Download Multi-segmental give

Muscle imbalance and
sensory motor control
Alex Sapir, BPT, MaPT
Geoffrey Douglas Maitland
Born: 27 August 1924, Adelaide
Died: 22 January 2010, Adelaide
Patience is a virtue: don’t assume
anything any but prove it.
Geoffrey Maitland 1999
Modern manual therapy
Segmental Restriction
Сегментарное
ограничение
подвижности
Segmental give
Сегментарная
гипермобильность
Multi-segmental
Restriction
Мультисегментарное
ограничение
подвижности
Multi-segmental give
Мултисегментарная
гипермобильность
Non-mechanical
problem
Segmental Restriction
Multi
Multi--segmental Restriction
Mechanical
problem
Segmental give
Multi--segmental give
Multi
The Three System That Contribute
to Active Joint Stabilisation
Control Subsystem
Neural
Joint
Stability
Passive Subsystem
Joint
Active Subsystem
Muscles
Passive Subsystem
Articular Anatomy
Glenoid Labrum
Capsule and Ligaments
Other Stabilizing Mechanisms
Articular Anatomy
Glenoid Labrum Contribution
the
labrum is analogous to a chock-block
‫‪Capsule and Ligaments‬‬
‫בניגוד למפרקים אחרים‬
‫בעלי תושבת לא‬
‫עמוקה אין למפרק‬
‫הכתף רצועות מתוחות‬
‫וחזקות המאפשרות‬
‫תנועה סביב ציר‬
‫מסוים‪.‬‬
‫‪Capsule and Ligaments‬‬
‫ ברוב התנוחות הפונקציונליות הרצועות רפויות ולא‬
‫תורמות ליציבות‪.‬‬
‫ רצועות הכתף מקבלות חשיבות כמייצבים רק‬
‫בסופי טווחי התנועה‪.‬‬
‫)‪(Matsen et al, 1994; Warner et al, 1992‬‬
‫ ‪ Neutral zone‬גדול‪.‬‬
‫ חשיבות רבה של המערכת‬
‫האקטיבית‪.‬‬
The Inferior Glenohumeral
Ligament Complex (IGHLC)
• is the primary
ligamentous stabiliser of
the shoulder.
• alternatively
tightening in external or
internal rotation.
(O'Brien et al, 1990a)
Muscle function
Concentrically shorten and accelerate motion
for mobility function
Isometrically hold or eccentrically lengthen and
decelerate motion for stability function
Provide afferent proprioceptive feedback to the
central nervous system (CNS) for coordination
and regulation of muscle function.
Comerford and Mottram (2001)
Postural muscles are those which hold the
body erect and work against gravity.
They
are more or less continualy active.
Phasic muscles are recruited when
movement is required and are therefore
less frequently activated.
Janda 1985
Classification of Muscle
Function
STABILIZER
LOCAL
LOCAL
STABILIZER
MOBILIZER
GLOBAL
GLOBAL
STABILIZER
GLOBAL
MOBILIZER
LOCAL
STABILIZER
GLOBAL
STABILIZER
GLOBAL
MOBILIZER
- Muscle stiffness
to control joint or
segmental motion
- Controls the
neutral joint
position
- Does not
produce R.O.M.
- Activity is
independent of
direction of
movement
- Generates force
to control range of
motion
- Eccentric length
change ∴ control
throughout range
- Low load
deceleration of
momentum
- Non-continuous
activity
- Activity is
direction dependent
- Generates
torque to produce
range of movement
- Concentric
production of
movement
- Shock absorption
of load
- Non-continuous
activity
- Activity is
direction dependent
LOCAL
STABILISER
Subscapularis
and other deep
rotator cuff
muscles
GLOBAL
STABILISER
GLOBAL
MOBILISER
Subscapularis
Posterior deltoid
Infraspinatus
Teres major
Teres minor
Pectoralis minor
Latissimus dorsi
Teres major
Deltoid
Supraspinatus
Muscle imbalance
Segmental instability
Muscle imbalance
Muscle imbalance
Agonist – antagonist
Agonist – synergist
Bilateral muscles
Muscle chain
Muscle imbalance
Sensory motor control
The sensorimotor system is defined as all of the sensory,
motor, and central integration and processing components
involved in maintaining joint stability
Joint
movement – Proprioception –
mechanism that coordinates the transition
from one position to another
Joint position
Sensorimotor system
Sensorimotor system is defined as all of
the sensory, motor, and central integration
and processing components involved in
maintaining joint stability
Proprioception
Proprioception is defined as the afferent
information, arising from peripheral areas
of the body (including the mechanical and
dynamic restraints about the shoulder) that
contributes to joint stability, postural
control, and motor control
Three submodalities of proprioception
Proprioception has three submodalities
including
joint
position sense,
kinesthesia, and
sensation of force
Manual muscle testing
Relevance of the existing method
Need for sensitive instrument for
assessment of muscle imbalance
New approach – stretch reflex of the
contracted muscle
Alpha
– gamma co activation
Muscle Stretch Reflex
Response characteristics of the stretch receptor—
another example of frequency coding.
γ-motoneurons
There are two distinct populations of γmotoneuron: dynamic γ-motoneurons and
static γ-motoneurons.
Dynamic
γ-motoneurons have axons that
innervate only dynamic nuclear bag fibres
(bag1) .
Static γ-motoneurons innervate both nuclear
chain fibres and static nuclear bag (bag2)
fibres.
Descending neurons (pyramidal tracts!)
stimulate both alpha and gamma neurons.
This combined stimulation of the alpha
and gamma efferent neurons sets up a
situation in which there will automatically
be an increase in tension of the muscle if
the load is too heavy. This combined
stimulation of the two neuron types is
called alpha-gamma co-activation.
Muscle testing in 3 stages
1-st stage
Bring
Alpha motorneuron
2-nd stage
Hold
to testing position
in this position for 3 sec
Gamma 2 - static
3-d stage
Resist
Gamma1 - dynamic
Factors influencing muscle
reflex
Innervations
Muscle receptors
Golgi
tendon
Muscle spindles
Joint position
Pain inhibition
Other mechanisms
Deltoid
Deltoid
Compensated
hyperactive
Upper
trapezius
Deltoid
DELTOID
DELTOID (axillary C5
C5,6)
spinal level
SS (C4,5,6),Teres minor (C4,5), IS
(C4,5,6), Subsc (C5,6,7), Biceps (C5,6),
Brachialis (C5,6), Coracobrachialis (C
5,6,7),Supinator (C5,6)
peripheral nerve – axillary n – Teres minor.
Shoulder muscle innervation
C4 - SS, Teres minor
C5 – SS, Deltoid, IS,
Subscap, Teres Maj,
Biceps, Brachialis
C6 – Deltoid, IS, SS,
Subscap, Teres Maj,
Biceps, brachial
C7 – Subscap, Teres
Maj
Teres minor
Deltoid
Biceps
Subscap,
Triceps
Subscapularis
Subscapularis
upper and lower subscapular, C5,6,7.
Spinal level : IS (C4,5,6), SS (C4,5,6),
Biceps (C5,6), Brachialis (C5,6),
Coracobrachialis (C 5,6,7),Supinator
(C5,6), Triceps (C6.7.8), Ex carpi rad (C
6,7,8), FL car rad (C6,7), Pronator teres
(C6-7).
Supraspinatus
Supraspinatus
suprascapular, C5, 6
Spinal level
Teres minor (C4,5), IS (C4,5,6), Subsc
(C5,6,7), Biceps (C5,6), Brachialis (C5,6),
Coracobrachialis (C 5,6,7),Supinator
(C5,6)
Peripheral nerve
infraspinatus
Infraspinatus
Infraspinatus
suprascapular, C5, 6.
Spinal level:
SS (C4,5,6),Subsc (C5,6,7), Biceps
(C5,6), Brachialis (C5,6), Coracobrachialis
(C 5,6,7),Supinator (C5,6), Triceps
(C6.7.8), Ex carpi rad (C 6,7,8), FL car rad
(C6,7), Pronator teres (C6-7).
Peripheral nerve
supraspinatus
Teres minor
Teres minor - axillary, C4, 5, 6
IS (C4,5,6), SS (C4,5,6),Subsc (C5,6,7),
Biceps (C5,6), Brachialis (C5,6),
Coracobrachialis (C 5,6,7),Supinator
(C5,6),
Axillary – deltoid
Pectoralis Major — Clavicular
Division
Pectoralis Major — Clavicular
Division
lateral pectoral, C5, 6, 7
IS (C4,5,6), SS (C4,5,6),Subsc (C5,6,7),
Biceps (C5,6), Brachialis (C5,6),
Coracobrachialis (C 5,6,7),Supinator
(C5,6), Triceps (C6.7.8), Ex carpi rad (C
6,7,8), FL car rad (C6,7), Pronator teres
(C6-7).
Sternal Division ?
Pectoralis Major - Sternal
Division
Pectoralis Major - Sternal
Division
lateral and medial pectoral, C6, 7, 8, T1
Triceps (C6.7.8), Ex carpi rad (C 6,7,8), FL
car rad (C6,7), Pronator teres (C6-7), Ext
car ul (C 6,7,8), Fl car ul (C6,7,8), Ext dig
long (C6,7,8),
Clavicular division (later division), pec
minor (medial division)
Serratus anterior
long thoracic, C5, 6, 7
Spinal level : IS (C4,5,6), SS
(C4,5,6),Subsc (C5,6,7), Biceps (C5,6),
Brachialis (C5,6), Coracobrachialis (C
5,6,7),Supinator (C5,6), Triceps (C6.7.8),
Ex carpi rad (C 6,7,8), FL car rad (C6,7),
Pronator teres (C6-7).