Muscle Imbalance Evaluation and Treatment for the Low Back and Hip Areas

1. 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

2. 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…

3. 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

4. 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

5. 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

6. 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: • Vastusmedialisobliquus (knee joint), soleus (ankle) • Ex. of muscles Affecting multiple joints: • Psoas (lumbar/SI/hip), hamstrings (knee/hip)

7. 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

8. 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.

9. Reflexes at the level of the: Premotor Cortex Motor Cortex Brainstem Spinal Cord create Articular Receptors 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 resolves Return to normal muscle tone

10. 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

11. 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

12. 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

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

14. 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

15. 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

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

17. 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.

18. 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

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

24. 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

25. 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

26. 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)

27. 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

28. 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 Inhibitionleading 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

29. 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.

30. 1. OMM 2. Exercise Prescription create Articular Receptors Reflexes at the level of the: PremotorCortex, 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 resolves Return to normal muscle tone 1. OMM 2. Exercise Prescription

31. 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.

33. 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 Kneelingto Stand transfer with or without assistance

34. 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

35. 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

36. 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

37. 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)

38. 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

39. 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

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

41. 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

43. 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

44. 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, ChoiKwang Do, etc.

45. 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

46. Evaluating Muscle Firing Patternsof Lower Quarter Muscles

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

48. Testing: PELVIC CLOCKS Clock Orientation Start Position

49. Testing: PELVIC CLOCKS 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

50. Testing: PELVIC CLOCKS 3 O’clock 9 O’clock Problems: Lumbar rotation to the left, sacral torsion to the right , weak abdominal obliques, transversusabdominis Problems: Lumbar rotation to the right, sacral torsion to the left, weak abdominal obliques, transversusabdominis