Joint Stabilization Considerations and Basic Instruction of Back Rehab

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Joint Stabilization Considerations andBasic
Instruction of Back Rehab

• Brian Bradshaw and Amy Davis
• October 6, 2003

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In General

• Methods for stabilization must address the normal
  functional role of muscle AND the physiological
  dysfunction
• Stabilization involves inter-relationship between
  several muscles acting on the joint to protect it
  during functional movement

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Muscle Classifications

• 2 types
• Monoarticular
• Biarticular / Multijoint
• Each differs in its capacity to stabilize a joint

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Monoarticular Muscles

• Cross one joint and control one specific joint
  movement
• Are closely associated with joint stability
• May lie within a larger synergistic group but
  their individual contraction affects only one
  spinal region
• Anatomical arrangement enhances stabilization
  role
• Design allows them to control large joint forces
  rather than large ranges of motion

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Biarticular / Multijoint

• Functional qualities render them less able to
  provide joint support
• Capable of influencing more than one spinal
  region
• Anatomically designed for complex movement
  involving several areas of the body
• Clinically they are more likely to become
  overactive and tight
• Need to be monitored for substitution
• Examples
• Thoracic erector spinae and rectus abdominus

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Muscles Designed for Stabilization

• Some muscles are specifically designed for
  stabilization
• Location
• Stabilizers are usually deep and located close to
  the joint
• Often have extensive attachments to passive joint
  structures including the joint capsule
• Short length makes them ideal for increasing
  joint stiffness
• Examples
• C-spine
• Deep longus capitus, longus colli, semispinalis
  cervicus, segmental multifidus
• L-spine
• Lumbar multifidus, transverse abdominus

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Muscle Stiffness

• Reflects ratio of force change to length change
  in muscle
• Describes the spring like qualities of muscle
• High stiffness requires increased force for
  length change
• High stiffness in muscles surrounding a joint
  ensures good stabilization
• Low muscle stiffness is linked to poor
  stabilization

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Joint Stabilization through Co-contraction and
Co-activation

• Muscle co-contraction provides the biomechanical
  forces for added joint stability and protection
  especially in mid-range or neutral joint
  positions
• This is where passive joint structures are lax
  and passive restraint is minimal
• Functional benefits
• Protection of the joint from unexpected loads
• Maximizing joint congruency
• Equalizing pressure distribution over articular
  surfaces
• Centering the joint
• Stress absorption

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Continued

• Negatives
• Linked to greater energy expenditure and muscle
  inefficiencies
• Evidence of sustained co-contraction of
  transverse abdominus and deep fibers of lumbar
  multifidus to control trunk movement

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Co-contraction and Exercise

• Inadequacies of Unidirectional Strength Training
• Control of Joint Position
• Closed or Open Chain Exercise?

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Inadequacy of Unidirectional Strength Training

• Over training of the agonist muscles can reduce
  co-contraction of the antagonists
• Can be considered serious b/c it may compromise
  joint stability and predispose some groups to
  increased risk of injury
• Antagonists of hypertrophied agonists become
  markedly inhibited
• Unidirectional training is not advised for people
  that require control of joint stabilization
  through co-contraction

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Control of Joint Position

• Co-contraction is increased with unstable
  environments
• Increases in level of muscle co-contraction
  occurred with tasks that required high degree of
  precision and control

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Closed or Open Chain Exercises?

• Muscle protection of the joint is needed in both
  open and closed chain activities
• Warnings
• High levels of co-contraction may produce harmful
  levels of joint compressive forces which could
  result in injury rather than protection
• Continuous use of inappropriately high levels of
  muscle co-contraction may compromise freedom of
  movement and cause rigidity

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Muscle Control and Joint Pain

• The muscle control necessary for joint stability
  is also affected by pain and joint pathology.
  Pain and reflex inhibition resulting from injury
  or pathology in addition to a change in the
  sensory input to the muscles from damaged
  ligaments and capsules can influence the ability
  of muscles to support and protect a joint.
  Inhibition affects the slow twitch fibers which
  then comes more fast twitch in nature
  compromising their support function. These
  factors need to be addressed when designing a
  rehab program.

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Pain and Reflex Inhibition

• Reflex inhibition is defined as the situation
  that occurs when sensory stimuli impede the
  voluntary activation of the muscle
• Inhibition b/c of pain or fear of pain should not
  be considered reflex inhibition which is believed
  to be painless
• Reflex inhibition is elicited by abnormal
  afferent information from a damaged joint
  resulting in decreased motor drive to muscle
  groups acting across a joint
• Reflex inhibition causes weakness directly and
  may also contribute to muscle atrophy
• The joint involved is then predisposed to further
  damage
• Research has provided evidence that reflex
  inhibition is likely to affect some muscles more
  than others

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Continued

• Multijoint muscles appear less inhibited than
  monoarticular muscles
• Ligament damage can affect sensory input to
  muscles surrounding the joint and also to muscles
  more remote from the joint
• Injury to passive joint structures could be
  expected to affect both muscle stiffness and
  muscle proprioception

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Loss of Muscle Control and Decreased Antigravity
Function

• Loss of the stabilization function of muscles is
  not only associated with pain and reflex
  inhibition but can also occur in circumstances of
  normal function
• Has been linked to a reduced neural input to
  muscles as a result of a reduction in their
  antigravity supporting role

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Reasons For Decreased Neural Input

• Immobilization
• Bed Rest
• Sedentary lifestyle
• Microgravity environment
• Some specific motor patterns
• Posture relying on support from passive joint
  structures

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Beginnings of Back Stability

• Muscle Re-education is key to beginning a back
  rehab program
• Four exercises that are key, patient must be able
  to perform
• PELVIC TILT
• NEUTRAL POSITION
• ABDOMINAL HOLLOWING
• MULTIFIDUS CONTRACTION

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Before the Exercises Start

• Aim of all the exercises is only 30-40 of
  maximum
• 10 reps/ 10seconds
• Recognize neutral position
• Correct position with a pelvic tilt

• Patient comfort is important
• Inform patient of what is about to happen with
  each step

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Segmental Control

• The ability to distinguish the movement between
  of one segment and its neighboring segment
• Segmental Control is dependent upon
• Adequate muscle length
• Stabilization ability
  

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Lumbar-Pelvic Rhythm

• Lumbar-Pelvic Rhythm is the relationship of the
  movement of pelvis to that of lumbar movement
• Key to generating good back stability the pelvis
  need to tilt without the help of the lumbar spine
  in two planes
• Sagittal
• Frontal

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Basic Lumbar-Pelvic Rhythm

• Pelvic Movement is reached in forward flexion
  when hips reach 90 degrees
• Movement of pelvis on the hips must be /gt
  movement of lumbar spine on pelvis

• People with a history of back pain dont utilize
  a pelvic tilt, therefore movement for forward
  flexion comes primary from the lumbar spine

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Exercises that Asses LP Rhythm

• Knee raise standing
• Prone Kneeling
• Hip Hinge Standing

• Trendelenburg Sign (Frontal plane)
• False Hip ABduction

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Knee Raise Standing

• Object bring knee slowly to chest while
  observing patients lumbar region
• What to look for
• Phase I-hip flexion alone
• Phase II-Posterior tilt of pelvis as hip is 90o
• Phase III- Lumbar Flexion alone
• Excessive chest movement in Phase I
• Poor lumbar-pelvic rhythm

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Prone Kneeling

• Assessment is done in quadruped position
• What to look for
• Phase I-no lumbar/pelvic movement
• Phase II-Posterior pelvic tilt hip flexion
• Phase III- lumbar and thoracic flexion
• Immediate posterior pelvic tilt and lumbar
  flexion faulty lumbar pelvic rhythm

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Hip Hinge Standing

• Observe the ability of patient isolate pelvic
  motion from the lumbar spine in a functional
  position
• Normal is knee unlocked, anterior pelvic tilt
  with lumbar flexion
• When pelvic tilt is limited, greater lumbar
  flexion is needed.

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Trendelenburg Test

• When hip adductors are unable to hold
  inner-range contraction, pelvis drops toward
  lifted leg
• Adducting the weight-bearing limb

• Over time the muscle imbalance will lead to
  lengthening of hip abductors and shortening of
  hip adductors

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False Hip Abduction

• Checks for weakness of gluteus medius
• Performed as a Abduction straight leg raise
• If exercise is performed correctly, the patients
  pelvis remains level, while the hip abducts
• If performed incorrectly, the pelvis tilts
  laterally

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Pelvic Tilt

• The patients ability to perform a pelvic tilt is
  one of the basis to re-establish lumbar-pelvic
  rhythm, which will help with static loading of
  the stabilization system
• Patients have many exercise options to learn how
  to control a pelvic tilt

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Exercise Options for Pelvic Tilts

• Assisted while seating, standing or crook lying
  position
• Hip Hinge Action in kneeling position
• Hip Hinge (table support)

• Controlled forward bending
• Sitting pelvic tilt on Swiss ball
• Lateral pelvic tilt on Swiss ball

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Neutral Position

• Point in-between full flexion and full
  extension
• Established by tilting the pelvis posterior and
  anterior
• This is the most effective position for the back
  because
• Discs and facets are minimally loaded
• Soft tissues are at an elastic equilibrium

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Neutral Position cont.

• Treatment aim is to rebalance the length of the
  corresponding soft tissue elements
• Proprioception exercises will help patient obtain
  and maintain neutral position

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Proprioception Exercises

• Lephart Fu (1995) define it as a specialized
  variation of touch encompassing the sensations of
  both joint movement and position

• During an acute injury, the reflexes initiated by
  the displacement of mechanoreceptors and muscle
  spindles occur far more rapidly than brought
  about by pain (Barrack Skinner)

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Components of Proprioception

• Spinal regulates muscle stiffness
• Brain system controls static joint position
• Higher controls kinesthesia (movement sense)

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Static Joint Positioning

• Maintenance of balance and posture at the brain
  stem level
• Eyes open and eyes close enhance static joint
  position

• Exercises for static positioning are RPP and
  RAP, Reproduction of Passive and Active
  Positioning
• Key of exercises is precision of movement

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Abdominal Hollowing

• Main principle of this technique is to isolate
  the major abdominal muscles that stabilize the
  back (internal oblique and transversus abdominis)
• Basic definition is the pulling of the belly up
  and in at belly button without moving ribs,
  pelvis, and/or spine

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Before beginning the exercises

• Stability muscles are best utilized with
  endurance, therefore there is better recruitment
  at low resistance levels
• 30-40 maximum voluntary contraction is best for
  deep abdominal muscles, hold for 10 seconds and
  repeat 10 times
• Maintain neutral position

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Abdominal Hollowing Exercises

• 4 point kneeling (rectus abdominis dominance)
• Standing( link to pelvic floor contractions)

• 2-point kneeling or sitting (sit tall or kneel
  tall)
• Lying (performed prone pull away from floor, can
  use a biofeedback device

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Tips for performing hollowing

• Use multisensory cues such as auditory, visual,
  kinesthethic, and tactile
• Retroaponeurotic triangle- most superficial
  position of tranversus abdominis

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Common Errors

• Patients rib cage, shoulders, and pelvis dont
  remain still while performing hollowing
• Chest expanses(rib cage shouldnt lift or be
  depressed

• Lower ribs will be depressed if patient is using
  their external obliques
• Feet will press into floor when performing
  exercises such as kneeling, and lying

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Multifidius Contraction

• Multifidus is most important stabilizing muscle
  of the spine extensor group
• Those patients with back pain will lose the
  ability to contract the multifidus
• Exercises to contract this relies on two things
  tension/relax and proprioception

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Contraction techniques

• Prone lying and palpation of L4 and L5 with
  isometric contraction
• Rhythmic stabilization (PNF) apply resistance in
  one direction while patient contracts back

• Using your thumb and knuckle of first digit on
  either side of lumbar vertebrae, and have patient
  feel the muscle swelling

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Summary

• Patient must learn to control muscles which
  contribute to back stability
• Neutral position should be maintained with all
  exercises
• Proprioception sooner rather than later
• Always remember to take into consideration the
  patients injury, age, and body type, and body
  condition