Physical Medicine and Rehabilitation, NMM/OMM

Physical Medicine and Rehabilitation, NMM/OMM
Muscle Imbalance Evaluation and Treatment for the Low Back and Hip Areas Jose S. Figueroa, D. O. Physical Medicine and Rehabilitation, NMM/OMM AOCPM&R, Fall 2013

Case Study In 1998 a 33 y/o gentleman presents with a 5 year history of right shoulder pain, which did not stop him functionally, but significantly affected his sleep. Diagnosed originally with biceps tendonitis, and given some OMM treatments with good but temporary relief. Dr. Greenman saw him and stated that he had a muscle imbalance…

Objectives Learn concepts of neuromuscular imbalances and their contribution to chronic musculoskeletal dysfunction in the lumbar, pelvic and hip areas. Learn the muscles that commonly affect the low back, pelvic and hip areas. Be introduced to the evaluation and treatment of muscle imbalances of the lower quarter: Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns Diagnose and manually treat tight/short muscles Diagnose weak or pseudo-paretic muscles Teach a home exercise prescription to address the tight/short and weak or pseudoparetic muscles Follow-up for re-evaluations and exercise adjustments Teach patients how to self-treat certain common somatic dysfunctions

Most of the information in this lecture is derived from the works of
Phillip Greenman, D.O.(he is the one in the pictures) Dr. Vladimir Janda, a specialist in rehabilitation medicine at the University of Charles, Prague, Czechoslovakia, deceased in 2006

Road Map Muscle Imbalances Muscles commonly affected by imbalances
Causes of Muscle Imbalances Overview of Diagnosis and Treatment of Muscle Imbalances Hands On Workshop: Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns Diagnose and manually treat tight/short muscles Home exercise prescription (HEP) for the tight/short muscles HEP for the weak or pseudoparetic muscles Part Two

Muscle Balance The relationship between the strength and the length of the muscles around a joint or multiple joints. Ex. of muscles affecting one joint: Vastus medialis obliquus (knee joint), soleus (ankle) Ex. of muscles Affecting multiple joints: Psoas (lumbar/SI/hip), hamstrings (knee/hip)

Muscle Imbalance Theory
According to Dr. Janda, it is a malregulation by the central nervous system (CNS) leading to: Some muscles becoming tight Some muscles becoming weak Loss of control of integrated muscle function Loss of Symmetry and Control Caused by some form of musculoskeletal disturbance

Musculoskeletal Disturbance
Can be caused by acute or chronic events. Examples include changes in lifestyle, or poor ergonomics, or trauma, or disease, etc. Examples: stress, participating in a poorly designed exercise program, sedentary lifestyle, joint and/or soft tissue disease or trauma, spending too much time working in front of a computer, loss of a limb, etc.

MUSCLE IMBALANCE CYCLE
Reflexes at the level of the: Premotor Cortex Motor Cortex Brainstem Spinal Cord Articular Receptors create affect 1. Musculoskeletal Disturbance cause MUSCLE IMBALANCE CYCLE Adds to Alpha Motor Neuron stimulates muscle fiber to contract. Gamma System: stimulates muscle spindle to adapt Creation of Muscle Imbalances which maintain the wrong positions of the joints Alteration in muscle tone, affecting joint position and function create remains Return to normal muscle tone resolves

Understanding Motor Control
Movement: is performed by combined muscle pull, which is very controlled in a very complicated manner Controlled movements require many CNS signals (afferent and efferent) with precise timing and number CNS controls movement through proprioception It produces useful movements that adapt to our constantly changing environment Needs precise input from many receptors This appraisal is done through a variety of receptors sensitive to changes in temperature, light, pressure, pain, position, etc. The CNS receives these signals along with signals from within muscles, joints, tendons, and other body structures, and is led to generate and distribute myriad signals in an orderly array to various muscles

Sit Up Straight, Please Pelvic Clock
Helps to give you an awareness of the location of the trunk when in postural balance Used in the supine, seated and standing postures Let’s try the pelvic clock SEATED Work on the Sit Stand Transfer, using the pelvic clock Give examples of how to use this for getting up from the floor and from a chair

Functional Disturbance
Injuries or diseases can cause muscles to react differently than normal because of: Guarding joints or organs Inability to move properly due to tissue or nerve damage Chronic vs. Temporary: When the injury is chronic, the changes are longer lasting. Chronic poor posture re-trains the muscles in patterns of movements that eventually become incompatible with normal function

Muscle Function Disturbance
Chronic articular or muscle dysfunction feeds the afferent loop with more nociception and abnormal mechanoreceptor information, perpetuating ongoing aberrant muscle tone.

Muscle Imbalances Some muscles become tight (tonic)
Some muscles become weak (phasic) Altered motor control (impaired proprioception) Either muscles do not contract when they are supposed to, so they act as if they were weak Or muscles contract too early when moving certain joints or too much when maintaining certain postures

Functional Disturbance
There are two main ways that the muscles react to functional disturbance: Some muscles become tight/short Usually the slow twitch fiber type muscles Some muscles become weak (or pseudoparetic) Usually the fast twitch fiber type muscles

Slow-twitch Fiber Type
Oxidative metabolism, high capillary density, greater endurance, characteristic red color Twitch speed is slow, making their function more tonic or postural Slow-twitch muscles react to functional disturbance by shortening and tightening.

Fast-twitch Fiber Type
Glycolytic metabolic pathway, fatigue rapidly, have low capillary density, whitish color. Twitch speed is fast and shorter lasting, making their function phasic. Fast-twitch muscles react to functional disturbance by weakening or becoming pseudoparetic

Table 1. Common upper and lower extremity muscles and their reaction to injury

Body Region Function: Primarily Postural/Tonic (Short and Tight) Function: Primarily Phasic (Weak) Pelvic and Hip Region Hamstrings Iliopsoas Rectus Femoris Tensor Fascia Lata Thigh Adductors Piriformis Vastus Medialis Obliq. Vastus Lateralis Gluteus Maximus Gluteus Medius Gluteus Minimus

Leg Gastrocnemius Soleus Tibialis Anterior Peroneus Body Region
Function: Primarily Postural/Tonic (Short and Tight) Function: Primarily Phasic (Weak) Leg Gastrocnemius Soleus Tibialis Anterior Peroneus

Body Region Function: Primarily Postural/Tonic (Short and Tight) Function: Primarily Phasic (Weak) Neck and Trunk Erector Spinae Group -Lumbar Region -Cervical Region Quadratus Lumborum Scalenes Sternocleidomastoid Deep Cervical Spine Flexors Erector Spinae muscles -Mid-thoracic Rectus Abdominis External Obliques Internal Obliques Transversus Abdominis

Shoulder Girdle Body Region
Function: Primarily Postural/Tonic (Short and Tight) Function: Primarily Phasic (Weak) Shoulder Girdle Pectoralis Major Levator Scapulae Upper Trapezius Biceps Brachii Latissimus Dorsi Middle Trapezius Lower Trapezius Rhomboids Supraspinatus Infraspinatus Triceps Brachii Serratus Anterior Deltoid

Stand Up, Please Static Active Stretch: muscle is put on a passive stretch with little to no movement, while its antagonist is being used to maintain the position of the muscle stretched and to reciprocally inhibit the muscle stretched. Examples: Rectus Femoris Chest stretch

Causes of Muscle Imbalance
Noxious stimulus (due to acute or repetitive trauma, chronic injury, arthritis, space occupying lesion, neurologic injury, metabolic disease, loss of a limb, etc.) Prolonged postural disturbance (resulting in a prolonged alteration of the center of gravity, with mechanical responses requiring long term muscle adaptations)

Causes of Muscle Imbalance
Excessive physical demands (usually chronic overuse or under-use or chronic lack of rest-especially stage IV sleep) Emotional problems or other psychological factors (tightness and fatigue that result when we are "uptight" or stressed, anxious, depressed, etc.) We show emotion with our muscles Muscular action tends to create and/or accentuate emotion

Reflex Pathways are involved in maintaining muscle imbalances
Co-Contraction: Lumbar erector spinae and psoas contracting to stabilize an injured lumbar spine: What would someone look like who has this? Reciprocal Inhibition: Psoas tightening causing weakness of gluteus maximus Pectorals tightening causing weakness of interscapular muscles Reciprocal Inhibition leading to Substitution Hamstrings doing most of the hip extension instead of the gluteus maximus Still need to address the offending tight muscle: Iliopsoas Tensor fascia lata doing most of the hip abduction due to a weak gluteus medius / minimus Still need to address the offending tight muscle: Adductor

Muscle Function Disturbance
This vicious cycle can be interrupted and reprogrammed through OMM Specific Exercises prescribed in the Proper Sequence Thus, the overall muscle tone and balance can be returned to (and maintained in) a more normal state.

Re-Programming MUSCLE IMBALANCE CYCLE
1. OMM 2. Exercise Prescription Articular Receptors create Reflexes at the level of the: Premotor Cortex, Motor Cortex, Brainstem Spinal Cord affect 1. Musculoskeletal Disturbance MUSCLE IMBALANCE CYCLE cause Re-Programming Adds to Alpha Motor Neuron stimulates muscle fiber to contract. Gamma System: stimulates muscle spindle to adapt Creation of Muscle Imbalances which maintain the wrong positions of the joints Alteration in muscle tone, affecting joint position and function create remains Return to normal muscle tone resolves 1. OMM 2. Exercise Prescription

Functional Capacity! Despite the osseous pathology of his own lumbar spine, Dr. Greenman used to demonstrate all of the exercises in his text and to his patients. This demonstrates the functional capacity in the presence of significant osseous pathology. This demonstration was a powerful motivational tool.

Kneel “Up” Straight, Please
Pelvic Clock Kneeling Floor: sit to kneeling transfer From knees fully bent to knees at 900 flexion Kneeling to ½ kneeling maneuver One foot on the ground The other foot with the ball of the foot on the ground ½ Kneeling to Stand transfer with or without assistance

Diagnosis of Muscle Imbalances Three Specific Types of Clinical Testing
Evaluate Proprioception Through balance testing Evaluate the sequence of muscle contraction (muscle “firing” patterns) during specific movements to evaluate which muscles contract out of sequence, acting as if they were weak Evaluate asymmetry in muscle lengths Muscles are isolated as much as possible and then tested for symmetry in their lengths and compared with estimations of normal

Treatment of Muscle Imbalances
General Principles: Goal: restoration of proper muscle length, strength and control of muscle function Start with OMM May need a home exercise prescription (HEP) HEP should address muscle control (i.e., proprioception re-training) When treating muscle imbalances: Quality of movement is more important than quantity

General Treatment Sequence
Establishing a process of re-evaluations to monitor progress Establish a level of patient commitment to follow through Re-training proprioception home exercises (single leg stance) PT (more advanced intervention)

General Treatment Sequence
Stretching the tight muscles manual stretches in the office (Dr. or PT) home stretches (self-stretches) Re-training or strengthening late contracting (pseudoparetic) or weak muscles home “strengthening” exercises Teaching the patient how to self-treat specific recurring somatic dysfunctions on their own

Hands-On session Diagnosis and Treatments of Common Muscle Imbalances of the Pelvis and Low Back

Treating Impaired Proprioception
Retrain balance with bare feet on a carpeted surface in order to stimulate the propioceptors of the sole of the foot Practice “shortening the foot”-also stimulates the proprioceptors of the soles Goal: the capacity to symmetrically stand on one leg with arms crossed and eyes closed for 30 seconds Do the best possible if unable to reach goal

Look to your feet, Please
Remove your shoes See if you can shorten one of your feet now Let’s test each other’s SINGLE LEG standing balance

Treating Impaired Proprioception
Bilateral exercises that help increase proprioception and increased body awareness: Walking, Swimming (may need mask/snorkel) Properly taught Pilates Bilateral Martial Arts movements like some of the ones found in Tai Chi, Choi Kwang Do, etc.

Evaluating Muscle Firing Patterns of Lower Quarter Muscles

PELVIC CLOCKS Three dimensional evaluation of function of the lumbar spine and pelvis. Used diagnostically and therapeutically.

Testing: PELVIC CLOCKS
Clock Orientation Start Position

12 O'clock 6 O’clock Problems: pubic dysfunction, iliosacral dysfunction, sacral dysfunction (base posterior), lumbar extended dysfunction, tight psoas, tight paraspinals, weak abdominals Problems: pubic dysfunction, iliosacral dysfunction, sacral dysfunction (base anterior), lumbar flexed dysfunction

3 O’clock 9 O’clock Problems: Lumbar rotation to the left, sacral torsion to the right , weak abdominal obliques, transversus abdominis Problems: Lumbar rotation to the right, sacral torsion to the left, weak abdominal obliques, transversus abdominis

Testing: HIP EXTENSION FIRING PATTERN

Testing: HIP EXTENSION FIRING PATTERN
Hamstrings. Gluteus maximus. Contralateral lumbar erector spinae (low). Ipsilateral lumbar erector spinae (low). Contralateral lumbar erector spinae (high). Ipsilateral lumbar erector spinae (high). Significant finding is late firing of the gluteus maximus.

Other Firing Patterns Hip Abduction Firing Pattern on Sidelying
Normal: Gluteus medius, Tensor fascia lata (TFL), Quadratus lumborum (QL) and Erector Spinae Abnormal: substitution with weakness of gluteus medius and early firing of TFL (causing IR and flexion of the hip) and QL. Worst scenario is that the motion is initiated by the firing of the QL. Pelvic Tilt Heel Slide Pelvic Tilt with Hip Abduction and External Rotation Active Trunk Rotation

Evaluating and Treating Muscle Length Asymmetry
of Lower Quarter Muscles

Stretching: PSOAS & RECTUS FEMORIS

Manual Stretching of Muscles
Manual Stretching done at the clinic is very important because it can significantly increase the muscle lengths further than self-stretching alone can. “Supercharges” the patient’s home stretching routine Sustained Stretch: secs, 2 or 3 reps. Muscle Energy: Post-isometric Relaxation and Stretch

Stretching: RECTUS FEMORIS PRONE

Stretching: PSOAS PRONE
Anterior Hip Capsule Stretch

SELF STRETCH: PSOAS

SELF STRETCH: RECTUS FEMORIS

Stretching: ADDUCTORS

Stretching: ADDUCTORS (Long)

Stretching: ADDUCTORS (Short)

SELF STRETCH: ADDUCTORS

Stretching: PIRIFORMIS

Stretching: PIRIFORMIS
Above 90 degrees

Self Stretch: PIRIFORMIS
Above 90 degrees Below 90 degrees

Self Stretch: PIRIFORMIS (Prone)

Stretching: LATISSIMUS DORSI

Stretching: LATISSIMUS DORSI
Manual Stretch

Self Stretch: LATISSIMUS DORSI

Strengthening / Retraining of Lower Quarter Muscles

Strengthening/Retraining: GLUTEUS MAXIMUS
Prone hip extension. Bridging.

2. Contract Gluteus & hold knee. 1. Contract Gluteus.

3. Isometric hold. 4.Concentric contraction.

Strengthening/Retraining: GLUTEUS MAXIMUS BRIDGING
Contract transversus abdominus or maintain a slight 12 o’clock pelvic tilt. Use two legs to bridge and contract buttocks. Single leg bridge.

Strengthening/Retraining: GLUTEUS MAXIMUS BRIDGING

Strengthening/Retraining: ABDOMINALS
Sit backs. Curl ups. Supine leg slides with stable transversus or posterior pelvic tilt. Norwegian exercise.

Rectus abdominus Transversus abdominus

Oblique abdominals

Strengthening/Retraining: ABDOMINALS Sit Backs
Performed in three stages, arms in front, arms crossed, and hands behind neck. Maintain a lumbar lordosis throughout. Strengthens transversus abdominus in subconscious mode. Strengthens abdominals in a lengthened position.

Start position. Level one.

Level Three Level Two

Pause shortly. Then move on to the second part of the program.
Questions ??????????????

Physical Medicine and Rehabilitation, NMM/OMM

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