Download Kinematics of Stabilization

KINEMATICS OF
STABILIZATION
Cap City Sport Symposium
April 14th, 2017
Richard Ulm, DC, MS
STABILIZATION
THANKS TO DR. DAPORE AND THE CAP
CITY SPORT SYMPOSIUM TEAM FOR THE
OPPORTUNITY TO PRESENT HERE.
RICHARD ULM, DC, MS
[BACKGROUND]
•
Treating physician at Columbus Chiropractic &
Rehabilitation Center in Dublin, Ohio
•
International instructor of Dynamic
Neuromuscular Stabilization (DNS) for the
Prague School of Rehabilitation.
•
The primary goal of my treatments is to
improve/restore the patients functional stability.
•
Lead instructor for Athlete Enhancement
•
I’m lucky to present all over the world on
rehabilitation, weight training and manual therapy.
STABILIZATION
“WEAK CORE”
STABILIZATION
OUT WITH OLD!
Since the mid 1990’s, therapists and trainers have
been training trunk stabilization via activation of
the transversus abdominus (TrA) by “drawing their
belly button inward” or “hollowing”.
This action is a concentric contraction of the TrA.
While this has been shown to produce a
contraction of the TrA, it does not activate the
trunk stabilizers in a way similar to how it
activates in function.
INSUFFICIENT MUSCULAR STABILIZATION OF THE LUMBAR
SPINE ASSOCIATED WITH LOW BACK PAIN
Paul W. Hodges & Carolyn A. Richardson | Spine1996
Methods:
Activation pattern/timing of the deltoid and transverse abdominus was measured in
patients with and without low back pain during shoulder flexion and abduction.
Results:
• Re-demonstrated that the transverse abdominus activates before agonist muscle
contraction (movement).
• Patients with lower back pain had delayed activation of the transverse abdominus.
Conclusion:
Activation of the TrA is essential in treating patients with LBP.
STABILIZATION
Most of the exercises designed to “activate” the transverse
abdominus involved drawing the abdomen in, which is a
concentric contraction of the TrA.
IN WITH THE NEW!
Over the past 20 years, Pavel Kolar, PT, Paed has
revolutionized the rehabilitation profession’s
understanding of stabilization, movement and function.
He has demonstrated the essential roll the diaphragm
plays in stabilization and how stabilization is more
about regulation of intra-abdominal pressure than
abdominal activity.
He has created assessment tests, rehabilitation
exercises and published research demonstrating these
principles.
Dr. Pavel Kolar of the Prague School of Rehabilitation
STABILIZATION
IN WITH THE NEW!
Prof. Kolar is a physiotherapist with a PhD in
pediatrics. He is from the Prague School of
Rehabilitation and has worked with great minds like
Vladimir Janda, MD (who identified the postural
syndromes: Lower-Crossed, Upper-Crossed and
Layered) and Karl Lewit, MD (a famous manual
therapist who was an early pioneer to such techniques
and post isometric relaxation and dry needling).
Prof. Kolar is the creator of Dynamic Neuromuscular
Stabilization (DNS), a powerful approach to
assessment and rehabilitation based on the
neurophysiological principles of developmental
kinesiology.
Dr. Pavel Kolar of the Prague School of Rehabilitation
STABILIZATION
AND
ANATOMY
KINEMATICS OF
STABILIZATION
STABILIZATION
- ANATOMY OF STABILIZATION Static Structures
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Pelvis
Ribcage
Lumbar spine
Dynamic Structures
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Thoracic Diaphragm
Abdominal wall (EO, IO, TA)
Quadradus lumborum
Erector spinae
Thoracolumbar fascia
Pelvic Diaphragm
Transversospinalis group
STABILIZATION
[Axial] Skeletal System
Thieme: Atlas of Anatomy
Components: Ribcage, spinal column,
pelvis
• The rigid frame to which the muscular
components of the trunk attach.
• Positioning of the ribcage, spine and pelvis
has a strong influence on both the magnitude
and quality of trunk stability.
•
STABILIZATION
Thoracic Diaphragm
[Facts]
Origin: Central tendon
Insertion:
• Costal Division: inner surface of the 7th-12th ribs
• Spinal Division: vertebral bodies of L1-L3
Action: Caudal translation of the central tendon, upward
rotation of the 7-12th ribs
• Innervation: Phrenic Nerve (C3-5), Vegus Nerve
• Comprised of a horizontally oriented, non-contractile central
tendon surrounded by vertically-oriented muscle fibers.
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Divides the thoracic cavity from the abdominal cavity.
Thieme: Atlas of Anatomy
•
•
STABILIZATION
Thieme: Atlas of Anatomy
STABILIZATION
Transversus Abdominus
[Facts]
Origin: inner surface of the 7-12th ribs, deep
layer of the thoracolumbar fascia, iliac crest,
inguinal ligament.
•
Insertion: linea alba, pubic crest
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Action: unilateral: ipsilateral rotation;
bilateral: compression of the abdomen.
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Horizontal muscle fiber orientation.
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Often the emphasis of training and research.
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Fibers blend with the diaphragm.
Thieme: Atlas of Anatomy
•
STABILIZATION
External Oblique
[Facts]
Origin: outer surface of the 5-12th ribs
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Insertion: linea alba, iliac crest
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Action: unilateral: ipsilateral lateral flexion,
contralateral trunk rotation; bilateral: trunk flexion,
downward rotation of the ribs.
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Diagonal muscle fiber direction (inferior/medial)
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Works with the contralateral internal oblique to
form the anterior oblique sling - important
functional/anatomical sling that connects the
shoulder to the opposite hip.
Thieme: Atlas of Anatomy
•
STABILIZATION
Internal Oblique
[Facts]
Origin: deep layer of the thoracolumbar fascia, iliac
crest, anterior superior iliac spine, iliopsoas fascia
•
Insertion: 10-12th ribs, linea alba
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Action: unilateral: ipsilateral lateral flexion,
contralateral trunk rotation; bilateral: pelvic
retroversion.
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Diagonal muscle fiber direction (superior/medial)
•
Works with the contralateral external oblique to
form the anterior oblique sling - important
functional/anatomical sling that connects the
shoulder to the opposite hip.
Thieme: Atlas of Anatomy
•
STABILIZATION
Serratus Posterior Inferior
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Origin: Spinous process of T11-L2, thoracolumbar
fascia.
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Insertion: lower margin of the 9th-12th ribs
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Action: creates downward rotation of the ribs
during maximal expiration, stabilizes the T/L junction
for the diaphragm and the psoas.
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Also assists in controlling tension of the
thoracolumbar fascia to improve stability of the
lumbar spine.
Thieme: Atlas of Anatomy
[Facts]
STABILIZATION
Thoracolumbar Fascia
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Origin: lumbar spine (deep layer to the transverse
processes, superficial layer to the spinous processes),
sacrum, ilium.
•
Insertion: erector spinae, latissimus dorsi, serratus
posterior inferior internal oblique, transverse
abdominus.
•
Action: Acts as a stable fixed point for many of
dorsal muscles. Profoundly important in stabilization
of the lumbar spine.
Thieme: Atlas of Anatomy
[Facts]
STABILIZATION
Quadratus Lumborum
•
Origin: Iliac crest
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Insertion: 12th rib, costal process of L1-L4
vertebrae
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Action: unilateral: ipsilateral lateral flexion; bilateral:
lumbar extension.
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Deepest layer of the dorsal aspect of the abdominal
wall.
Thieme: Atlas of Anatomy
[Facts]
STABILIZATION
Transversospinalis [Facts]
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Thieme: Atlas of Anatomy
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Comprised of: multifidus, semi-spinalis, and rotatores
muscles
Origin: sacrum (multifidus), transverse processes throughout
the entire spine.
Insertion: spinous processes. Multifidus: 2-4 levels above
insertion; Semi-spinalis: 4-6 levels above insertion; Rotatores:
1-2 levels above insertion.
Action: unilateral: spinal extension, ipsilateral lateral flexion,
contralateral rotation, bilateral: spinal extension.
Makes fine-tune adjustments to the spine to ensure proper
joint loading.
Extremely important for generating and controlling spinal
rigidity.
STABILIZATION
Pelvic Floor
[Facts]
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Comprised of: Comprised of the
iliococcygeus, pubococcygeus and
puborectalis muscles.
Origin: Pubis, sacrum, obturator
fascia, coxyx.
Insertion: coxyx, ischial spine
Action: Controls and stabilizes the
pelvis. Holds the abdominal contents
in place.
Works in opposition to the
diaphragm to regulate IAP.
Thieme: Atlas of Anatomy
•
STABILIZATION
Stabilization begins with concentric
contraction of the thoracic diaphragm.
STABILIZATION
Thieme: Atlas of Anatomy
ANALYSIS OF DIAPHRAGM MOVEMENT DURING TIDAL BREATHING AND DURING
ACTIVATION WHILE BREATH HOLDING USING MRI SYNCHRONIZED WITH SPIROMETRY
Kolar et. al | Journal of Physiological Research 2009
Methods:
MRI and spirometry was used to measure diaphragm movement during isometric
activation of upper extremity movement against resistance with and without respiration.
Results:
• Significant diaphragm contraction was noted during resisted shoulder flexion (isometric
activation)
Conclusion:
The diaphragm contributes to both respiration and stabilization.
STABILIZATION
CONCENTRIC CONTRACTION OF THE DIAPHRAGM PULLS
THE CENTRAL TENDON DOWNWARD TOWARDS THE PELVIS.
STABILIZATION
Thieme: Atlas of Anatomy
Caudal movement of the diaphragm
compresses the abdominal contents
and pushes them into the torso
musculature.
STABILIZATION
The Diaphragm and Outward-Pushing Force
Expiratory Position
of the diaphragm
Diaphragm
Pelvic Floor
Inspiratory Position
of the diaphragm
STABILIZATION
The abdominal wall will
then eccentrically activate
in opposition to this
outward-pushing force.
STABILIZATION
Initially activation of the abdominal wall is via the
,
physical contact between the abdominal organs and the
abdominal wall.
This is created by the contracting
diaphragm physically pushing the
abdominal contents into the
abdominal wall.
STABILIZATION
Co-Contraction and Spinal Stability
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Righ
Spine
Thieme: Atlas of Anatomy
TRUNK
STABILIZATION
Eventually,(at near maximal efforts) the
gaseous pressure in the abdomen increases to a point where
the actual IAP can contribute to this outward-pushing force to
increase spinal rigidity even more.
Ideal Gas Law
(aka Bolye’s Law)
PV = nRT
TRUNK
The CNS will regulate
the contractile strength
of the abdominal wall
and work with the
descending diaphragm
to control spinal rigidity.
STABILIZATION
TRUNK
STABILIZATION
Thieme: Atlas of Anatomy
Thoracolumbar Fascia
Stabilization & the Thoracolumbar Fascia
Posterior
Spine
TRUNK
Intra-Abdominal Pressure
(Centrifugal Force)
STABILIZATION
Anterior
TRUNK
STABILIZATION
TRUNK
STABILIZATION
Sequence of Events
Concentric contraction of the diaphragm
(generates the outward-pushing force within the abdomen)
Eccentric activation of abdominal wall & pelvic floor
(regulate the volume and therefore pressure within the abdomen)
TRUNK
STABILIZATION
Bracing vs. Hollowing
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Utilizes concentric
contraction of the
diaphragm to generate IAP.
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Utilizes concentric contraction
of the transverse abdominus for
stability.
Activates the full abdominal
musculature for maximal
co-contraction.
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Inhibits contraction of the
diaphragm.
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Eccentrically activates the
traverse abdominus.
Does not increase IAP to any
significant degree.
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Promotes chest breathing
Natural way of stabilizing.
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Unnatural way of stabilizing.
BRACING
HOLLOWING
TRUNK
STABILIZATION
TRUNK
STABILIZATION
AND
POSTURE
STABILITY
TRUNK
STABILIZATION
Any distortion in a
patient’s posture prohibits
optimal stabilizing
strategies and may result
in pathology.
TRUNK
STABILIZATION
For optimal function and
stability, the diaphragm
and the pelvic floor
should be parallel.
TRUNK
STABILIZATION
TRUNK
STABILIZATION
TRUNK
Why is
posture so
important
for
stability?
STABILIZATION
•
Direction of diaphragm excursion is
caudal, towards the pelvis, which
optimizes co-activation of the entire
abdominal wall.
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Maximal change in volume necessary
for maximal bracing events.
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Utilizes all three divisions of the
diaphragm for increased contractile
force output.
PHYSIOLOGICAL
PATHOLOGICAL
TRUNK
STABILIZATION
TRUNK
STABILIZATION
TRUNK
STABILIZATION
STABILIZATION
PRECEDES
MOVEMENT
For more information on this subject, Dynamic Neuromuscular Stabilization (DNS)
and Pavel Kolar, visit:
www.athlete-enhancement.com/dns-a-course-columbus
A DNS Clinical A-Course will take place here in Columbus on June 9-11th, 2017
- Approved for CEUs for PTs, ATCs, and Chiropractors -
Columbus Chiropractic & Rehabilitation Center
6077 Frantz Road, Suite 103
Dublin, Ohio 43017
Bibliography:
1. Bordoni, B, and Zanier, E. Anatomic connections of the diaphragm: Influence of respiration on the body
system. Journal of Multidsciplinary Healthcare (6): 281-291, 2013.
2. Hodges, PW, Eriksson, AE, Shirley, D, and Gandevia, SC. Intra-abdominal pressure increases stiffness of the
lumbar spine. Journal of Biomechanics 38(9): 1873-1880, 2005.
3. Hodges, PW, and Richardson, CA. Relationship between limb movement speed and associated contraction of
the trunk muscles. Ergonomics 40(11): 1220-1230, 1997.
4. Hodges, PW, and Gandevia, SC. Changes in intra-abdominal pressure during postural activation of the human
diaphragm. Journal of Applied Physiology 89(3): 967-976, 2000.
5. Kolar, P, and Andelova, V. Clinical Rehabilitation. Prague: Rehabilitation Prague School, 2013. N. pag. Print.
6. Kolar, P, Sulc, J, Kyncl, M, Sanda, J, Cakrt, O, Andel, R, et al. Postural function of the diaphragm in persons
with and without chronic low back pain. Journal of Orthopedic and Sports Physical Therapy 42(4): 352-362, 2012.
7. Kolar, P, Sulc, J, Kyncl, M, Sanda, J, Neuwirth, J, Bokarius, AV, et al. Stabilizing function of the diaphragm:
Dynamic MRI and synchronized spirometric assessment. Journal of Applied Physiology 109(4): 1064-1071, 2010.
8. Schuenke, M, Schulte, E, Schumacher, U, Ross, LM, Lamperti, ED, and Voll, M. Atlas of Anatomy: General
Anatomy and Musculoskeletal System. Stuttgart, NY: Thieme; 2010.