Functional vs. Structural

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Percival Hall
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1 Functinal Assessment, Rehab, and Taping f Musculskeletal Disrders Bartn N. Bishp, DPT, SCS, CKTI, CSCS Chief Clinical Officer Sprt and Spine Rehab Kaizenvatin Lifestyle Functinal vs. Structural Structural faults treated with functinal treatment Functinal vs. Structural Need t treat the deficit apprpriately" Functinal faults require functinal treatment" Structural faults require structural treatment 1

2 Structural Deficits Jint dysfunctin" Malalignment" Fractures Functinal Deficits Pr psture" Inhibitin f a muscle" Phasic Chain" Muscle ver facilitated" Tnic Chain" Inability t d sprt, skill, leisure, ADLs" Treatment Paradigm Structural Exam Functinal Exam Structural Treatment Functinal Treatment 2

3 Janda s Muscle Imbalance Syndrmes Treatment Paradigms The traditinal, structural apprach tends t be mre extrinsic : Treat what we can see" " The functinal apprach takes a mre intrinsic perspective t treat what we can t see Things we can t see Prpriceptin" Mtr prgrams" Chain Reactins" Muscle Imbalances 3

Prpriceptin Jint mechanreceptrs" Capsules & ligaments" " Muscular receptrs" Gamma mtr neurn & muscle spindle" Cutaneus receptrs" Pressure, temperature, vibratin Structure vs.

4 Prpriceptin Jint mechanreceptrs" Capsules & ligaments" " Muscular receptrs" Gamma mtr neurn & muscle spindle" Cutaneus receptrs" Pressure, temperature, vibratin Structure vs. Functin 37 Prpriceptin" Hiltn s Law : a nerve that innervates a jint als tends t innervate the muscles that mve the jint, as well as skin and fascia Structure vs. Functin 38 Hiltn s Law example" Musculcutaneus nerve supplies elbw jint with pain and prpriceptin fibers. It als supplies biceps, brachiradialis, and skin. 4

Prpriceptive" Exterceptive MOTOR OUTPUT" Muscle Facilitatin" Muscle Inhibitin Chain Reactins 41 Muscular Chains" Slings :

5 The musculskeletal & central nervus systems functin as ne unit: The SENSORIMOTOR SYSTEM Any lesin within the system is reflected by adaptive changes elsewhere in the system Sensrimtr System CNS CNS PROCESSING PNS SENSORY INPUT" Visual" Vestibular" Prpriceptive" Exterceptive MOTOR OUTPUT" Muscle Facilitatin" Muscle Inhibitin Chain Reactins 41 Muscular Chains" Slings : cntinuus cnnectins thrugh muscle, fascia, and bne" Synergists & Antagnists intercnnected in clsed tensegrity system" Integral links fr mvement" 5

Chain Reactins Neurlgical Chains" Upper Quarter C-Activatin (Janda)" Tnic Chain" flexin, internal rtatin, adductin, prnatin" " Phasic Chain" extensin, external rtatin,

adductin" " Phasic chain" ankle DF & EV, hip external rtatin & abductin functin: creeping, crawling, gait Upper Quarter Chains Tnic Chain!

6 Chain Reactins Neurlgical Chains" Upper Quarter C-Activatin (Janda)" Tnic Chain" flexin, internal rtatin, adductin, prnatin" " Phasic Chain" extensin, external rtatin, abductin, " supinatin functin: prehensin, reaching, grasping Chain Reactins Lwer Quarter C-Activatin (Janda)" Tnic chain" ankle PF & INV, hip flexin, internal rtatin & adductin" " Phasic chain" ankle DF & EV, hip external rtatin & abductin functin: creeping, crawling, gait Upper Quarter Chains Tnic Chain! Phasic Chain pectralis majr" upper trapezius" levatr scapula" masseter/lat. pterygid" SCM" Scalenes" subccipitals" UE flexrs serratus anterir" rhmbids" middle/lwer trapezius" deep neck flexrs" upper limb extensrs 6

7 Lwer Quarter Chains Tnic Chain gastrc-sleus" tibialis psterir" hip adductrs" hamstrings" rectus femris" ilipssas" TFL" pirifrmis" thraclumbar extensrs" quadratus lumbrum" Phasic Chain perneals" tibialis anterir" Vastus medialis/ lateralis" gluteus medius/ minimus" gluteus maximus" Transverse abdminus" Muscle imbalance is a systematic and predictable respnse f the mtr system Changes in the system will be reflected by adaptive respnses within the system Tnic muscles are prne t tightness Tnics are T Tight Phasic muscles are prne t weakness Phasics Fail t Fire 7

8 Flexrs (Tnic) Prne t tightness / shrtness gastrc-sleus" tibialis psterir" hip adductrs" hamstrings" rectus femris" ilipssas" TFL" pirifrmis" thraclumbar extensr " quadratus lumbrum" pectralis majr" upper trapezius" levatr scapula" masseter/lat pterygid" SCM" Scalenes" subccipitals" UE flexrs Extensrs (Phasic) Prne t weakness / lengthening perneals" tibialis anterir" vastus medialis/ lateralis" gluteus medius/ minimus" gluteus maximus" transverse abdminus serratus anterir" rhmbids" middle/lwer trapezius" deep neck flexrs" upper limb extensrs Muscle Imbalance & Jint Pathlgy 8

9 Vicius Cycle f Muscle Imbalance Jint Dysfunctin Unbalanced" Frces Altered" mtr prgram Abnrmal Jint" Bimechanics Abnrmal" mvement " pattern Structural v. Functinal Pathlgy Dysfunctin (Lund et al, 1991)" Characteristic f several types f musculskeletal pain" Neurphysilgical mdel, based n afferent input" Muscle Imbalance" Agnists becme inhibited" Antagnists becme facilitated" Nrmal prtective adaptatin; NOT the cause f pain Typical muscle respnse t jint dysfunctin is similar t spastic muscles in structural CNS lesins Usually develps with muscle inhibitin in ther muscles, resulting in a muscle imbalance. 9

Flexrs TIGHT" Subccipitals" UpTrap/Levatr TIGHT" Pectrals WEAK" Rhmbid" Lwer Trap Janda s

10 Presence f Janda s Crssed Syndrmes indicates the presence f CNS-mediated muscle imbalance Requires treatment f the Sensrimtr System Janda s Upper Crssed Syndrme WEAK" Cervical " Flexrs TIGHT" Subccipitals" UpTrap/Levatr TIGHT" Pectrals WEAK" Rhmbid" Lwer Trap Janda s Lwer Crssed Syndrme WEAK" Abdminals TIGHT" Thraclumbar" Extensrs TIGHT" Hip Flexrs WEAK" Gluteus Max 10

Janda s Layer Syndrme Cmbinatin f bth upper and lwer crssed syndrmes" Marked impairment f the mtr regulatin" Sign f prer prgnsis due t lngstanding dysfunctin Functinal

Watch the upper cervical spine Clinical Ra(nale Shws veractivity f subccipitals Exercise Recmmenda(ns Pain r inability t pen at least 3 Thracic extensin t psitin c-spine

11 Janda s Layer Syndrme Cmbinatin f bth upper and lwer crssed syndrmes" Marked impairment f the mtr regulatin" Sign f prer prgnsis due t lngstanding dysfunctin Functinal Exam, Rehab, Treatment Cervic-Thracic Muth Opening Screen" Instruc(ns Patient seated r standing cmfrtably. Patient t pen the muth as wide as pssible. Watch the upper cervical spine Clinical Ra(nale Shws veractivity f subccipitals Exercise Recmmenda(ns Pain r inability t pen at least 3 Thracic extensin t psitin c-spine in fingers wide. Viewing frm side, neutral shutting ff subccipitals; Upright lk fr any anterir translatin f Head Nd; dynamic cervical ismetrics the cciput = subccipital ver activity extensin 11

Upper Cervical Extensin Test" Instruc(ns Perfrm dynamic cervical extensin ismetric with a yellw r red Thera-Band pull frm in frnt f patient Clinical Ra(nale Shws weakness f lngus clli Upper cervical

Patient is supine and ask patient t slwly raise the head frm the table and then slwly lwer the head back t starting psitin Clinical Ra(nale Evaluates deep neck flexr strength and ver-activity f

extensin at all times) Janda Shulder Abductin Test" Instruc(ns Have patient start with arm at side and elbw bent t 90 degrees and wrist neutral.

12 Upper Cervical Extensin Test" Instruc(ns Perfrm dynamic cervical extensin ismetric with a yellw r red Thera-Band pull frm in frnt f patient Clinical Ra(nale Shws weakness f lngus clli Upper cervical extensin at any pint in the mtin inability t keep head in neutral Exercise Recmmenda(ns Deep neck flexin upright head nd, dynamic cervical ismetrics fr extensin Deep Neck Flexin Test" Instruc(ns Patient is supine and ask patient t slwly raise the head frm the table and then slwly lwer the head back t starting psitin Clinical Ra(nale Evaluates deep neck flexr strength and ver-activity f SCM/scalenes Exercise Recmmenda(ns SCM r Scalenes ver activity; Upright head nd, SCM and Scalenes Shaking; Chin prtrusin (nt stretches, dynamic cervical ismetrics fr keeping chin tucked t chest extensin at all times) Janda Shulder Abductin Test" Instruc(ns Have patient start with arm at side and elbw bent t 90 degrees and wrist neutral. Slwly raise arm t side Clinical Ra(nale Evaluates the ver-activatin f the upper trap fr patients with neck pain Scapular hike at any pint in the mtin; pain. Exercise Recmmenda(ns Strengthening f the middle deltid, supraspinatus, and stretching f the upper traps/levatr scapulae 12

Thracic Extensin Screen" Instruc(ns Stand against wall with heels 1-2 inches away frm wall; raise arms up (lats) r elbws at 90 degrees (Pecs) Clinical Ra(nale Evaluates thracic extensin which lack f

W-Vs, Wall Angels, Standing Jacks, Lat Stretches Instruc(ns In push up psitin, n tes r knees, lwer and rise up, then shift frm side t side and shift superlaterally Clinical Ra(nale Evaluates the

and mid trap exercises; inferir perfrm angle: lwer trap vectr, scap/sagittal flexbar scillatin 90/90 ER With and Withut Retractin" Instruc(ns Have patient stand naturally, abduct arm t 90 degrees and

13 Thracic Extensin Screen" Instruc(ns Stand against wall with heels 1-2 inches away frm wall; raise arms up (lats) r elbws at 90 degrees (Pecs) Clinical Ra(nale Evaluates thracic extensin which lack f puts the upper cervical spine in extensin and the lwer c-spine in flexin Inability t flatten TL junctin withut lsing wall cntact; Nte where tensin ccurs when perfrming; Pain Exercise Recmmenda(ns W-Vs, Wall Angels, Standing Jacks, Lat Stretches Instruc(ns In push up psitin, n tes r knees, lwer and rise up, then shift frm side t side and shift superlaterally Clinical Ra(nale Evaluates the activatin f the serratus anterir and lwer and middle traps Push Up Screen" Exercise Recmmenda(ns Scapula wings (unilateral Depends n failure medial brder: mre significant); Inability t serratus ant and mid trap exercises; inferir perfrm angle: lwer trap vectr, scap/sagittal flexbar scillatin 90/90 ER With and Withut Retractin" Instruc(ns Have patient stand naturally, abduct arm t 90 degrees and externally rtate. Measure range. Red mtin after ding scapular retractin Clinical Ra(nale Have patient stand naturally, abduct arm t 90 degrees and externally rtate. Measure range. Red mtin after ding scapular retractin Exercise Recmmenda(ns Range shuld be mre than 85 degrees Scap stab strengthening lwer trap vectr, rws, with retrac6n. Withut retrac6n it serratus prgressin, Y-I-T. External rtatin, shuld be at least 90 degrees f swrd. ER stretching external rta6n 13

Functinal Examinatins and Apprpriate Rehabilitatin Exercises Lw Back/Lwer Quarter Overhead Deep Squat Test" Instruc(ns Have patient hld bar ver head, feet shulder width, tes straight and squat dwn

strengthening, with thighs, weight shift, r bar hip mbility, ankle drsiflexin mbility, cmes frward.

14 Functinal Examinatins and Apprpriate Rehabilitatin Exercises Lw Back/Lwer Quarter Overhead Deep Squat Test" Instruc(ns Have patient hld bar ver head, feet shulder width, tes straight and squat dwn keeping bar ver head and heels n grund Clinical Ra(nale Evaluates hip, ankle, and thracic spine mbility as well as cre strength Exercise Recmmenda(ns Pain, Inability t break hrizntal Depends n : Cre strengthening, with thighs, weight shift, r bar hip mbility, ankle drsiflexin mbility, cmes frward. Knee valgus during glute med/max strengthening, thracic any part extensin mbility Instruc(ns Have patient stand n ne leg and perfrm a squat. Have them d repeatedly. Stand n 6-8 inch stepand tuch the heel f ther ft t flr Single Leg Squat" Clinical Ra(nale Evaluates activatin f the gluteus medius, maximus, quadriceps, and sleus length Exercise Recmmenda(ns Knee pain, valgus f knee, Clams, fire hydrants, step dwn, running excessive ft prnatin, man, bwler s squat, single leg stance trendelenburg, bdy lean, activities, sleus stretching Heel lifts 14

Sleus stretch, glute med strengthening, knee lad, Trendelenburg quadriceps/vmo strengthening Frward Lunge Screen" Instruc(ns Patient perfrms frward lunge Clinical Ra(nale Evaluates

cre stabilizatin, ankle), knee pain, inability t quadriceps strengthening maintain upright trunk Single Leg Stance Test" Instruc(ns Stand n ne leg, lk straight ahead, ppsite leg ideally

15 Instruc(ns Stand n 6-8 inch step. Step dwn and tuch the heel f the ther ft t the flr Clinical Ra(nale Evaluates activatin f the ft instrinsic musculature Step Dwn Test" Exercise Recmmenda(ns Pain, Heel raises up, Valgus Sleus stretch, glute med strengthening, knee lad, Trendelenburg quadriceps/vmo strengthening Frward Lunge Screen" Instruc(ns Patient perfrms frward lunge Clinical Ra(nale Evaluates activatin f the gluteus medius, quadriceps, and hip mbility Exercise Recmmenda(ns Valgus knee lad, excessive Depends n failure glute med/max knee flexin (knee anterir t strengthening, cre stabilizatin, ankle), knee pain, inability t quadriceps strengthening maintain upright trunk Single Leg Stance Test" Instruc(ns Stand n ne leg, lk straight ahead, ppsite leg ideally at hip height and nt tuching stance leg. Get balance with eyes pen, then clse eyes Clinical Ra(nale Evaluates balance, cre stability, and glute medius stability Exercise Recmmenda(ns Trendelenburg (lss f height), gain Depends n failure glute strengthening, f height, inability t maintain cre, r balance training balance fr minimum f 15 secnds 15

Instruc(ns Patient stands with back against wall with feet frward. Raise arms up t tuch thumbs t walls. Mve supine t table and repeat if unable t perfrm. Then flex knees t chest.

Recmmenda(ns Lat stretch, thracic extensin exercises, diaphragmatic breathing exercises/ retraining Thracic Rtatin Test" Instruc(ns Hld bar in frnt f bdy and rtate t each directin while sitting.

<50 degrees rtatin with bar Thracic rtatin strengthening (if active in frnt, <45 degrees with bar insufficiency); Assisted thracic rtatin; behind, lss f >20 degrees frm Scapular stabilizer exercises

16 Instruc(ns Patient stands with back against wall with feet frward. Raise arms up t tuch thumbs t walls. Mve supine t table and repeat if unable t perfrm. Then flex knees t chest. Clinical Ra(nale Evaluates lat drsi length as well as thracic extensin and diaphragm weakness Pain, inability t tuch walls with thumbs with head t sacrum tuching wall Lat Length Test" Exercise Recmmenda(ns Lat stretch, thracic extensin exercises, diaphragmatic breathing exercises/ retraining Thracic Rtatin Test" Instruc(ns Hld bar in frnt f bdy and rtate t each directin while sitting. Then Hld bar behind back thrugh arms and rtate again Clinical Ra(nale Evaluates the mbility f the thracic spine in rtatin Exercise Recmmenda(ns Pain. <50 degrees rtatin with bar Thracic rtatin strengthening (if active in frnt, <45 degrees with bar insufficiency); Assisted thracic rtatin; behind, lss f >20 degrees frm Scapular stabilizer exercises frnt t back Vleeming s Active and Resistive SLR Test" Instruc(ns Have patient lift ne leg 20 cm ff table keeping it straight. Switch sides. Then perfrm again and prvide resistance. Finally, d again after asking patient t brace. Clinical Ra(nale Evaluates cre stability via activatin f the transverse abdminus r bliques Exercise Recmmenda(ns Pain r pelvis rtates in any part f Ab Bracing; New Abs; Multi-Planar Vertical the mtin n either side. Unilateral Stabilizatin; Abdminal activatin via psterir failure is mre significant. weight shift with band (all depends n patient s ability t stabilize after activatin 16

Janda Hip Extensin Test" Instruc(ns Patient prne n table, keeps leg straight and extends hip.

excessive Glute max strengthening 4-way hip, glute firing f lumbar paraspinals and/r squeezes, running man, squats hamstrings; early anterir pelvic tilt Janda Hip Abductin Test" Instruc(ns Patient

Watch fr the belt line t stay in place Clinical Ra(nale Evaluates activatin f the gluteu medius t create hip abductin Exercise Recmmenda(ns Belt line mving tward ribs Glute med strengthening 4-way

17 Janda Hip Extensin Test" Instruc(ns Patient prne n table, keeps leg straight and extends hip. Palpate hamstrings, glute max, and cntralateral lumbar paraspinals Clinical Ra(nale Evaluates activatin f the glute max, paraspinals, and hamstrings Exercise Recmmenda(ns Delay f glute max and excessive Glute max strengthening 4-way hip, glute firing f lumbar paraspinals and/r squeezes, running man, squats hamstrings; early anterir pelvic tilt Janda Hip Abductin Test" Instruc(ns Patient sidelying n table. Expse waist and have patient abduct leg. Watch fr the belt line t stay in place Clinical Ra(nale Evaluates activatin f the gluteu medius t create hip abductin Exercise Recmmenda(ns Belt line mving tward ribs Glute med strengthening 4-way hip, (activatin f QL), external rtatin clams, mnster walk, running man, f tes r flexin f hip bwler s squat Single Leg Bridge Test" Instruc(ns Patient supine n flr (nt table if pssible) and perfrms a bridge (arms n chest r up). In bridge, ne leg is kicked straight. Hld this psitin fr 10 secnds Clinical Ra(nale Evaluates glute max activatin ver hamstring and lumbar paraspinals Exercise Recmmenda(ns Pelvis drps t grund, Glute max activatin bridges, glute sets, hamstring cramps, pelvis 4-way hip, hip hinging running man, rtates, lwer back pain, can t bwler s squat hld fr 20 secnds 17

Instruc(ns Patient standing in bare feet and they fall frward until they start t fall. Ask the patient t catch his/ herself. Watch the tes fr gripping int the grund.

18 Instruc(ns Patient standing in bare feet and they fall frward until they start t fall. Ask the patient t catch his/ herself. Watch the tes fr gripping int the grund. Clinical Ra(nale Evaluates activatin f the ft instrinsic musculature Vele s Reflex" Exercise Recmmenda(ns Delayed firing f the ft Ski jumpers, Janda shrt ft, rlling twel, intrinsics (unilateral is wrse) marble pick up, brushing sle f ft with a cmb Cmmn Glute Exercises MSSE 2013 TRAC Preceedings 2013 Glute Max Ac6va6n Gmax Healthy 40 Gmax LBP 20 0 Clams Clams TB Prne Hip Ext Stand Hip Ext TB S/L Hip ABD Stand Hip ABD TB Quad Hip Ext Quad Hip Ext TB Bridge Bridge TB FireHydrant FireHydrant TB Lunge Lunge TB RunningMan RunningMan TB 18

Glute Med Ac6va6n 60 50 40 30 Gmed Healthy Gmed LBP 20 10 0 Clams

Quad Hip Ext Quad Hip Ext TB Bridge Bridge TB FireHydrant

19 Glute Med Ac6va6n Gmed Healthy Gmed LBP Clams Clams TB Prne Hip Ext Stand Hip Ext TB S/L Hip ABD Stand Hip ABD TB Quad Hip Ext Quad Hip Ext TB Bridge Bridge TB FireHydrant FireHydrant TB Lunge Lunge TB RunningMan RunningMan TB Fire Hydrants Clams 19

fr the pain AND the cause f the pain Think glbally, act

20 Running Man Principles f Prpricep6ve Taping Nt all tapes are the same Tape the area that yu exercise/massage Tape fr the pain AND the cause f the pain Think glbally, act lcally (and glbally) Taping t Inhibit Internal Rtatrs 20

21 Taping t Facilitate Psterir Cuff Taping t Facilitate Psterir Cuff Taping t Facilitate Lwer Traps 21

22 Thank 22

BROCKTON AREA MULTI-SERVICES, INC. MEDICAL PROCEDURE GUIDE. Date(s) Reviewed/Revised:

BROCKTON AREA MULTI-SERVICES, INC. MEDICAL PROCEDURE GUIDE. Date(s) Reviewed/Revised: Page 1 f 6 Subject: Range f Mtin Exercises Date Develped: 4/2010 PROTOCOL FOR: All trained staff PURPOSE: Range f Mtin (ROM) exercises are very imprtant if an individual has t stay in bed r in a wheelchair.