Download Low Load/Speed - Ontario Kinesiology Association

John Gray, Rkin, MSc, CSCS
May 7, 2016
Ontario Kinesiology Association
A bit about me...
~20 years in Ortho / S&C
Multi-disciplinary facility & Private practice
• Recreational & active populations
• Competitive athletes (OVA, FIVB, OAA)
• + Chronic / Post-surg / Pain clientele
Education:
• PhD Studies at UW (McGill)
• Sahrmann Movement Impairment
• Kinetic Control International (UK)
• Clinical Skills Specialist Diploma Program
Acknowledgements
Rob Werstine, PT & Jack Miller, PT, PhD
http://www.clinicalskillsspecialist.com/
• Treatment Based Classification
Dr. Stuart McGill, PhD
• Clinical decision-making process
• UW Research Activities
Evolution of Stability Training:
Spine
Stability
Segmental
Stabilization
Core
Stability
Motor
Control
Saal & Saal, ca. 1988
Hodges (1996)
Chek (2000)
Sahrmann ‘02? –
O’Sullivan ’05 –
…etc.
Transversus onset timing,
“instability”, & LBP:
 Cholewicki et al. (2002)
 During moderate perturbations, LBP patients show delayed
onset in MANY muscles.
 AND different people had different muscles that were most
dysfunctional, and different number of dysfunctional
muscles.
 Van Dieen & Cholewicki (2003)
 Trunk muscles in patients with LBP COMPENSATE their
recruitment patterns to enhance stability of the lumbar
spine during voluntary movements.
Strength v Control
“Force Control” Methods:
Biomechanical / Strength
+ Strength & Power ~ Stability for Sport
• Fatiguing Loads & Improved Work Capacity
+ Recovery of Muscle Atrophy
+ Linked to Functional Movements ~ Sport / Skill Specific
- Does not consider pain responses
- No correction of intersegmental translation control
- Does not decrease recurrence of injury / pain
What is Impaired Movement Control?
•
•
•
•
Altered movement performance that has increased tissue stress
Decreased proprioception to the area
Repetitive over different postures / movements
May or may not produce pain
What is Movement Control Exercise?
• Modification of posture/alignment, movement
and muscle activation strategies
• Goal of optimization of load (via movement and
stiffness).
“Movement Control” Methods:
Motor Control Retraining
+
+
+
+
Can DIRECTLY influence PAIN related changes to MU recruitment
Can improve intersegmental translation control
Evidence supports its use to DECREASE RECURRENCE risk
Able to influence recruitment patterns in GLOBAL muscles
- Non-functional activation of muscles required
- Unable to recover (disuse) atrophy or increase muscular power
- Progressions often misused as replacement for strength training
Motor Control Stability vs. Strength
Good Mov’t Poor Mov’t
Control
Control
STRONG
WEAK
++ -+
+- -Pain Free
Good
Performance
Poor
Performance
Painful
Adapted from Comerford & Mottram (2010)
Cochrane Reviews
Chronic Non-Specific Low Back Pain (Saragiotto et al., 2016)
29 Trials (n=2431)
vs. Other Exercise:
• Little or no difference
vs Minimal Intervention:
• Probably reduces pain at short, intermediate and long-term follow-up.
• Probably improves function and recovery
vs Manual Therapy:
• Probably no difference
vs Electrophysical Agents:
• May be slightly more effective for pain, disability, recovery and quality of life
Cochrane Reviews
Acute Non-Specific Low Back Pain (Macedo et al., 2016)
3 Trials (n=197)
vs. Other Exercise:
• No benefit
vs Spinal Manipulative Therapy:
• No benefit
vs Medical Treatment:
• No benefit
Re: reducing future risk of re-injury:
• Unable to support
What is wrong with this question?
Low Back Pain is:
A SYMPTOM
NOT
A DISEASE
Exercise Prescriptions
Classification of LBP
Current Approaches
Assessment
Varies greatly between methods
Must be:
• Comprehensive (movement, posture and muscle activation)
• Include sensory function and psychological issues.
However, tests and their interpretation differ greatly:
•
•
•
•
Movement between limbs and spine (McGill, 2007; Sahrmann, 2002)
Movement between parts of the spine (Sahrmann, 2002)
Quality of the muscle recruitment strategy (Richardson, 2004)
Provocation of painful tissues (McGill, 2007)
Treatment
Is motor control training even appropriate?:
• Treatment Based Classification (2015)
Indicates additional evaluation on what type of exercise?
• Classification into Subgroups?
(Sahrmann, 2002; O’Sullivan, 2005)
• Clinical-reasoning approach
(McGill, 2007; Richardson, 2004)
Correction of Motor Control Faults
Posture
Movement
Muscle Activation
Breathing Issues
Continence /
other pelvic floor
issues
Belief and
Attitudes
Optimization of Motor
Control
Optimization of motor
control
Static Progression
Dynamic Progression
Adjacent regions
Sensory function
Static control of
lumbopelvic orientation /
alignment
Dunamic control of
lumbpelvic orientation /
alignment and movement
Balance issues
Muscle strength
and endurance
Functional Re-Education
Specific to patient goals
Fitness
Adapted from Hodges (2013)
Physical Therapy
DOI: 10.2522/ptj.20150345
Published February 25, 2016
Medical
management
Triage by
first
contact
provider
Rehabilitation
management
Self-care
management
Triage by first
contact
provider
Medical
management
Red lights
 Neurological: major motor
weakness, bowel-bladder
disturbances, saddle
anesthesia
 Infection: fever, risk of UTI,
immune suppressed
 Fracture: Trauma
,Osteoprosis
 Tumor: Past cancer, weight
loss, fever, night pain
 Inflammation: morning
stiffness > 1 hour, <20 y/o
or > 50 y/o.
Triage by first
contact
provider
Rehabilitation
management
Yellow lights
 Back/neck dominant pain
 No significant distal limb
pain
 Negative neurological
screen findings
 Expectation that treatment
will help
 Short duration of
symptoms
 Low FAB-Q < 19.
Triage by first
contact
provider
Managed
Self-care
Green lights
 Intermittent axial spine
pain
 Low RMDQ/NDI score
 Very low FABQ score
 Functional ROM
 Minimal muscle
guarding at rest
 Episodic self treatment
abolishes pain.
Disability – Low
Symptom status –
Controlled
Pain – Low to None.
Medical
management
Triage by
first contact
provider
Rehabilitation
management
Self-care
management
Disability – Moderate
Symptom status – stable
Pain – Moderate to low
Disability – High
Symptom status – Volatile
Pain – High to Moderate
Functional
Optimization.
Medical
management
Triage by
first contact
provider
Rehabilitation
management
Movement
control
Self-care
management
Symptom
modification
Determine optimal
management approach
Medical
management
Symptom
modification
Treatments
Directional
preference
exercises
Manipulation/
mobilization to
“reset” neuro/pain
system
Dry needling
Modalities PRN
Rehabilitation
management
Movement
control
Self-care
management
Functional
optimization
Hierarchical progression for symptom modulation
Is the patient
highly
irritable
If yes
address by
OTC
meds/consult
MD re
prescriptive
meds
Does the
patient have:
Leg dominant
pain
Peripheralize/
with both
flexion/extens
ion
Crossed
SLR or ++ve
SLR
Soft neuro
signs
Consult MD
re Pre-GABA
meds
Active rest
Does the
patient
centralize
with sagittal
plane
movements?
If yes use
directional
preference to
centralize
+/- manual
therapy in
direction of
preference
Does the
patient fail to
centralize in
sagittal
plane?
If yes
Is there a
lateral
component?
Lateral glides
Does the
patient stop
centralizing
?
And no
symptoms
below
knee/elbow
Low
FABQ/NDI
Short
duration
+ve stress
test for pain
but no spasm
Manipulation
Determine optimal
management approach
Medical
management
Symptom
modification
Rehabilitation
management
Movement
control
Self-care
management
Functional
optimization
Treatments
Sensory motor
exercises
Stabilization
exercises
Flexibility
exercises
Manual therapy
to increase ROM
Hierarchical Progression for Movement Control
Is there a
sensitized
neurological
structure?
If yes address by
Unloading
then sliders
then tensioners
Is there a joint
mobility or muscle
flexibility
impairment?
If yes
Flexibility
exercises
Joint manipulation
/ mobilizations into
the motion barrier
Dry needling
ART
Hold/relax
Is there a motor
control
impairment?
If yes motor
control exercises
DNF
TA
McGill Big 3
Is there a muscle
endurance
impairment?
If yes
endurance/postural
control exercises
Determine optimal
management approach
Medical
management
Symptom
modification
Rehabilitation
management
Movement
control
Self-care
management
Functional
optimization
Treatments
Strength and
conditioning
exercises
Work or sport
specific tasks
Aerobic
conditioning
General fitness
exercises
Hierarchical progression for functional optimization
Is there ongoing
fear of activity?
If yes can it be
overcome with
education /reasurance?
Is there significant
general
endurance
impairment?
If yes start with
general
endurance work
Remember that
the patient has
often not done
this before
Is there a
significant
postural control
issue?
If yes educate and
help them focus
on trunk control
during sustained
activities
Is there a
work/ADL/sport
specific
impairment?
If yes work on
specific tasks that
replicate most
components of
activity.
Hierarchical progression for functional optimization
Part 2:
Movement Control Training
Movement Control Testing
APPROACH IS INDIVIDUALIZED:
1. Identify Area of Concern (pain, history of injury)
2. Identify Relevant Uncontrolled Joint Movement
• Site (e.g., hip)
• Direction (e.g., flexion)
3.
Evaluate the Severity of the Movement Impairment
• High Risk = linked to a history of injury
• Low Risk = no link to injury
Q: What habits may predispose client to this?
Movement Control Testing Classification
Low Load
Low Speed
High Load
Low Speed
Low Load
High Speed
High Load
High Speed
The “Weak Link” and
Movement Impairment
High Load
Low Load
• Slow, Static
• Non-fatiguing /unloaded
• Fatiguing and /or Fast
MOVEMENT CONTROL
STRENGTH &
NEURAL ADAPTATION
Local Muscles
• translation control
Global Muscles
• functional range
Global Muscles
• functional range
Identifying Weak Links:
Failure of Low Load Tests Identifies Risk of:
1. Injury Associated with a minor incident or unguarded movements
2. Overuse injury / repetitive low load injury, or static posture
3. Injury recurrence
Failure of High Load Tests Identifies Risk of:
1. Injury Associated with Fatiguing Loads
2. Overuse injury associated with repeated high load activity
3. Loss of power / strength / speed consistency
Treatment Approach:
Does training of motor control
need to be cognitive?
• Movement and not muscles?
• Clinical trials show that cognitive training is associated
with changes in the activation of trunk muscles
• Cognitive attention to correction of muscle activation
induces greater change in the behaviour of the muscle and
cortical brain map organization. (see Tsao & Hodges)
Train the Movement or Muscle?
MUSCLE:
History of Injury
• Present Functional or Proprioceptive Loss
• Recovery is not automatic (Hides et al, 1997)
• Infiltration of Fatty Tissue
• Neural Insufficiency to affected muscles.
•
MOVEMENT:
• Complete recovery from injury
• Apparently Healthy
Beevor’s Axiom
Beevor's axiom "the brain knows nothing of individual muscle
action, but knows only of movement.“
Charles Edward Beevor (1854-1908), an English anatomist
Cortical Mapping and Muscle
Tsao & Hodges
2007, 2008, 2010
SMUDGING of
cortical map
responsible for
muscle action
Restored via
specific muscle
activation strategy
Movement Function & Dysfunction
• Muscles produce max force
at middle range
• Inefficient and appear
functionally weak when
having to produce force in
inner “shortened” range or
outer “lengthened” range
Inner Range
'shortened'
Physiological
Insufficiency
Middle Range
'neutral' or
resting position
Optimal
Force Efficiency
Force Inefficiency
'functionally weak'
Outer Range
'lengthened'
Mechanical
Insufficiency
Movement Function & Dysfunction
Habitual lengthening
or shortening affects
the F-L relationship
relative to body
positions
Postural changes may create Physiological Insufficiency
at “Neutral” Joint position!
Application of Motor Control (Low
Load/Speed) Retraining Strategies:
1. Practice the failed test exercise until it is easily passed
2. Direction Dissociation
i.
Actively control movement at problem site
ii. Produce movement at an adjacent site ABOVE and BELOW
IMPORTANT FACTORS:
1. Slow or static contraction that can be sustained for at least 2 minutes
2. Must be low effort
3. Must not compensate with adjacent muscles
Direction Dissociation
Hoffman et al., 2012
Direction Dissociation
May be categorized according to the following:
Low Load
Low Speed
High Load
Low Speed
Low Load
High Speed
High Load
High Speed
Low Load:
Movement Control Retraining
1. Choose ONE Low Load/Speed to control the Weak Link
1. Above
2. Below
What compensatory movements can you find when
performing the RETRAINING EXERCISE?
IMPORTANT FACTORS:
1. Slow or static contraction that can be sustained for at least 2 minutes
2. Must be low effort
3. Must not compensate with adjacent muscles
Eccentric Control
Those with a history of injury or unresolved functional losses
often show loss of eccentric control.
Eccentric contraction is COGNITIVELY CONTROLLED
Fang et al., J Neurophysiol. 86: 1764–1772, 2001
Cortical activities for movement preparation (feed forward) and execution, were
greater in eccentric than concentric tasks
Semmler et al. Journal of Physiology (2002), 545.2, pp. 681–695
• strength of motor unit synchronization is greatest during lengthening contractions
• likely to be enhanced feedback from muscle spindles compared with postural and
shortening contractions
Training the Stability Systems
Biomechanical & Motor Control Approaches
are SEPARATE PROCESSES that need to be
trained CONCURRENTLY.
BOTH Methods are essential for complete
recovery.
Hodges, PW. (2003) Orthop Clin N Am Apr;34(2):245-54.
Low to High Load Transition:
1. Increase Resistance
i. Bands, tubing, dumbbells, etc.
2. Increase Speed
i. Fast, alternating limb movements
3. Decrease External Stability
i. Must still be able to maintain control
Q: Do Unstable Surfaces retrain Slow or Fast Motor Units Function?
Parallel Integration
Low Force or Speed
High Load or Speed
Local “Motor Control” Stability
Automatic integration into loaded function
Global “Motor Control” Stability
Progression by adding load or speed
Asymmetrical Strengthening
Symmetrical Strengthening
Extensibility / Flexibility
Part 3: Practical
Generalized
Movement Control Approach
1. ‘Initial’ Phase:
1. Cognitive Control of underactive muscles
2. Control Movement Dysfunction
1. Stabilize the mobile area
3. Address changes in adjacent joints
1. Control of active range
2. Total range of movement
3. Reduce external support
Generalized
Movement Control Approach
2. ‘Intermediate’ Phase:
1. Continue with ‘initial phase’ targets
2. Increase physiological demand
1. Circuits of exercises
2. Increase hold times
3. Cardiovascular conditioning
Generalized
Movement Control Approach
3. ‘Advanced’ Phase:
1. ‘initial phase’ targets should be automatic
2. Add interval cardio
3. Progress to increase:
1. Loads
2. Speeds
3. Plyometric / Ballistic
4. Sport-specific / work-specific
Overly-simple client example:
Hx:
55 y/o Male
Gradual Onset
P +/- resolved & localized
No leg pain
P= 1-4/10 daily
Generally improving


Sitting > 15 minutes
Driving
Bending Forward
Lifting / Carrying
Rising from Chair/Toilet
Walking (quickly)
Standing
Laying prone
… and the movement control impairment is?
LUMBAR FLEXION
Generalized
Movement Control Approach
Initial Phase: Posture and Movement Control
Develop patterns to CONTROL LUMBAR FLEXION
• Same site, OPPOSITE direction
• Lumbar “NEUTRAL”
Initial Phase: Cognitive Control
What muscles COMPROMISED?
• Lower abdominals (TrA/IO)
• Gluteus Maximus
• Gluteus Medius
Isolated holds do not relate to TrA alone!
• Any underactive muscle will adapt.
Initial Phase
Address changes in adjacent joints (Hodges, 2013):
HIPS
THORACIC SPINE
Restricted
Flexion
Flexion
++ Range
Extension
Extension
HIP Movement Control (Low Load)
• Back Bridge
• Waiter’s Bow
• Seated Forward Lean
Progression toward functional positions
+/- Glute Contraction in:
• Concentric Phase
• Eccentric Phase
• End Range (Inner Range Hold)
Guidelines for Low Load Movement
Control Training
Low Load/Speed:
• Slow and controlled
• Muscle active during both concentric AND eccentric phases*
• No momentum or bouncing (“moving through water”)
• Able to perform for 2 minutes (or 20 reps) WITHOUT FATIGUE
• Progression is to remove support (increase proprioceptive
demand) NOT increase resistance.
• INCREASED COGNITIVE DEMAND
Guidelines for Movement Control
Endurance Training
• Big Three
• Chair Squat
• Shortstop Squat
Progression toward functional positions
Keep going! +/- Glute Contraction in:
• Concentric Phase
• Eccentric Phase
• End Range (Inner Range Hold)
Movement Control Exercises
Transition to High Load
High Load/Speed:
•
Controlled dynamic (force and speed) and can be ballistic in nature
• Should be < 20 reps (appreciate the grey area though!)
• INCREASED CONTRACTILE DEMAND
• INCREASED FATIGUE WILL UNCOVER MOVEMENT IMPAIRMENT
Guidelines for Strength Training
• Deadlifts
• Goblet Squat
• Drop-jumps
Progression toward Sports / Work Demands
Pay special attention:
• Sport-specific or Simulation?
• Emphasize Dynamic Correspondence
ANYONE CAN MAKE YOU TIRED.
Take Home Points:
1. Identify movement classification to improve outcome.
2. Know “WHEN” is your client and “WHO” is most
appropriate for that treatment stage
3. Retrain “COGNITIVE CONTROL” in initial phase
4. Allow for overlap in treatment phases
5. Match training with work/sport demand