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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