THEORETICAL BACKGROUND OF POSTURAL CONTROL

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1 2015 한국보바스소아학술대회 THEORETICAL BACKGROUND OF POSTURAL CONTROL Postural Control Role In The Human Movement 대전보람병원 이기훈

2 Key word Postural control : 중력에대응공갂에서자세를유지어떤동작을수행이가능하도록하는배경보행이나 manual skill 발달의기초 중추신경계 - 공갂에서의신체의위치와움직임에대한정보를제공하는많은감각정보를받아들임. - 통합 - 여러조절단계 - 몸통및사지의귺육에적절한수축과이완유도

3 Key word Vestibular system Muscles which locate around the neck are most important, which is the basis for the postural control of human movement The top is the head which is the keystone of the central line

4 Gravity

5 Human Movement The same way to move against gravity Normal postural control mechanism All of these are all generated postural control, without conscious control

6 Terminology Postural control: the ability to control the body s position in space for the dual purposes of orientation and stability 1) Orientation: the ability to maintain appropriate task-specific relationships between the body segments and between the body and the environment 2) Stability: the ability to control the center of mass relative to the base of support

7 3 components of postural control mechanism - Normal postural tone - Reciprocal innervations - Common movement pattern (learned pattern)

8 Human movement postural tone Postural tone generated by changes in the location of the head - move on the same axis against the BOS - activate the neural system of the brain

9 Human movement reciprocal innervations Reciprocal innervations - Agonist, antagonist, synergist - Proximal stability, distal mobility

10 Human movement - common movement pattern Previous information, current information Adaptive, anticipatory

11 Postural tone In daily life, human keep working against gravity to maintain the head in the axis Postural tone starts to work from the moment the head in space

12 Terminology Tone : resistance of muscle to stretch phasic and postural Phasic tone rapid contraction in response to a high- intensity stretch, as in tendon reflex response Postural tone prolonged contraction of antigravity muscles in response to the low-intensity stretch of gravity. When postural tone is depressed, the trunk and limbs cannot maintain themselves against gravity

13 Postural tone An appropriate activation of muscle of the body to maintain the head & body on midline against gravity Information tools which are the vestibular network of eye, inner ear, muscle spindles of the neck and trunk

14 Mechanisms for modulation of postural tone Postural tone automatically works to allow head movement in space in order to do something with volition

15 Mechanisms for modulation of postural tone Standing Soldier military standing at attention Lying down in bed Initial wakefulness with opening of eye Sitting

17 Mechanisms for modulation of postural tone Straightened neck with 2 columns of upper trapezius

18 The Neck Muscles which locate around the neck are most important, which is the basis for the postural control of human movement It works with vestibulospinal reflex, vestibulocollic reflex, vestibuloocullar reflex For connecting with vestibular neural network, neck muscles are composed of highest density of muscle spindle then other muscles

19 Mechanisms for modulation of postural tone Hemiplegia muscle weakness, hypertonus SCM, upper trapezius column weakness or disappearance Premature diplegia low proximal tone Weak or shortened neck -inability to watch with two eyes and to straighten the neck

20 Basis of neural network for the modulation of postural tone Otolith, the utricle and saccule. - LVN - ipsilaterally extensor m. in the cervical & lower lumbar segment of spinal cord Semicircular canal - MVN - bilaterally cervical or upper thoracic of spinal cord - extensor m. facilitation, flexor m. inhibition

21 Netter 97

24 Basis of neural network for the modulation of postural tone Vestibular nuclei 1. Sensory information about head movement & head position relative to gravity 2. Gaze stabilization 3. Postural adjustment 4. Autonomic function and consciousness

25 Model Components Sensory Organization Balance/postural control via three systems: Somatosensory Visual Vestibular

26 Somatosensory System Dominant sensory system Provides fast input Reports information Self-to-(supporting) surface Relation of one limb/segment to another Components Muscle spindle Muscle length Rate of change GTOs Monitor tension Joint receptors Mechanoreceptors Cutaneous receptors

27 Vestibular System Not under conscious control Assesses movements of head and body relative to gravity and the horizon (with visual system) Components Cerebellum Projections to: Brain stem Ear Resolves inter-sensory system conflicts Gaze stabilization

28 Sensory-Motor Integration Sensory Input Processing Motor Response Somatosensory Vestibular Visual 1 0 Processor Motoneurons 2 0 Processor Cerebellum Eye Movements Postural Movements

29 Normal Postural Control Sensory System The somatosensory system provides information about the body with reference to supporting surfaces. The somatosensory system receives information from muscle spindles, joint receptors, tendon organs, and mechanoreceptors.

30 Basis of neural network for the modulation of postural tone Modulation Of Postural Tone Higher Position

31 Basis of neural network for movement of the body Standing The top is the head which is the keystone of the central line Vestibular system contributes to the generation of postural tone regarding to the location of the head for maintaining posture and for preparing the body movement

32 Basis of neural network for movement of the body In sitting: gluteus maximus initiator of respond the change of head location Rest a sofa - head flexed, body lean backward Sacrum sitting When intend to do something - head higher, pelvis upright, gluteus maximus, back m extension

33 Basis of neural network for movement of the body The most important consideration is the adequate & right activation of the head Gluteus maximus

34 Basis of neural network for movement of the body For another instance - human stand up Head flexion, proximal m. flexion Pelvis automatically ant. tilting - leg flexion for supporting the weight of the head & the body

36 Special consideration body part human movement 1. Eye with the head 2. Neck dynamic stability 3. Shoulder joint 4. Hand 5. Proximal dynamic stability 6. 3-dimensional pelvic movement 7. Ankle, foot

37 HEAD / EYE NECK DYNAMIC STABILITY CERVICAL AND THORACIC SPINE PROXIMAL DYNAMIC STABILITY 3 DIMENSIONAL PELVIC MOVEMENT WITHOUT or WITH BOS THE PELVIS MOVES ONTO THE HIP JOINT FOOT /ANKLE, TOE AS A BOS HAND MOVEMENT POSTURAL TONE AXIS

38 Altered vestibular system Eyes - connecting signals from the vestibular network - helping modulation of postural tone VOR Neck collarboration Vestibular network of the eye and head - axis에대해몸의위치변화감지- 머리의조절

39 VESTIBULO-OCCULAR REFLEXES

40 Altered vestibular system Sub- occipital spine (atlas- axis complex) Trapezius, SCM Deep m.

41 Altered vestibular system Hyperextended and asymmetric posturetypical hypertonic pattern Insufficient sensorimotor experience Womb - flexed posture, connective movement Neck m. (flexor part)

42 Altered Vestibular System Spastic Diplegia Hyperextended neck and eye which leads extended body. Different head Location mainly activate special muscles group of extension for maintain axis.

43 The eye Hyperextended neck, both eye not stable - alteration of axis - lead to change muscle, body alignment C1,C2 segment fixed Neutralization of altered vestibular system - therapist correct the altered vestibular system, normal axis, bring the eyes back to the middle

44 Altered Vestibular System Extended Child

45 The neck Muscles which locate around the neck are most important, which is the basis for the postural control of human movement It works with vestibulospinal reflex, vestibulocollic reflex, vestibuloocullar reflex For connecting with vestibular neural network, neck muscles are composed of highest density of muscle spindle then other muscles

46 The neck Spastic quadriplegia, dystonic athetosis - Activated mainly extensor group - Caused by dysfunction of the brain - Hyperextended neck - Hyperextended body d/t maintain the body axis

47 The neck Hyperextension inhibit C1-C2 complex movementaltered vestibular system Spastic diplegia - Hyperextended neck - Short neck, - Disappearance of the SCM, Upper part of trapezius, C7

48 The neck Cannot function optimally - lead to shortness of trapezius, deep capital extensor m. - Strong axis & information center의기능을할수없게됨

49 The neck Head sense its location & movement Neck- rotation, flexion, extension Vestibular information 을적절히할수가없음 C.P 에서 postural tone 유지가불가능하면움직 일수없다

50 The neck Lack of rotation from cervical to thoracic spine - Unable scapular movement dissociation - Unable shoulder joint movement

51 The neck Hemiplegia - low proximal tone Less movement on more affected side Hypertonus Poor body scheme Less weight bearing

52 The weakness of the neck Weak neck proximal m. tone low Premature diplegia - insufficient postural tone, vestibular information Build up muscle of neck c proximal Activate two-eye watching Spinal rotation

53 The weakness of the neck Hyperkinetic athetosis Fluctuating postural tone - poor head movement Neck brace - move axis

54 The weakness of the neck Hemiplegia - Asymmetry in posture and movement SCM, upper trapezius - activate weak & inactive m. - postural tone appropriate and correct axis the body

55 Connective movement of cervical, thoracic and lumbar spine Cervical spine rotation - thoracic spine rotation - lumbar spine rotation Vestibular network of CNS - eye not midline, neck weakness - low proximal tone - poor connect movement of the spine

57 Connective movement of cervical, thoracic and lumbar spine Diplegia - connective movement difficult Dissociated movement of the scapular d/t especially poor neck movement - because hyperextension or flexion

58 Power and speed: chin tuck Chin goes toward the spine chin tuck Weak neck- power, speed not produce Hyperextension inhibit chin tuck

60 Axis keeper Neck, hand, gluteus maximus, ankle, toe Most strongest stabilizer chin tuck Facial muscle masseter Hand- pushing, pulling Gluteus maximus- sever as posture of extension

61 Axis keeper Landau reaction - gluteus maximus strongly contract Upright sitting- highest head position, pelvic ant. Tilting In standing maintaining axis from top to bottom

63 Axis keeper Ankle, toe - strongly contribute BOS bipedal stance, dynamic movement Head is suddenly displaced or lose correct head alignment - running, ballet

64 Axis keeper Head is weak or altered vestibular system - all axis keeper will weaken or disappear

65 Proximal dynamic stability Proximal, neck dynamic stability - Stabilization body for distal part movement - Stabilization of rib cage Start to postural tone upon alertness (eye opening) Automatic activation Initiation of any kind of movement

66 Proximal dynamic stability Abdominalis, quadriceps, femoris, gluteals, diaphragm Proximal, pelvis conversely - 3-dimensional pelvic movement Neural signal from the CNS Neuromuscular junction Enough number of muscle fiber Thus, activation and building up proximal m. are very important

67 Proximal dynamic stability 3-dimensional pelvic movement - Forward, backward, diagonal Crawl one leg flexion, other leg extension Greater flexion opposite greater extension

68 Proximal dynamic stability If weak - not generate postural tone Inactive trunk, muscle tone extensor Neck proximal stability distal part move Rib cage & pelvis arm, leg appropriate movement Proximal neck, pelvis, core muscle

69 Physiologic postural reflex response Head righting reaction - 출생직후출현 - 지면에엎드려눕히면고개를들어올리는반응 - Landau 와 derotative righting reaction으로통합 Landau reaction - 엎드린상태에서영아의배를손으로받치고들어올림. - Neck extension, trunk extension

71 Physiologic postural reflex response Derotative righting reaction 1) Head on body righting reaction - 머리를한쪽으로돌리면어깨, 몸통, 골반, 다리가그방향으로돌아감. 2) Body on body righting reaction - 다리를한쪽으로꼬아옆으로돌리면골반, 몸통, 어깨관절, 상지순으로꼬인몸을푼다. Optical righting reaction - 몸을한쪽으로기울였을때, 고개를똑바로위치하려고하는 반응

72 Physiologic postural reflex response Labyrinthine righting reaction - 눈을가리고몸을한쪽으로기울이면전정기관의수용체가자극 목주위귺육의귺긴장도가변함. 고개를똑바로정위자세로위치

73 Physiologic postural reflex response Equilibrium reaction ( 평형반응 ) - 무게중심이몸의중심에서벗어났을때몸의중심의안정성을다시확보 ex) 앉은자세에서팔을뻗어물건을잡으려할때 - Sitting, standing Protective reaction - 무게중심의이동이너무빠르고, 너무커서무게중심을유지하여안정성을회복할수없을때 ex) Parachute reaction

75 Thank You for Your Attention.

New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck: the Key Link in Prematurity Treatment

Journal of Health Science 5 (2017) 56-72 doi: 10.17265/2328-7136/2017.02.002 D DAVID PUBLISHING New Ideas of Treatment for Cerebral Palsy I Capital Flexion of the Neck: the Key Link in Prematurity Treatment