“The process of discovery is seeing what others have seen before and thinking something new.”
Albert Einstein
It is what we think we know that keeps us from learning
Claude Bernard
The only thing that interferes with my learning is my education.
Albert Einstein
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What is the point of being alive if you don’t at least try to do something remarkable.
John Green
Outline for Part I
• Review of how the NMS works Ø Consider impact of spine on extremities & vice
versa Ø How does the lower extremity (LE) ‘really’
work? Ø How does the upper extremity (UE) ‘really’
work? Ø What is the impact of the core?
• Introduction or explanation of the GMA
Outline for Part II
• Review of the concept of GMA and GPD • Review the implications • Hands on lab in Module 7 • Cite articles • Discuss integrative approach with utilization
of GMA • Q&A
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Glossary • PFLM – Performance for Life Method • GMA – Global Mechanical Assessment • GPD – Global Proprioceptive Deficit • RSL – Reciprocal Limb Syndrome • FFA – Feed Forward Activation • FB – Feed Back • APAs – anticipatory postural adjustments • CPAs – compensatory postural adjustments • SAID-specific adaptation to imposed demand
Presumption(s)
• An intact nervous system free of pathology or injury performs as a neutral conduit of signals.
• The mechanical indicators of techniques are a direct indicator of change in the nervous system.
• The changes in the horizontal stay changed in the vertical
Where did this come from?
• Clinical observation that seemingly minor injuries were persistent despite quality care by ATCs, DCs, PTs, MDs.
• Noting that asymmetrical dorsiflexion was prevalent in many cases.
• Testing extremities prior to adjusting the spine indicated a tendency towards a pattern of contralateral dysfunction of UE and LE
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Process of GMA
• Use the extremities as long levers to challenge the CNS to properly anchor and operate.
• Compare sides via isometric mirror image tasks.
• Observe quality of anchoring and operation. • Determine if reciprocal limb coupling
inefficiency is involved. RLS
Prevalence of GPD Group / Team Gender Total GPD Number GPD Percentage
Y N Y N
Non-athletes Male 29 23 6 79.3% 20.7% Female 25 22 3 88.0% 12.0% Total 54 45 9 83.3% 16.7%
Athletes Diving Male 7 6 1 85.7% 14.3% Female 19 17 2 89.5% 10.5% Total 26 23 3 88.5% 11.5%
Track & Field Male 14 10 4 71.4% 28.6% Female 9 8 1 88.9% 11.1% Total 23 18 5 78.3% 21.7% Total Male 21 16 5 76.2% 23.8% Female 28 25 3 89.3% 10.7% Total 49 41 8 83.7% 16.3%
Total Subjects Male 50 39 11 78.0% 22.0% Female 53 47 6 88.7% 11.3% Total 103 86 17 83.5% 16.5%
Theory of GPD
• Because it has nothing to do with pain the patient is not aware of its’ presence.
• Because it appears to change the efficiencies within the NMS instantaneously the potential for injury may increase or decrease without perception.
• If you don’t check for it pre and post you don’t really know if a change has occurred.
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Reinjury
Functional Instability
Ligamentous injury
Decreased Neuromuscular Control
Proprioceptive Deficit
Structural Instability
Cycle of Injury – Lephart,Fu,Scott
1
2
3
4
Mechanical Model Neuromechanical Model
Potential for Injury/ Reinjury
Functional Instability
Ligamentous injury
Decreased Neuromuscular Control
Proprioceptive Deficit
Structural Instability
Cycle of Injury – Chiropractic / Neuromechanical Model Downes 2002
6
7
4
5
Mechanical Model Neuromechanical Model
Subluxation – Corrupted Signal
1
2
3
Panjabi’s article / implications
• A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction. Manohar M. Panjabi. Eur Spine J (2006) 15: 668–676
environment, GRF, Shock absorption, adaptation to surface change, footwear design, long lever mechanical actions
• Upper extremity – almost everything except ambulation. Reach to … touch, grasp, lift, hit … long lever muscle coupling actions
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“Core”
The LPHC
What does it do? • Produces force (concentric) • Reduces force (eccentric) • Provides stability (isometric) • Houses the center of gravity • Anchors both the LE & UE • Must maintain tri-planar stability & mobility • Effects neuromuscular efficiency
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Deep and Superficial Fibers of the Lumbar Multifidus Muscles are Differentially Active During Voluntary Arm Movements- Moseley, Hodges, Gandevia
2 layers of multifidus • Deep
Ø Lumbar stabilization Ø Activated with Transverse Abdominus Ø Deep multifidus has a role in controlling
intersegmental motion (shear & rotation) Ø Near center of spine so moment arm is small Ø Exerts effect throughout spine ROM w/o
compromise of length-tension relation
• Superficial Ø Span up to 6 segments Ø Contributes to control of spine orientation Ø Distant from center of lumbars giving an effective
moment arm for: ¡ Extension ¡ Rotation ¡ Control of lumbar lordosis
Ø Activated by UE movement
• Both feedforward driven
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Findings
• Superficial Ø With single arm movements, the onset of EMG in the
erector spinae & superficial multifidus relative to deltoid was dependent on the direction of movement.
• Deep Ø Onset of deep multifidus & Transverse Abdominus
was not dependent on direction
Clinic Relevance • If deep inactivated, superficial have potential,
with movement of UE, to rotate lumbars • Psoas & erector spinae may substitute for
inactivated deep • May explain “picked up a paper clip & my back
• Slosberg reports that adjusting (+) impacts multifidus
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The Role of the Core Stability in Athletic Function Kibler & Press
• ‘Core stability’ is the ability to control the position & motion of the trunk over the pelvis to allow optimum production Ø Transfer and Ø Control of force and Ø Motion to the terminal segment in integrated athletic
activities
• Core muscle activity is best understood as the pre-programmed integration of local, single-jt muscles and multi-jt muscles to provide stability and produce motion.
Sports Med 2006; 36 (3): 189-198pp • This results in proximal stability for distal mobility, • A proximal to distal patterning of generation of
force, and • The creation of interactive moments that move and
protect distal joints. • Evaluation of the core should be dynamic, & include
evaluation of the specific functions (trunk control over the planted leg) & directions of motions (3-planar activity). STAR excursion or similar
• Rehab should include the restoring of the core itself, but also include the core as the base for extremity function / efficiency.
• No isometrics beyond 8-10 seconds- ischemia results. Bad training idea! McGill
Fundamental Gait Cycle
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Weight Distribution in Gait
Rotation in Gait
Kinetic chain implications
• What is impact on: Ø Foot? Ø Knee? Ø Hip? Ø Low back? Ø Lumbar disc?
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Ground Reaction Force
Functional areas
Rearfoot / mid-foot / TTJ
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Hick’s windlass effect
Lower Extremity Summary
• It is all mechanical linkages • Driven by muscles • Stabilized by ligaments • Most corrections are mechanical by design • Orthotics • Braces • Taping
• Rotator cuff is ‘overloaded’ when the scapula is inefficient
Scapulothoracic articulation • 2:1 ratio in translation • 3 phases with different
ratios • 80-140 degrees
scapula contributes more to arm elevation than the glenohumeral joint
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Anchored?? Really??
UE Complex – Posterior • Static & dynamic
stabilization begins at the scapulothoracic relationship
• From spine to elbow myo-kinetic
• From elbow to phalanges biomechanical
Posterior scapular stability- And the 5 scapular stabilizers are ???
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Anterior scapular anchoring
Effect of Altered Resting Shoulder Position From Borstad 2006
Effects of Altered Resting Shoulder Position
• Sahrmann has proposed that rather than a direct link between alignment deviations & impairment, alignment deviations are likely to be linked to movement dysfunction & movement dysfunction subsequently leads to impairment.
• This analysis confirms only an alignment-anatomical variable relationship, but combined with the kinematic findings, it supports an alignment-pathomechanical alteration relationship.
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Principles
• We use the lower extremity by default, the upper extremity by selection
• Homeostasis is balance not optimal performance Ø Homeostasis or homeodynamic Ø Pulse vs. HRV
• The body seeks ease, comfort and pleasure …get the job done and we can rest!
• SAID
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The spine as an anchor • Scap- C0-T12 • Add humerus- C0-Ilium • Which muscles move the
spine? • What is their relationship to
muscles that move the UE? • Superficial layer we palpate,
are shown left Ø If dysf(x) look @ UE? Ø Substituting to stabilize spine?
The starting point - LPHC
• All kinetic chains must have an origin • All kinetic chains must have an anchor • The lumbo-pelvic hip complex (LPHC) serves
as the foundation for all movement & postural events
• Core Stabilization should be the initial area
of rehab in all kinetic chains
CORE
So where are we going?
• Principles Ø Core is the anchor Ø Upper and lower extremities are long levers with
completely different primary operating systems
• Process Ø Utilize these levers to observe the NMS under a
‘An intact motor system can adapt via central nervous system control and muscle system activity. The adaptations of the motor system are represented by muscle imbalances’
Craig Liebenson, DC
General Adaptation Process / Homeostasis
• Specific • Adaptation
to
• Imposed • Demand
• What demand do you put on pt to create a specific adaptation?
• Remove interference w/o Δ of SAID?
• Musculoskeletal vs. visceral?
• Biochemical or psychosocial
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Kinetic link system
• Uncoiling process from Ø Feet, knees, hips, lumbo-pelvic complex Ø Shoulder, elbow, wrist, phalanges
• Coiling process from Ø Shoulders, LPHC (lumbo-pelvic, hip complex) Ø Feet, knees Ø Wind up of upper extremity complex
Shoulder Injuries
• Multifactorial • Primary
impingement (compressive tendinitis)
• Primary tensile overload (tensile tendinitis)
• Others
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Service / overhead mechanics
• Balance counterbalance critical
• Power developed with cervical extension
• Windup opposite of ground stroke but still circular in design
• Impingement at g/h and IVF possible
Complex Force Coupling
Golf is a system in motion
• Winding and unwinding
• Weight distribution shift
• Conventional and unconventional shots and club management!
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Approach
• Local, Regional, Global • Assessment, Care, Management
Ø How does assessment impact care paradigm? Ø What is your current management paradigm? Ø What do you do afterwards?
¡ 90/10 rule in office. 90/10 doctor ¡ After, that is outside office, 90/10 patient!
“You cannot solve the problems you now have at the same level of thinking you used to create them.”
