Lumbar Stabilization for the LQ Patient

Transcription

Evaluation and Rx Models in
Orthopedic Manual Therapy
Spinal Stabilization
Training for the Lumbar
and Lower Quarter Patient
Biomechanical
Neurophysiological
Biochemical
Psychological
Alec Kay PT, DMT, OCS, ATC, FAAOMPT
Jim Rivard PT, MOMT, OCS, FAAOMPT
The Ola Grimsby Institute
www.olagrimsby.com
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Overlapping of Models
The Manual Therapy Lesion
1. Collagen Trauma
2. Receptor Damage
Psychological
Biomechanics
3. Reduced Muscle Fiber Recruitment
4. Tonic Fiber Atrophy
Biochemical
5. Reduced Anti-Gravity Stability
6. Motion Around Nonphysiological Axis
7. Trauma/Acute Locking
Neurophysiological
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1. Collagen Trauma
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Rivard/Kay: Ola Grimsby Institute 2009
8. Pain/Guarding
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2. Receptor Damage
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3. Reduced Motor Recruitment
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5. Reduced Anti-Gravity Stability
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7.Trauma / Degeneration
Acute Locking
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4. Tonic Fiber Atrophy
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6. Motion Around a
Non-Physiological Axis
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8. Pain/Guarding/FearAnxiety of Movement
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”Neuromuscular Neutral Zones”
Ball in the Bowl
Inverted
portion of
“Toe” region
to form
hypothetical
“bowl”
Progression from Panjabi’s Mechanical Neutral Zones
Neutral Zone
• Eversull et al. (2001) defined “the lumbar
displacement or tension below which muscles
remain reflexively active”.
Motion
Instability
or
Represents
“Toe” region
of length
tension of
collagen
Neutral Zone
or
Joint Play
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Range
of
Motion
Hypermobility
• Displacements greater than 5% to 15% trigger
activity in the LM that contribute to stability
in the lumbar spine.
or
Pathology
Panjabi, 1989; OGI Forum 1996
Ligamento-Muscular Reflex
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Neuromuscular Neutral Zone
Changes with Pathology
The NNZ will be greater with collagen
trauma or with cyclical loading of
mechanoreceptors, creating a
desensitization that might lead to a
significant loss of stiffening of the
lumbar spine from muscle contraction,
leaving the spine unstable and
unprotected.
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(Eversull et. al 2001)
Globalization of the Neuromuscular
Neutral Zone Concept
Apply the same concept to
the lower limb in our
example today.
Consider the osteokinematics
of the chain, rather than a
small strand of collagen.
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(Solomonow et al. 1999)
Targets for treatment of NNZ
Changes with Anterior knee pain
Local
• Normalize mobility and recruitment in the
lumbar spine.
• Facilitate stability in the hips for patellafemoral joint.
Global
• Lumbo-pelvic movement patterns/
synergy.
• Lower limb pronation; increased dynamic
Q-angle.
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Examples of Local Changes
in Recruitment
Knee Motor Inhibition
•Knee Inhibition
• Studies have highlighted reduced VMO/VL EMG
activity ratios in individuals symptomatic for PFPS
•Hip Inhibition
•Multifidus
Inhibition
when compared with asymptomatic individuals
(Souza
and Gross 1991, Cemy 1995, Boucher et al. 1992, Miller et al. 1997,
Sakai et al. 2000, Jan et al. 2009).
• Delay in recruitment and reaction time
•Transversus
Abdominus
(Van Tiggelen et
al. 2009).
• Dysfunction eccentrically
(Owings et al. 2002).
• Many studies to support and refute these findings.
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Hip ABD and ER Weakness Correlates
well with Patella Femoral Pain
Multifidus: Evidence of Atrophy
• Unilateral, segmental atrophy found within 48
hours of acute onset of LBP:
• Chichanowski 2007
• Tyler et. al, 2006
•Hides et al. (1994)
• Brindle 2003
•Hides et al. (1996)
• Ireland et. al, 2003
• Real Time Ultrasound found an average of 24%
smaller multifidus on side of pain (n=41)
• Powers 2003
• 34 patients had wasting at L5, L4 at S1, and 1
at L4
• Mascal et. al, 2003
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24% Loss of Volume Within 48 Hours
Atrophy Pre or Post Injury?
Rapid atrophy of the lumbar
multifidus follows
experimental disc or nerve root
injury (Hodges et al. 2006).
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(Hides et al. 1994)
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Atrophy is the Result of
Injury/Collagen Trauma
•3 groups of piggies
•Disc injury
•Medial branch dissection
•Sham procedure
•Unisegmental atrophy of LM immediately
with disc injury
•More distal segments affected with nerve
injury
•No change with sham group
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Motor Control Issues
• Hodges and Richardson (1996) looked at healthy and
LBP individuals and feedforward activation of TrA with
upper limb movement.
• Significantly lower activity in patients.
• Dysfunction of motor control may lead to decreased
stability and segmental stiffening.
• Possibly due to reflex inhibition from pain, effusion,
ligament or capsule stretch, or possible CNS
mechanisms as well.
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Altered Motor Control
with Training
Fascicle Specialization
Regions of the LM
The Lumbar Multifidus is a an
example of an individual
muscle representing the
osteo/arthrokinematic
organization in all joints.
EMG investigating deep vs.
superficial fibers.
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Motor Control Changes
• O’Sullivan et al. (1997) confirmed with clinical
test that CLBP patients with spondylolysis or
spondylolisthesis had poorer ability to
appropriately recruit their deeper abdominals.
• Using surface EMG, the control group had
significantly greater activity in their IO than
their RA during the drawing in maneuver
compared to patients.
• Patients had poorer ability to selectively
activate deep abdominals, “robbing them of
needed segmental stability”.
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Lower Quarter Instability
• O’Sullivan et al. (1998) had 2 groups of patients with LBP:
the control group did general activity and the
experimental specific exercise group (SEG)
• The SEG group had a significant increase (p=0.013) in IO
activity during the drawing in maneuver compared to
before intervention
• The control subjects who performed curl-ups
significantly increased the activity of the RA during the
testing.
• This shift in synergy might reflect a neurological change,
altering the motor program for recruitment.
• In a different study the same authors shows that the SEG
had significantly decrease pain intensity and functional
deficit scores.
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(Moseley et al. 1994)
• Internal rotation of
femur
• Hip: adduction, internal
rotation, flexion
• Knee: valgus moment or
hyper-extension
(Grelsamer et al. 2001)
• Rearfoot: Pronated
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Pattern Inhibition
• Ankle to hip (Janda V 1986.
Bullock-Saxton J et. al 1994)
• Back to hip (Shum, Wong)
• Back to knee (Hart et al,
2006)
•Hip to back (Hossein,
Segmental Inhibition
•The Facilitated Segment
•Segmental Sensitization
•Hyper-Reactive Segment
•Central Sensitization
Nelson-Wong)
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• Korr (1947): Korr defined Facilitated Segment: Barriers
having been lowered.
Ascending and descending
intersegmental neurons
• Efferents are maintained on edge in a state of excitation:
easily triggered into activity by relatively few additional
impulses from any source.
Sensoring endings in
spinous process
• Result of the sustained barrage of impulses into the
segment of the cord with the lesion.
Recording Electrodes
• They are rendered and maintained hyperexcitable to all
impulses that reach them regardless of the source.
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• There is a palpable change in tissue texture and a
decrease in joint mobility.
• A stimulus of the nervous system almost anywhere
will result in increased electrical activity of the
muscles serviced by nerve roots derived from a
facilitated segment.
• Rick Kring(OGI Extensive Literature Review)
• Comparison of the classic literature on
segmental facilitation and somatic dysfunction to
modern basic science on central sensitization
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• The Facilitated
Segment (Korr 1947)
Spinal Muscles
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Biomechanical Model
• Restore axis of motion
• Normalize arthrokinematics
(joint play)
• Normalize osteokinematics
(range of motion)
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Local Mobilization
Biomechanical:
•Restore axis of motion (arthrokinematics) and range of motion
(osteokinemtatics) through soft tissue work and joint
mobilization/manipulation.
Proximal Manipulation /
Distal Effect: UQ
• Upper limb sympathetic influence with cervical mobilization/
manipulation (Petersen et al. 1993; Vicenzino et al. 1994/1995/1998b; Chiu
and Wright, 1996/1998; Sterling et al. 2001, McGuiness et al. 1997).
Neurophysiological:
• A single HVLAT to the right C5/6 zygapophyseal joint elicits
• Immediate improvement in contraction of the transverse
abdominus immediately following Ls manipulation (Gill et al. 2007).
an immediate increase in resting EMG activity of the biceps
• Lumbar HVLAT increasing postsynaptic facilitation of alpha
motoneurons and/or corticomotoneurons innervating
paraspinal muscles (Dishman et al. 2008).
• Increased gluteus maximus strength with mobilization of
anterior hip capsule (Yerys et al. 2002).
(Dunning and Rushton 2009).
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bilaterally, irrespective of whether or not cavitation occurs
• Cervical manipulation reducing the inhibition of elbow
flexors, improving motor performance (Suter and McMorland 2002).
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Proximal Manipulation /
Distal Effect: LQ
Global Models
• A single lumbopelvic joint manipulation has been
shown to acutely increase quadriceps force output and
activation (Suter et al. 1999 and 2000, Hillermann et al. 2006) in
individuals with anterior knee pain.
• Biomechanical Chain - “back bone connected to the
pelvic bone - pelvic bone connected to the thigh bone
- thigh bone connected leg bone….”
• Lumbopelvic joint manipulation increased quadriceps
force (3%) and activation (5%) immediately following
intervention, but not present after 20 min. Participants
free of knee pathology (Grindstaff et al. 2009).
• Neuophysiological Models
• Local “normalization” - inhibition and facilitation.
• Segmental patterns of pain, motor dysfunction and
sympathetics (Korr 1947).
• C0/1 manipulation increasing hip ROM - as increase
SLR, reduced hamstring tone (Pollard and Ward 1998).
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• Central influences- feedforward, balance and motor
pattern learning.
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Treatment Plan
Motor Learning Suggestions
• Manual Techniques: Soft tissue work and
mobilization and manipulation
• Minimize cognative participation of patient
• Exercise for normalization: address tissue repair,
pain inhibition, edema reduction, joint mobilization,
range of motion
• Exercise for performance enhancement:
coordination, motor learning, endurance, speed,
strength and functional skill
• Do not focus on specific muscles or
movement
• Minimize feedback
• Provide external attention focus for
instruction and feedback
• Education
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Skill Acquisition
Pay Attention
• Long recognized that being too concerned with or
paying attention to one’s movements can disrupt the
performance of well-practiced skills (Bliss 1892–1893, Boder,
• Two types of focus for
motor skill learning:
- Internal Attention
Focused
- External Attention
Focused
1935).
• Anecdotal evidence suggests expert performers do not
concentrate on their movement pattern when performing a
highly practiced skill, but perform the skill automatically
(Gallwey 1982, Garfield and Bennett 1985).
• May not be effective to instruct learners to be
consciously aware of their body movements during the
execution of a skill (Singer 1985/1988, Singer and Suwanthada 1986).
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It’s All About Me
It’s Not All About Me
• Internal attention
focus: Attention is often
focused internally on
range of motion,
flexibility, specific
muscle recruitment,
strength performance or
endurance.
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• External attention
focus: focusing the
learners’ attention on the
effects of their
movements or the effects
on an apparatus or
implement.
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Negative Attention Focus
External Attention Focus
• Therapists may focus too much on training individual
muscles, delaying acquisition of functional skills or patterns
• Singer et al. (1993) demonstrated that
“nonawareness” strategies produce more effective
performance during acquisition of a new skill.
• Focusing on a person's own body movement, can be
detrimental to the performance of well-learned skill as well
as learning new skills (McNevin et al. 2000).
• Evidence for the notion that consciously directing
attention to one’s movements (Baumeister 1984, Masters 1992), is
detrimental for performance…
• Whereas preventing learners from focusing on the details
of their actions results in more effective performance and
learning (Hardy et al. 1996, Maxwell et al. 2000, Singer et al. 1993).
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• Nonawareness strategies instruct learners to perform
a task without consciously attending to the movement
pattern, while awareness strategies require the learner
to consciously attend.
• The emphasis is placed on the body's affect on the
external environment not internally on the body itself.
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Evidence for External Focus
Coaching Styles
• By inducing an ‘‘external’’ focus of attention the
• Use externally focused instruction on the effects of the
motor learning process is enhanced
movement rather than internally on the movement itself.
- External instruction in gait training with an assistive device would be to
• Lower motor response time than internal focus
move the walker further forward (external) as opposed to taking a longer
step (internal).
approaches, indicating a higher degree of
- Instruction of terminal knee extension during gait would be to visualize
automaticity.
kicking a ball (external) as opposed to straightening the knee (internal).
• Feedback should be externally focused
• Reduced EMG with performance.
• Improved performance of local muscle and
athletic skill.
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focus may be necessary.
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Balance Training
Balance Training
• Riley measured postural sway, standing upright,
eyes closed, touching a curtain very lightly with
their fingertips.
• Standing on stabilometer
with finger tip touch
hanging sheet
• A curtain was used because it would not provide
any mechanical support for posture.
• Internal Focus: ‘‘Try to
minimize movement of the
index finger over the
duration of the trial’’.
• External Focus: ‘‘Try to
minimize movement of the
sheet over the duration of
the trial’’.
• Touching the curtain significantly reduced
postural fluctuation, as compared with not touching
it —but only when the participants were asked to
minimize movements of the curtain (external
attention).
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(Riley et al. 1999)
Distance of Attention
(McNevin et al. 2003)
(McNevin et al. 2002)
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Balance Training
• Internal-focus group: focus
on their feet (while looking
straight ahead).
• External-focus group 1:
look straight ahead but focus
on outside markers 26cm
• External-focus group 2:
look straight ahead but focus
on center markers
• Focus on the feet reduced
the learning process
• Distance between the
action and its effect is critical
factor
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(Shea 1999).
• Early in the rehabilitation process some level of internal
• Participants balanced on a
stabilometer, required to
hold a tube horizontal with
hands
• Instructed to focus on
either their hands (internal
focus) or the tube (external
focus).
• External group was
superior in keeping the tube
horizontal
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(Wulf et al. 2003)
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Specific Muscle Training
• Performed biceps
curl with a weight bar
• Internal focus: curl
while focusing on their
arms
• External focus: curl
while focusing on
movements of the bar
(Vance et al. 2004)
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Basketball Free Throw
External Biceps Attention
• Executed faster (greater angular velocity) - even though
speed was not a goal of the prescribed task.
• A 2nd experiment within the study controlled for speed
• During the initial repetitions iEMG activity was lower with
an external focus reflecting a greater economy in
movement production
• “Thus, it appears that the adoption of an external focus
indeed results in the production of more economical
movements than does the adoption of an internal focus”.
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External Focus-Free Throw
• Free throw accuracy was
greater when participants
adopted an external
compared to internal focus.
• Internal focus condition:
“concentrate on the
“snapping” motion of their
wrist during the followthrough of the free throw
shot.”
• EMG activity of the biceps
and triceps muscles was
lower with an external
relative to an internal focus.
• External focus
condition: “concentrate on
the center of the rear of the
basketball hoop.”
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(Zachry et al. 2005)
Volley Ball Serve to Target
•Internal-focus feedback
•External-focus feedback
• Toss the ball high enough in
front of the hitting arm.
• Toss the ball straight up.
• Snap your wrist while hitting
the ball to produce a forward
rotation of the ball.
• Imagine holding a bowl in
your hand and cupping the ball
with it to produce a forward
rotation of the ball.
• Shortly before hitting the ball,
shift your weight from the back
leg to the front leg.
• Shortly before hitting the ball,
shift your weight toward the
target.
• Arch your back and accelerate
first the shoulder, then the
upper arm, the lower arm, and
finally your hand.
• Hit the ball as if using a whip,
like a horseman driving horses.
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(Wulf et al. 2002)
(Vance et al. 2004)
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(Zachry et al. 2005)
Criteria for Movement
• Does the participant adopt the correct
stance?
• Does the participant show a sufficient
backswing with a high elbow?
• Does he or she begin the forward motion of
the hitting arm by rotating the trunk forward?
• Does he or she accelerate the lower arm
until hitting the ball?
• Is the weight shift recognizable?
• Is the arch of the back released quickly and
forcefully?
• Is a hip flexion visible?
• Is the ball being hit with the open hand and
with a wrist snap so that it receives a forward
rotation?
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(Wulf et al. 2002)
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2nd Exp.: Soccer Kick
Internal-focus feedback
• Position your foot below the
ball’s midline to lift the ball.
• Position your bodyweight and
the nonkicking foot behind the
ball.
• Lock your ankle down and use
the instep to strike the ball.
• Keep your knee bent as you
swing your leg back, and
straighten your knee before
contact.
• To strike the ball, the swing of
the leg should be as long as
possible.
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Attention-Feedback-Retention
External-focus feedback
• Strike the ball below its
midline to lift it; that is, kick
underneath it.
• Be behind the ball, not over it,
and lean back.
• Stroke the ball toward the
target as if passing to another
player.
• Use a long-lever action like
the swing of a golf club before
contact with the ball.
• To strike the ball, create a
pendulum-like motion with as
long a duration as possible.
(Wulf et al. 2002)
External Attention: Golfing
Results for both experiments:
• External focus superior results to
internal focus.
• Reduced feedback frequency was
beneficial under internal-focus
feedback conditions, whereas 100%
and 33% feedback were equally
effective with external-focus.
• Retention: benefits not merely
temporary but were also seen after
1-week with no-feedback.
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External Attention: Tennis
• Attention to external
effects of their movements
relative to other external
cues to hit tennis balls at a
target.
• One group focusing on the
ball coming toward them
• The other group focusing
on the ball leaving the racket
(effect).
• Effect group had more
effective learning
Golfers did better with
accuracy when focusing
on the head of the golf
club (external focus)
then when instructed to
focus on the swing of
their arms.
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(Wulf et al. 1999)
External Attention: Skiing
• Teaching skiing using a ski
machine
• Internal focused group:
instructed to focus on their
feet and to exert a force with
their right foot when the
platform moved to the right.
• External focused group:
instructed to focus on the
wheels under the platform
and exert force on these
wheels when the platform
moved to the right.
• The externally focused
group performed best.
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(Wulf et al. 1998)
(Wulf et al. 2002)
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(Wulf et al. 2000)
Coaching and Feedback
• Learning is enhanced with the perception of
self-control (Janelle et al. 1995 and 1997).
• Learners should even be able to decide when
and how frequently they want feedback.
• If learning is taking place, less feedback
should be required over time (Janelle 1997).
• Constant feedback can be detrimental to the
learning process (Winstein et al. 1990).
• Reduce the amount/frequency of feedback
(Wulf et al. 2002).
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Secondary Force Moment Options
Nothing New Under the Sun
• Second line of resistance that targets a specific
• Knott and Voss (1963): Movement is not a simple
planar movements but combinations all 3 planes.
muscle, fiber direction or muscle group.
• Secondary line of resistance to facilitate
secondary motor recruitment (plane) during a
primary movement pattern.
• Secondary resistance can be gravity, manual,
free weight, elastic or pulley system.
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• Dysfunction in more than one plane of motion.
• Second resistance (manual) was applied to facilitate
an additional plane of recruitment during the primary
movement.
• The transverse plane for rotational motion was
identified as the most often implicated, and was first
addressed in the manually resisted PNF approach.
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Medical Exercise Therapy (MET)
Squat with Bilateral
Valgus Moment
• Primary Movement:
squatting for hip and
knee extensors
• Concepts used since the
1960’s
• Extension pattern training
with squat
• Secondary force moment
induced for hip abduction
• Training to control knee
valgus during squatting
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“Do not let the band
shorten during squat.”
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Lat. Lunge: LQ Resistance
Squat: Trunk Recruitment
• Primary Movement: Hip,
knee and back extensors
• Primary: Open chain
emphasis of hip bilateral
abduction training
“Lengthen the band as far
as you can.”
• Secondary Force
Moment: valgus force at
knee for recruitment of
hip abductors, minor
external rotators
• Secondary Force Moment:
horizontal resistance for
recruitment of TrA and rotary
components of multifidus
• Secondary Force
Movement: Placing band
around forefoot
facilitates hip external
rotators of lunging hip
(left hip pictured).
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• What happens when force
line changed from above or
below?
• What happens with
dumbbells held ant. or lat.?
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Lateral Walking: Horizontal
Resistance with Resistance
“Maintain handle directly
in front of the body.”
Lateral walking for right
hip abductors on push
off.
• Primary Movement: anterior
lunge for extension pattern.
• Secondary Force
Moment: horizontal force
line held away from the
trunk—recruitment of
TrA, multifidus and right
external rotators.
• Bilateral hold for anterior
and posterior rotary mm.
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transverse plane of resistance.
• Unilateral: emphasis on
anterior mm (right hand).
• What happens if force is
changed to the left hand?
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Lateral Lunge with
Horizontal Resistance
“Keep the handle fixed at
the naval.”
Anterior Lunge: Lateral
Force Moment
left lateral lunge.
• Secondary Force
Moment: horizontal force
moment facilitating
anterior muscles in
transverse plane.
• What happens with
handle on the left with
lunge toward the right?
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Lateral Lunge: Anterior
Force Moment
lateral lunge for left hip.
• Secondary Force
Moment: anterior force
moment through
opposite shoulder.
“Don’t let the weight
stack move.”
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Right Step-Up: Diagonal
Trunk Pattern
Right Leg Balance: Upper
Quarter Reaches
balance training of the right
lower extremity
Right step-up for
horizontal force line through
right hand.
extension pattern.
• Secondary Force
Moment: Diagonal force
moment from below.
• Tri-planar motion
“Lift the handle from
above your shoulder.”
• Facilitation of left side
multifidi and left hip
external rotators.
through hip and trunk.
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“Hold the handle still
while reaching up/down.”
• Increase stabilization of
the hip and lumbar spine
with rotary components in
hip and lumbar spine.
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Hip External Rotation with
Lumbar Extension
Anterior Lunge with
Sup./Post. Resistance
weight bearing hip
weight bearing hip
external rotation.
external rotation.
• Secondary Force
• Secondary Force
Moment: gravity - for
Moment: What muscles
extension pattern of hip
or planes of movement
and lumbar spine.
are occurring?
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Take Home Message
• Find your language or external attention focus instruction
and emphasis.
• If not already doing so, expand treatment model for the
biomechanical chain and the myokinematic chain.
• Incorporate spinal manipulation for motor facilitation, even
with extremity diagnoses.
• Try secondary force moments with current exercises you
already are using.
• Try changing secondary force moment with each set of an
exercise to vary the neurological challenge.
• Be creative and have fun!
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Lumbar Stabilization for the LQ Patient

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