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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 • • • Pelvis Ribcage Lumbar spine Dynamic Structures • • • • • • • 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. • • 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 • Action: unilateral: ipsilateral rotation; bilateral: compression of the abdomen. • Horizontal muscle fiber orientation. • Often the emphasis of training and research. • Fibers blend with the diaphragm. Thieme: Atlas of Anatomy • STABILIZATION External Oblique [Facts] Origin: outer surface of the 5-12th ribs • Insertion: linea alba, iliac crest • Action: unilateral: ipsilateral lateral flexion, contralateral trunk rotation; bilateral: trunk flexion, downward rotation of the ribs. • Diagonal muscle fiber direction (inferior/medial) • 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 • Action: unilateral: ipsilateral lateral flexion, contralateral trunk rotation; bilateral: pelvic retroversion. • 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 • Origin: Spinous process of T11-L2, thoracolumbar fascia. • Insertion: lower margin of the 9th-12th ribs • Action: creates downward rotation of the ribs during maximal expiration, stabilizes the T/L junction for the diaphragm and the psoas. • Also assists in controlling tension of the thoracolumbar fascia to improve stability of the lumbar spine. Thieme: Atlas of Anatomy [Facts] STABILIZATION Thoracolumbar Fascia • 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 • Insertion: 12th rib, costal process of L1-L4 vertebrae • Action: unilateral: ipsilateral lateral flexion; bilateral: lumbar extension. • Deepest layer of the dorsal aspect of the abdominal wall. Thieme: Atlas of Anatomy [Facts] STABILIZATION Transversospinalis [Facts] • • • • • Thieme: Atlas of Anatomy • 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] • • • • 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 ue bliq al O tA bdo min al O s Lef in dom t Ab bliq u es 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 • • • • Utilizes concentric contraction of the diaphragm to generate IAP. • Utilizes concentric contraction of the transverse abdominus for stability. Activates the full abdominal musculature for maximal co-contraction. • Inhibits contraction of the diaphragm. • Eccentrically activates the traverse abdominus. Does not increase IAP to any significant degree. • Promotes chest breathing Natural way of stabilizing. • 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. • Maximal change in volume necessary for maximal bracing events. • 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.