BTM III - Sensorimotor Training + Stability - A 2024 PDF

Sensorimotor stimulation Stability testing Dagmar Pavlu 21.10. 2024 Czech School  Vladimír Janda (1928 – 2002) ◼ Czech neurologist, Physical medizin and rehabilitation ◼ Theory and practice of muscle imbalances ◼ Sensorimotor training  Karel Lewit (b. 1916...

Sensorimotor stimulation Stability testing Dagmar Pavlu 21.10. 2024 Czech School  Vladimír Janda (1928 – 2002) ◼ Czech neurologist, Physical medizin and rehabilitation ◼ Theory and practice of muscle imbalances ◼ Sensorimotor training  Karel Lewit (b. 1916) ◼ Czech neurologist ◼ Manual therapy  František Véle (b. 1921) ◼ Czech neurologist, neurophysiologist V. Janda Janda V. (2001): „Nothing is definitive, no conclusion can be considered as dogma“  Janda´s important findings included  Chronic musculoskeletal pain - patients exhibit characteristic and predictable patterns of muscle imbalance  The sensory and motor systems function as one: the sensorimotor system  Chronic musculoskeletal pain has important CNS component; treatment must focus on motor programming  Sensorimotor Training  Developed in early 1970´s  Based on work of Freeman and Wyke (1965): correlated poor foot proprioception with poor motor programming  Emphasized proprioception and reflexive muscle stabilization of entire body rather than strengthening of isolated joints  Progressive dosing of proprioception into sensorimotor system  Method of Sensorimotor Stimulation SMS (Method of Sensorimotor Stimulation)  Developed by Janda and Vávrová in 70´s of 20th century  Janda´s Approach  to FACILITATE proprioceptive system  to STIMULATE subcortical paths ◼ Spinocerebellar ◼ Spinothalamic ◼ Vestibulocerebellar  to ACHIEVE automatic coordinated movement patterns  Important in SMS  the goal is to achieve a quality of movement patterns that is as close as to normal as possible  to prevent injury and/or microinjury, fast reflex muscle contraction is needed to protect joints  Concept of motor learning - two stages -  to achieve new movement performance ◼ brain cortex is strongly involve in this proces  automatisation of new movement, skills ◼ reduction of cortical participation ◼ control by sub-cortex Facilitation - 3 key areas  Cervical spine  SI Joint  Foot receptors in this 3 areas - the main proprioceptive influence Receptors from the sole  facilitation in different ways: ◼ stimulation of the skin receptors ◼ active contraction of the intrinsic muscles of the foot Deep neck muscles  contain more proprioceptors than are found in other striated muscles (Abrahams, 1977)  should be considered for maintaining posture and equilibrium rather than for producing dynamic movement SI joint  in clinical practice, the sacral region is now recognized as an important area in the control of posture and equilibrium (Hinoki and Ushio, 1975) C-spine - SI joint - Foot SMS – Applied Reseach (1)  Buloock-Saxton J., Janda V (1993) noted improvements in gluteal muscle firing more than 200% after SMT  Heitkamp et al. (2001) noted significant improvement in balance and strength, as well an improved muscle balance with SMS in normals SMS – Clinical Reseach (2)  SMS improves proprioception, strength and postural stability ◼ Older adults  (Rogers et al. 2001, 2002, 2003) ◼ Ankle Instability  (Eils, Rosebaum 2001, Freeman et al. 1965, Gauffin et al. 1988) ◼ Knee Instability  (Beard et al. 1993, Ihara, Nakayama 1966) ◼ ACL Reconstruction  (Pavlu, Novosadova 2001) ◼ Postural Stability  (Pavlu et al. 2004) SMT – Clinical Reseach (3)  SMT and balance training ◼ risk sports injuries  (Ekstrand et al. 1983, Heidt et al. 2000, Wedderkopp et al. 1999) ◼ risk ACL injury  (Caraffa et al. 1996, Cerulli et al. 2001, Myklebust et al. 2003) Sensory Motor Devices and Aids  SMS is not a rigid program or system  SMS can be used in all cases and can be tailored to each patient  various balance exercises are used  any equipment required is simple and inexpensive  Haltegriffe Exercise aids  Wobble and rocker boards  Stability trainer  Balance shoes  Trampolines (various types)  Fitter  Twister BOSU Pro Single Pack  FlexBar  Balls  etc. Exercise aids - traditional  Haltegriffe BOSU Pro Single Pack 1277702 xb20 Multi-Balance  Exercise program - methodology -  preparative procedures ◼ joint mobilization, muscle stretching  exercise program in upright position ◼ short foot ◼ postural correction ◼ balance exercises ◼ walking  exercises with trampoline, fitter, balls, flexbar, etc. Preparative procedures (1)  respecting the approach of motor learning and motor regulation, any dysfunction in the periphery should be normalized first, because any pathologic or unwanted proprioceptive information from the periphery results in functional adaptive processes of the entire central nervous system Preparative procedures (2)  „normalisation“ of skin, joints and their adjacent structures, followed by muscles and their fascia  the trigger points, either active or latent, should be treated, and muscle imbalance, which is always present to some degree, is improved by a reasonable stretching program Exercise program in the upright position (1)  Correction begins in distal areas and gradualy continues proximally: ▪ modeling of the foot comes first, followed by correction of the position of the knee, than the pelvis, and finaly the head and shoulders.  Exercises are performed in bare feet, which increases proprioceptive stimulation and forces the therapist to pay attention to better control: ◼ last but not least, while using the balance aids, it helps to decrease the potencial danger of injuries Exercise program in the upright position (2)  exercise should by no means provoke pain and should not lead to physical (somatic) fatigue  from the beginning, the awareness of posture warrants special attention  exercises should begin on stable surfaces and then progress to more labile surfaces Exercise program in the upright position (3)  exercises can be divided into those that focus on training the transfer of weight or the center of gravity and those that focus more on balance and muscle coordination in general Short foot (small foot) (1)  shortening and narrowing of the foot, the toes are relaxed as much as possible  SF helps to increase afferent input, mainly from the sole Short foot (2) Short foot (small foot) (3)  SF improves the position of the body segments and stability of the body in the upright position, and helps to improve the required springing movement of the foot during walking Short foot (small foot) (4)  Initially, the formation of the small foot is difficult to perform in erect posture: starting in sitting position: ◼ sitting, with passive modeling by the therapist ◼ semiactive (passive modeling by the therapists in combination with active patient effort) ◼ active self-formation  Proprioceptive stimulation can be increased by additional pressure applied toward the knee and thus via the shin to the foot. Postural correction  Standing position: ◼ progression  active sways of the body  pushing (therapists)  extremities movement  etc.  Standing on one leg: ◼ progression  active sways of the body  pushing (therapists)  extremities movement  etc. Postural correction Balance exercises  standing + postural correction  standing + impulse  standing + knee bending  standing + extremities movement  standing on one leg + postural correction  standing on one leg + impulse  standing on one leg + knee bending  standing on one leg + extr. movement ◼ 3 axis - rocker board + wobble board Balance exercises - rocker board - Balance exercises -wobble board - Balance exercises -wobble board Walking  ½ step forward ◼ stable and unstable base of support  ½ step backward ◼ stable and unsatable base of support  squats, lunges, steps ◼ stable and unstable base of support  jumps ◼ stable and unstable base of support  walking + rocker-, wobble board, stability trainer, etc.  walking with balance shoes ½ step forward ½ step backward Walking - Balance Shoes ( 1) Walking - Balance Shoes (2)  increase the demands on the entire postural mechanism and automatically, without a conscious effort, help to correct posture  after 1 week of training: ◼ increasing of speed of muscle contraction (research results) Walking - Balance Shoes (3)  the subject should try to control the posture in particular the position of the pelvis, shoulder girdles and head  the steps should be short but quick  the feet should be held parallel  lateral and vertical shift of the pelvis should be avoided  gait should be trained in place first, if necessary with some support to avoid instability and falls Walking with Balance Shoes (3) in combination with resistance of Thera-Band TWISTER  helps to improve the activation of the trunk and buttock muscles  twisting movements specifically activate the deep intrinsic spinal muscles  during exercises it is easy to control the symmetry of the movement  the twister does not specifically increase proprioception, but it improves coordination and automatizes trunk and pelvic control FITTER  functions in a similar way as the twister, although the estimation of body asymmetries is less recognizable  stabilization of gluteus medius muscle FITTER (Swinger) FITTER (Swinger) TRAMPOLINE (1)  joging or jumping activates proprioceptors more effectively than a similar exercise performed on a firm floor  protection of joints because the trampolin functions as a shock absorber TRAMPOLINE (2) TRAMPOLINE (3)  exercises on a trampoline do not need to be performed in an upright position only  exercises performed while sitting are particularly effective in strengthening the abdominal muscles, and four point kneeling is recomendid for elderly women with kyphosis related to osteoporosis TRAMPOLINE (4) SPACECURL  SMS in 90´s of the 20 th century  facilitation of vestibulo- cerebellar paths FlexBar  SMS in 90´s of the 20 th century  Oscillation ◼ Progression:  Frontal sagital  Changing in intensity and speed  Changing of BOS Project FlexBar oscillation - exercises Goal of experiment : - to judge the prospective differences of the EMG-records - at various designs of oscillation exercises - to fix therapeutic recommendations of the mode of application. Methodology (1) FlexBar-projekt  20 probands of  healthy population  aged 20-40  FlexBar green  EMG measurement in standing position ◼ different shoulder positions by each person ◼ exercises in various planes (movement of FlexBar) Methodology (2) FlexBar-projekt Electrical activity measurement of the:  m.flexor hallucis brevis dx.  m.flexor hallucis brevis sin.  m.rectus abdominis dx.  m.rectus abdominis sin.  m.erector spinae L dx.  m.erector spinae L sin.  m.trapezius dx. pars descendens  m.trapezius dx. pars ascendens Results (1)  large inter-individual variety of the EMG-records with the FlexBar exercises, as possible identically performed  FlexBar oscillation-exercises can be used for the improvement of the local as well as the general body stability Proband I.-Shoulder 120, FlexBar sagital, green Proband S.-Shoulder 120, FlexBar sagital, green Shoulder 120, S-Plane Results (2)  FlexBar oscillation - exercises can also be used for functions improvement of muscles, which are important for the stabilization of shoulder girdle (activation of m. trapezius – lower p.) Results (3)  for a longer time repeated FlexBar oscillation-exercises induce fatigue and subsequent an increase of activation of m. trapezius upper p. important for instruction on the exercise performing Results (4)  the effectiveness of the oscillation exercises depends on the route and performing quality of oscillations Conclusions - FlexBar  The EMG investigations of FlexBar exercises are capable to supply a valuable information concerning muscle function improvement and stabilization.  Although a lot of work has been already done, but with regard of the high problem complexity further investigations are necessary. INDICATIONS for SMS (1)  SMS is beneficial when used as a part of any exercise program in that it helps to improve muscle coordination and motor programming or regulation and increases the speed of activation of a muscle  better control of the trunk, improved activation of the gluteal muscles, and thus better stability of the pelvis are achieved INDICATIONS for SMS (2)  SMS can help to compensate proprioceptive loss in aged subjects and thus help in preventing falls INDICATIONS for SMS (3)  Unstable knee  Sprained or unstable ankle  Idiopathis scoliosis  Faulty posture  Postural defects in general  Chronic back or neck pain  Prevention or treatment of ataxia  etc. CONTRA – INDICATIONS SMS  patients with acute pain syndromes  full loss deep sensibility SUMMARY (1)  SMT is based on increasing proprioception into the CNS in order to facilitace automatic movement patterns and reflexive stabilization  SMS emphasizes quality of movement and stabilization of body rather than strengthening of isolated joints SUMMARY (2)  Progressively dosed exercises progress control of the COG and BOS in various postures and neuromuscular challenges  SMT can be effective in treatment of lower extremity instability, fibromyalgia, and chronic low back and back pain References Janda V., Vávrová M.: Sensory motor stimulation. In: Liebenson C. (Ed.): Rehabilitation of the Spine: A Manual of Active Care Procedures. Williams and Wilkins, Baltimore 1996. Page P.: Janda´s Sensorimotor Training for Chronic Musculoskeletal Pain. Proceedings of WCPT-Congress, Barcelona 2003 Pavlů D.: Exercises with FlexBar (EMG-Analysis), Proceedings of TRAC-Meeting, Salzburg 2004. Pavlů D.: Special physiotherapeutical methods and concepts (in czech). CERM Brno, 2004.  STABILITY  Stability - definition of the term  Australian School  Test according to Véle STABILITY – INSTABILITY  different aspects different definitions STABILITY  definition of the term  physics, biomechanics  medicine ❑ Example: Stability (academic dictionary of foreign words) = the opposite of lability, constancy, … = keeping a certain property unchanged = maintaining a fixed equilibrium position = steady state © D.Pavlů INSTABILITY (general)  synonym for instability, wobble, imbalance (Academic Dictionary 1998) ❑ opposite of stability (in general) Stabilization, stability Panjabi (1992)  Stability is the result of the interplay of 3 systems:  passive  active  controller © D.Pavlů Panjabi (1992) aktiv steuerung pasiv CONCEPT OF SPINAL SEGMENTAL STABILIZATION („Australian school “) THERAPEUTIC EXERCISE FOR SPINAL SEGMENTAL STABILIZATION IN LOW BACK PAIN Diagnostic procedures  Screening examination ◼ simple non-invasive procedures  Clinical evaluation ◼ PB, EMG-biofeedback, inspection, palpacion ◼ clinical experience  Special diagnostic procedures ◼ EMG-invazivní, UZ-imaging Concepts - notes on concepts  Concept of "Spinal segmental stabilization" ◼ Australian School of the 1970s ◼ Group of Physiotherapists (University of Queensland - Carolyn RICHARDSON, Gwendolen JULL, Paul HODGES, Julie HIDES) ◼ Dg. a Th. L-spine, later C  Deep stabilization system, DNS ◼ Kolář  Stabilization system - trunc Local Global  mm. intertransversarii  m. longissimus  mm. interspinales thoracis  m. multifidus p.thoracis  m. longissimus  m. iliocostalis thoracis lumborum p.lumborum p.thoracis  m. quadratus  m. quadratus lumborum lumborum p.med.  m. transversus abd. p.lat.  m. obliquus abdominis  m. rectus abdominis int.  m. obliquus (p.insert.fastia Th-L) abdominis ext.  m. obliquus © D.Pavlů abdominis int. Aus.: Richardson, C. et al. 1999 STABILIZER STABILIZER Pressure Biofeedback Evaluation of stabilization capabilities GOAL: - to evaluate the deficit in stabilizing abilities (L-, C-spine) An attempt at objectification and quantification of the examination © D.Pavlů Clinical examination according to the Australian school  „pressure biofeedback“  aspection, contour of the abdominal wall  segmental test - m.multifidus  test m.TA – prone position  raising the lower limb test - supine position © D.Pavlů Palpation mm. multifidi – L-spine  assessment of isometric contraction ability simultaneously with TA muscle contraction  Palpation - mm. Multifidi (převzato z: Richardson, Hodges, Hides 2009) Stability – L-spine  M. transversus abdominis  Mm. multifidi  Diaphragma  Pelvic floor Instrumental asessment methods Functional tests  Rhomberg  Timed Up and Go Test  Functional Reach Test  Four Square Step Test  Lateral Reach Test  Sit to Stand Test  Berg Balance Scale  Etc.  TEST Acc VÉLE Test acc Véle - guiding principle  instability in upright standing is manifested by increased activity of the toes (this activity is observable long before trunk deflections occur) Test acc Véle: implementation  Starting position: Stand + eyes open  Evaluation of toes - position, form Test acc Véle: EVALUATION 4 degrees ◼ full, perfect stability ◼ slightly disturbed stability ◼ poor stability ◼ significantly impaired stability Test acc Véle: grade A  full, perfect stability  toes lightly touching the mat, normal relaxed position Test acc Véle: grade B ▪ slightly disturbed stability ▪ toes are pressed against the mat Test acc Véle: grade C ▪ poor stability ▪ claw-like position of the toes, significant sinking of the toes into the mat Test acc Véle: grade D  significantly impaired stability  „tendon play“, noticeable supination and/or pronation movements of the feet Question ???? Individual work  Study the article of tests according to Kolář: ◼ Functional postural-stabilization tests according to Dynamic Neuromuscular Stabilization approach: Proposal of novel examination protocol  https://www.sciencedirect.com/science/ article/pii/S1360859220300231