in exercises mimicking patients
ADLs
SRAs
DE
Training with movements that are within patients fucntional range while being as functional as possible.
Progression continue until
Pt’s functional range includes ADLs, SRAs and DEs expected to be encountered
Functional exercise training program design
Acute variables
2-3 exercises
2-3 sets x 10-12 reps
Rest period approx 45 sec
2-4 sessions/week
Performance exercise training goals
High-level activites with narrow safety/stability margin
Atheletic activity performance enhancement and innjury prevention
Built on a foundation of conscious-kinesthetic awareness of appropriate motor control
Performace exercise training goals
Sites of injury**
Soft tissue, osseous, fibro-osseous tunnels
Sites of nervous system branching
Sites of relative fixation to interface
Areas with high possibility of friction forces from unyielding interface structures
Tension points
Neurodynamic tensioners
Neurodynamic test that increases tension in neural structures
Relies on natural viscoelasticity of nervous system and does not exceed elastic limit
Does not produce plastic deformation or damage
Neurodynamic tensioners
Median nerve tensioner
Arm out to side palm up, extend wrist as far as possible, laterally flex head away
Ulnar nerve tensioner
Like going to hit yourself in side of head with wrist extended and head laterally flexed away
Radial nerve tensioner
Arm out, palm towards back fully flexed, laterally flex head away
Neurodynamic sliders/flosser
Neurodynamic maneuver whose purpose is to produce a sliding movement of neural structures relative to their adjacent tissues
Sliders can be thought of as
Tensioners with one end put on slack
Nerve flossing
Neurodynamic sliders
Lower extremity neurodynamic tensioners
Hands behind back, leg out front, flex head in
Sequence of subject postures in slump test
Pt sits erect
Pt slumps lumbar and thoracic spine while ex holds head in neutral
Pt flexes head and neck
Ex carefully applies overpressure to cervical spine as pt extends knee
Pt dorsiflexes foot
Pt extends head and neck
If symptoms are reproduced at any stage, further sequential movements are not attempted
Femoral nerve neurodynamic test
Prone knee bend
Slump knee bend
Obturator nerve neurodynamic test
Slump SLY/KF/HE HAb obturator test
Peroneal nerve neurodynamic test
PR/IN/SLR
PF/IN/SLR via shoulder
Tibial nerve neurodynamic test
DF/EV/SLR and reversal
Sural nerve neurodynamic test
DF/IN/SLR
Balance is an essential function of
Locomotion
Freeman first to suggest training for peripheral sensory deficit following
Ankle sprains
Freeman about ankle sprains established importance of addressing
Proprioceptive deficit throughout locomotor system
Janda’s contributions to sensorimotor training
Believed that msucle imbalances led to movement impairments and altered motor programming
Treatment approach janda
Normalize peripheral proprioceptive structures
Correct postural/muscle imbalance
Faciliatate correct motor program
Stages of motor learning according to janda
Voluntary control of movement
Automatic control of movement
Voluntary control of movement requires
Cortical integration and patient concentration
Constant feedback from positive and negative experiences
Voluntary control of movement
Feedback motor control
Inefficient for creating motor programs
Automatic control of movement
Coordinated movement pattern programmed in subcortical region
Requires less conscious processing, therefore quicker
Feedforward motor control
Essential to protect joints for dynamic functional stability
Automatic control of movement
Indications for sensorimotor training**
Post-traumatic, postoperative Chronic neck, back pain Faulty posture especially with respiratory dysfunction General hypermobility and/or instability Muscle imbalance Prevention of falls in senirs Maintenance of general fitness
Key postural areas according to janda
Foot
Pelvis espeically SI joint
Cervical spine
Foot
Cutaneous and intrinsic muscle proprioceptive input
Small (short) foot
Pelvis esp SI joint
Proprioceptive input
Neutral lumbopelvic position
Cervical spine
Proprioceptive input
The small (short) foot
Attempt by patient to draw metatarsal heads toward calcaneus thus raising medial longitudinal arch and shortening foot wihout flexing toes
Progression small short foot
Tactile stimulation
Passive remodeling NWB
Active-assisted remodeling NWB
Active remodeling NWB - partial WB - WB
Level 1 sensorimotor training - static phase
Maintain postural stability on progressively unstable surfaces
Exercises level 1 sensorimotor training staitc phase
Single leg balance eyes open
Single leg balance eyes closed
Single leg balance EO/EC on labile surfaces like balance board, wobble board, airex cushion, dynadisc, foam roller
Static phase level 1 program design
1-2 exercises
1-3 sets x 10-30 seconds or 10-20 repetitions
Rest period 30 sec
3-5 sessions/week
Level 2 sensorimotor training dynamic phase
Add arm and leg movements while maintaining postural stability on progressively unstable surfaces
Level 2 exercises
Reaches on stable surface
Reaches on unstable surfaces
Level 2 sensorimotor program design
1-2 exercises
2-3 sets x 10-12 repetitions
Rest period 30 sec
3-5 sessions/week
Level 3 sensorimotor training - fucntional phase
Perform functional movements on progressively unstable surfaces
Level 3 sensorimotor exercises
Single leg squat
Single leg deadlift
Single leg resisted movements
Balance sandal training
Level 3 sensorimotor program design
1-2 exercises
2-3 sets x 10-12 repetitions
Rest period 30 sec
3-5 sessions/week
Janda’s balance sandals
Sandals with balls on the bottom
Clinical application of balance sandals
Significant increases in gluteal activation and decreases in time to 75% MVC in 7 days
Increased leg EMG activity particularly ankel evertors and invertors in 11.6 + or - 14.9 weeks
Improved medial-lateral postural stability in stable and unstable ankles after 8 weeks of functional balance training
Janda balance sandal protocl
Initial stage
Second stage
Third stage
Jandas balance sandal initial stage
Stance training with support
Sandals in horizontal position
Second stage jandas balance sandals
Walking with support
Start with walking in place then progress to shoulder support only
Third stage jandas balance sandal
Short steps, a few meters forward and backward walking, sidestepping
1-2 minutes several times per day up to 15 minutes total
Patients in pain often worry that will cause more harm than good if
Active
Advice to let pain be your guide reinforces
Attitudes and beliefs that support pain-avoidance behavior
Clinicians goal in active care is to modify
Patient helath behavior in direction fo reactivation
Back pain traditionally viewed as
Acute, self-limiting condiiton
Now recognized as involving frequent reoccurrences and/or chronic course
Back pain
Many approaches for spine injury concerned only with
Diagnostic triage and pain managment
Pain-relief modalitis will always be accepted treatment
Patient education about self-care through gradual reactivation rapidly gaining scientific traction
Becoming
Standard of care for prevention of diability associated with spinal disorders
Keys to active self-care
Reassurance and advice
Cognitive behavioral approach
Multidisciplinary biopsychosocial approach
Reassurance and advice
Identify pt concerns and goals
Reassurance regarding seriousness of condition
Specific reactivation advice
Key points in initial report of findings reassurance and advice
Identify spine-related worries and fears
Provide assurance that there is no serious disease
Explain that injuries and degeneration can be pain precipitators but likely pain perpetuators are controllable factors
Provide specific activity modification and reactivation advice
Cognitive behavioral approach
More structured approach involving cognitive behavioral classes/sessions
Cognitive behavioral approach
Address pt worries and fears
Teach methods to reduce fear and apprehension
May be appropriate for subacute patienst at heightened risk for chornic pain or chronic pain patients
Comprehensive, multidisciplinary approach that combines CB model with strategies that address return-to-work obstacles
Employer issues
Compensation issues
May be appropriate for chronic patients if steps 1 and 2 arenot successful
Patient education alone often not sufficient to
Engage patients in active self-care model
Must take patient-centered approach
Patient is not a diagnosis or label
Report of findings shifts model from biomedical/HCP-centered fix to biosocial/patient-centered cope and adapt model
Enhancing patient motivation to resume activity
Collaboratively establish functional goals
Reassurance that the spine is not damaged
Education that gradual reactivation will enhance recovery whereas rest with interfere with recovery
Consistent verbal and written messages
Make exercises simple enough to be performed at home without significant equipment needs
Establish realistic expectations regarding possiblity/probability of flare-ups
Tips for enhancing patient compliance
Education that hurt does not necessarily equal harm
Education that fitness is the key to prevention
Make exercises simple enough to be performed at home without significant equipment needs
Link exercises to specific fucntional deficits/goals
Encourage patients to work at an exercise level that is somewhat hard for them
Establish realistic expectations regarding possibility/probability of flare-ups
