Solving the puzzle 23/08/ Workshop. (C) Trish Wisbey-Roth DESIGNING A SPINAL STABILITY. Muscular system - A major dynamic support

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1 DESIGNING A SPINAL STABILITY PROGRAM TO OPTIMISE DYNAMIC FUNCTION. COMBINE BRAIN AND FUNCTIONAL PROGRESSION BY RETRAINING THE VIRTUAL BODY Trish Wisbey-Roth Olympic/Specialist Physiotherapist ( FACP) Masters of Sport Physiotherapy (AIS/UC) Active Rehabilitation Consultant Hides, 1997 Hodges, 2000; 2004 O Sullivan, 1997; 2000, Panjabi, 1994; 1995 Richardson et al, 1992;1999;2002 Holmich, 1999, 2007 Stuge, 2004 Vleeming, 2000 McGill, 2004 Muscular system - A major dynamic support Motor control involves much more than muscles. Belief Systems (Non) Copying Strategies Catastrophising Fear Solving the puzzle Brain Home & Work Factors Ergonomics Stress Security Support Cultural Nerve Pain & Disability Structural Bone Ligament Tendon Compromise Passive Stability Neural Compromise Restricted Glide Hypersensitivity Motor Control Increased/Decreased Muscle Activity Virtual Body Changes Balance Proprioception Functional Integration Module (Lee & Vleeming 1998) What do muscles have to do with pain? Form Closure Bones, joints, ligaments FUNCTION Force Closure Muscles, fasciae Muscles and their fascia are the main structures that provide stability to the spine when we move. Motor Control Emotions Neural recruiting patterns Awareness (Lee & Vleeming 1998) 1

2 Muscle stability occurs at 2 levels Control of your spinal posture against large forces/loads (bigger muscles-surface) e.g. lifting boxes. Control of the individual spinal and pelvic joints (deeper smaller muscles) e.g. to help you sit in a chair or maintain standing. Both levels of stability are needed. Selects those muscles most easily activated and well positioned to perform the required task The neural control system Transversus abdominis TrA controlled independently of other abdominal muscles and closely linked to the diaphragm and pelvic floor. (Hall, 1995; Hodges, 1997; Avery + O Sullivan, 2001) TrA contraction significantly increased SIJ stiffness and to much larger degree than bracing of all abdominal muscles. (Richardson et al 2002;) Global muscles balance external loads, so residual forces transferred to the core are manageable for the deep stabilisers. (Richardson, et. al. 1999; Danneels, 2000) Multifidus attaches low as S4, posterior SI and sacrotuberous ligaments, lumbar z -joint capsule i (DeRosa, 2001) When multifidus fatigues quickly, normal activities cause abnormal strain on passive structures. (Hides et al, 1995; Wilke, 1995) Multifidus Multifidus, A key postural muscle LBP patients have poorer ability to sense change in lumbar position even when not fatigued (Taimela et al, 1999; Hides, 2001) Mm receptors play a significant, perhaps primary role in joint position sense (Taimela et al, 1999). Multifidus activity can be changed by moving the body s center of gravity e.g.. head (Bogduk, 1987). 1 Dynamic function of the lumbar spine At L5 even activity of the deep back stabilisers are not enough to counter shear forces in lifting and bending tasks (Colewicki, et. al 1996; Wilke, 1995). Other muscles in addition to the deep stabilisers are required for dynamic control (Vleeming, 1995 a&b; Hodges, 2000). Thoracic component of the erector spinae produce majority of torque to extend spine on pelvis i.e. 80% at L4, L5 (Richardson et al, 1999). 1 2

3 Pelvic Floor Weak or asymmetrical left to right pelvic floor contraction correlated to stress incontinence. Pelvic floor (particularly pubococcygeus), help control : -the neutral zone of the SIJ, - prevent decent of the bladder, - leave hips free for movement and ribs free for respiration. Need to use feedback (Real-time Ultrasound useful) and train breathing. Pubococcygeus assists stabilisation of the lumbo-pelvic region Pubococcygeus Ischiococcygeus Coccygeus Muscle relationships for spinal stability Muscles effecting force closure - The outer unit Oblique abdominis internus Erector spinae Thoraco-lumbar fascia Transversus abdominis Multifidus The thorico lumbar fascia (TLF) bridges lumbar spine and pelvic girdle, connecting the inner and outer unit of muscle systems (Barker et al, 2000) The 4 outer unit slings:- 1) The posterior oblique sling 2) The posterior longitudinal sling (Vleeming 1995 a&b; DeRosa, 2001; Lee, 2001) 3) The anterior oblique system 4) The lateral pelvic/hip system (Snijders et al, 1995; Vleeming 1995 a&b; Lee 1999) 1 Thoraco Lumbar Fascia Effects on Segmental Control Global muscles aiding upright posture 10N of force through Lat Dorsi and/or Glut Max increased stability to L/S and SIJ bilaterally. (Briggs, 2004) 10% Glut Max co contraction with Multifidus and pelvic floor increased stability of the SIJ three fold Superior glut max inserts into ITB and continuous with multifidous fascia. ( Vleeming 1995) Glut max deep fibres cross SIJ to PSIS, lateral sacrum and ischial tuberosity Compression forces required to control shear forces in the SIJ, provided by large global muscles working in discrete synergistic groups (Snijders et. al, 1995; Vleeming, 1995 a&b, 2000). In subjects with LBP/SIJ pain, biceps fem early activation bilaterally, inhibited Glut Max ipsitaterally. (Hungerford, 2003; Gibbons, 2004.) 3

4 Posterior oblique sling Gluteal Amnesia (Cholewicki & McGill 1992, McGill 2004) latissimus dorsi thoraco -lumbar fascia Occurs with L/S & SIJ dysfunction and results in SIJ compression. (Vleeming 1998) With hamstring activity, psoas/iliacus activity to resist reaction forces (McGill 2004). Gluteus Maximus Posterior longitudinal sling (Lee, 1999) The anterior sling (Lee, 1999) Sacrotuberous ligament Semi membranosus Multifidous and deep layer TLF Conjoint Tendon of Semitendinosus and Long Head of Biceps Femoris Fascial link between internal oblique & adductor longus increases anterior stability Internal oblique/ Tranverse Abdominus Pubic Symphasis Adductors Anterior pelvic floor The anterior sling (Lee, 1999) The lateral pelvis and hip control system Inguinal Canal and inferior fascia of external oblique Internal and external Oblique fascia Adductor Longus Fascia connects with fascia of Pubic symphasis and contra lateral antero lateral oblique's. Glut med/min, TFL and contra lateral adductor longus work with muscles of the spine and legs, to control lateral shift of trunk and pelvis on hips. Can influence lower limb injuries. Gluteus maximus Hamstrings Gluteus medius Quadriceps 4

5 Iliacus Glut Med Glut Min Piriformis Hip joint dynamic stability - deep anterior view Psoas major Coxxygeus Pectineus Add longus Add Brevis Pain affects postural equilibrium Postural sway allows fine tuning of postural responses to changes in internal/external forces. With pain, motor control will limit movement, directly affecting postural sway (McGill, 2007). Limiting velocity of movement, greater muscle co contraction. Muscle co contraction:- spinal stiffness spinal compressive forces (Hodges & Mosley, 2003). Low back pain and postural sway Induced LBP, L/S Movt. compensated by hip and ankle movement. (M Smith et al 2005) Result is greater overall Postural sway. These protective adaptations within the Virtual body makes controlling dynamic stability difficult. (Mok et al 2004; Hodges & Mosley 2004) Preprogrammed compensation in postural sway with induced LBP The Virtual body develops compensatory, feed forward strategies at the CNS level. Hip strategy is complex CNS task. dependency but also disturbance of visual cues. Hip strategy poor balance with small base and eyes closed (Mok et al 2004 & 2007). Virtual body changes to protect against perceived threat of pain Inaccurate virtual body creates changes in muscle recruitment, balance reactions and less variable movement strategies. Decreased ability to perform reposition tasks and increased reaction time ( Mok et al 2007). Effects of beliefs & coping strategies on the virtual body Threat value of pain has a direct impact on posture & motor control. Changes continue despite :- resolution of pain, anticipation of pain. Resolver/non resolver personality (Mosley et al 2004). Brain mapping: possible reorganisation of sensory Cortex (Mosley and Hodges 2006). 5

6 Addressing Virtual body and Psychosocial changes: Retraining with a variety of postures and partner work to encourage motor preplanning. Build confidence in normal movement with balance challenges to the L/S, hips and ankles. Progress exercises to face fears. Decrease hypervigilence and pacing/flare up strategies. Biopsychosocial Explain Pain training strategy to help reverse sensory motor cortex, Homunculus changes. A program to build confidence in normal movement Objective Measures Relaxation Strategies Progress Function Virtual Body Changes Environmental Input WISBEY-ROTH STABILITY GRADING Trish Wisbey-Roth Olympic/Specialist Physiotherapist ( FACP) Masters of Sport Physiotherapy (AIS/UC) Active Rehabilitation Consultant 1 2 Functional training : aim to train movement, not a muscle Control acute pain/inflammation and facilitate Intra muscular (I & II) fibre activity to address metabolic changes within muscles. Intermuscular coordination between muscle/facial groups and build endurance. Address fears and belief systems Grade 1 Virtual exercises Grade 1 - Virtual exercise Long, gentle contraction of key stabilising muscles to retrain effective injury prevention muscle patterns. Exercises performed in static and stable postures so can be commenced early in rehab Aim to maintain key muscle activity for minimum of 10 seconds per exercise while breathing. Combined muscle specific relaxation strategies 4 point kneeling Sitting 6

7 Stimulate balance, and functional control while building endurance (minimum seconds per exercise) Address individual maladaptive postures combined with muscle relaxation techniques Differentiation of hip from spine/pelvis movement Grade 2: Lower body weight shift with limb movement Lifting one arm with stabilising shoulder blade, upper body and neck posture Grade 2: Upper body control with ideal posture Movement of arms with ideal standing posture, to unload upper body nerves and neck and shoulder joints 3 4 Functional training goals (contd.) Dynamic function in joint angle, speed and contraction specific postures. Muscle hypertrophy. Introduce fear factor exercises. Encoding motor patterns for ability to react to changes by altering environment and challenges. Add cognitive loading. Injury prevention: Dynamic stability of the spine and limbs while spine and limb muscles are lengthening and shortening repetitively. Retrain stabilisers of spine and upper /lower body to control and protect in functional work/adl movements. Grade 3: Functional movement and strength Teach control of spine, hips, neck, shoulders with twisting activities. Grade 3: Slow controlled movements of the trunk Retraining weight shift under load, to challenge balance, strength and control for manual work. Lunges Grade 4: Speed and joint angle specific function Weight shift and good spinal muscle control in squatting positions. Injury Prevention: Teaching muscles of the spine and limbs to work effectively, both when they are shortening but also when lengthening to prevent strains. 7

8 Grade 4: Dynamic, adaptable stability & balance challenges. Functional training goals achieved 5 Progress proprioception training to labile surfaces/loads, small base of support and Plyometrics to build adaptable patterns ( McGill 2004). One legged stability, with balance challenged and loaded to encourage dynamic, adaptable stability. One leg loaded moves into squat than standing postures Generate quick appropriate strength throughout complex movements patterns, while preserving balance. (McGill 2004) Grade 5: Prevention with speed and endurance activities. Eccentric and dynamic movement retraining. Whole body functional postures under load to build dynamic balance, endurance and performance enhancement, for work and recreation. Ideal for injury prevention of leg, back, hip, shoulder for heavy manual workers Retrain eccentric function of key muscles in loaded, whole body movement and speed specific postures. Activation pattern fine tuning Utilise Video analysis / mental practice to optimise technique driven muscle recruitment. Objective Measures Relaxation Strategies Progress Function build confidence in normal movement Pain - VAS Psycho Social (OMPQ) Function Multi level RM24 Function Specific Satisfaction of Outcome Phil Gabel Short Form Format Breathing Gentle Muscle Contraction Relaxation Muscles in long/short position Static to Active Supported to Unsupported Range - Small to Whole Body Movement Stability - Stable to Unstable Speed & Direction - Uni to 3D 8

9 A program to build confidence in normal movement Virtual Body Changes Environment al Input Orientation & Start with less painful side. Range Increase range on less painfull side and use of mirrors Proprioceptive Cues Selective Muscle recruitment Timing Instructor Demonstration, Personal Stories, Encouragement, Supportive, Individualised Handout Personal with Text, Pictures, Cues and personalised key points Setting Music, Laughter, positive surroundings Group, Socialisation Sharing Experiences, Decrease Isolation Conclusion Address proprioceptive and Virtual body changes occurring with pain/distress. A focus on rigid stability may pain from compression sensitive structures. trauma along the kinetic chain e.g. hip and lower limb. The Virtual body should effectively preplan movt. then adjust with input from the periphery. Goal: Optimal dynamic function Links & Online Resources For more details and upcoming lectures To find out more about becoming a Bounce Back Agent For additional free Resources look in the Resources Section Providers Tab Menu 9