Musculoskeletal Dysfunction In The Athlete (The Shoulder) John M. Lavelle DO Spine Physiatrist.
The Shoulder Dysfunction: A Tense Active model of motor control
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Transcript of The Shoulder Dysfunction: A Tense Active model of motor control
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Shoulder Dysfunction:
A Tense Active Analysis
Shoulder Dysfunction:
A Tense Active Analysis
David López Sánchez, P.T., D.C.
XIVth FESSH Congress 3rd to 6th of June 2009
Poznan, Poland
David López Sánchez, P.T., D.C.
XIVth FESSH Congress 3rd to 6th of June 2009
Poznan, Poland
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Shoulder Pain
Shoulder Pain
The shoulder pain represent the third most common cause of musculoskeletal consultation in primary care. BMJ 2005;331:1124-1128
Near 40 to 50% of people who consult with a new episode of shoulder pain in primary care report persistent symptoms after 6 to 12 months. Rheumatology 1999, 38:160-3.
The severity of the impingement syndrome affects the diagnostic values of the commonly used clinical tests and those shows low specificity. Rheumatology 2008;47:679–683
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The cervicothoracic spine function & head posture have been related to shoulder dysfunction.The cervicothoracic spine function & head posture have been related to shoulder dysfunction.
Forward Head Diminished Suboccipital Space & increased
thoracic kyphosis Bruxism Cervicothoractic Hypomobility Forward Shoulder (Scapular Protraction) Humeral Internal Rotation
• Lewis JS, Green A, Wright C. Subacromial impingement syndrome: the role of posture and muscle imbalance. J Shoulder Elbow Surg. 2005;14:385–392.
• Finley MA, Lee RY. Effect of sitting posture on 3-dimensional scapular kinematics measured by skin mounted electromagnetic tracking sensors. Arch Phys Med Rehabil. 2003;84:563–568.
• Kebaetse M, McClure P, Pratt NA. Thoracic position effect on shoulder range of motion, strength, and three-dimensional scapular kinematics. Arch Phys Med Rehabil. 1999;80:945–950.
Shoulder Dysfunction and Posture
Dysfunctions?
Shoulder Dysfunction and Posture
Dysfunctions?
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Integrated TenseActive Model
Andry Vleeming PhD &
David López DC
Poland, November 2008
MOTOR
CONTROL
Tense-Activity Passive- Dynamic
Neural Activity
Moto-Activity
Voluntary, in Resting and Automatic
(Reflex)
Tense - Length Variation
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Functional Sensory-Motor Integration, propioceptive & kinesthetic Functional Sensory-Motor Integration, propioceptive & kinesthetic
Journal of Athletic Training 2002; 37(1):71–79.The Sensorimotor System, PartI:ThePhysiologic Basis of Functional Joint
Stability. BryanL.Riemann; Scott M. Lephart
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Fascies-capsules-tendons-ligaments-perineural layers- cartilages, conective tissues (Static & Dynamic Behavorial)
TENSEACTIVE SYSTEM
Muscle ActivityMuscle Activity Neural ActivityNeural Activity
Functional Sensory-Motor Integration, propioceptive & kinesthetic Functional Sensory-Motor Integration, propioceptive & kinesthetic
Joint MovementJoint Movement
David López Sánchez
XII Latinoamerican Congress of Physiotherapy & Kinesiology CLAFK, Bogotá, Colombia. 2006
TenseActive ConceptSpinal Motor Control
FUNCTIONAL MOTOR COMPLEX
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Integrated TenseActive Model
The connective tissue damage could produce corruption of the propioceptive and kinestethic afferents signals
Manohar Panjabi: XVI Chilean Congress of Kinesiology, Sept. 2005
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The Passive Sub System: it is?
The main stimulus for the mechanoreceptors is deformation of their differentiated microarchitecture by compression for the lamellated bodies and traction and torsion for the spray-like type.
My conviction is No: “The Connective System actually is a TenseActive System totally integrated to the Sensory Motor Function”. D.L.
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The Assessment of the
Anterior Head Translation
The Assessment of the
Anterior Head Translation
The suboccipital space distance, Cobb’s method, craniovertebral angle, sagittal shoulder posture and anterior head translation line are commonly used by clinicians assess the anterior head translation.
Harrison, 2002: AHT 15 mm (10mm or up to 1.0 inch) and found that 30 mm of AHT will increase the compressive and bending loads acting on the lower cervical spine by a factor of 1.25- 4.25.
Spine 2000, 25(16):2072–2078; Eur Spine J (2007) 16:669–678; Australian Journal of Physiotherapy 2001, Vol. 47;
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Shoulder TenseActive CORE Shoulder TenseActive CORE
The optimal kinetic chain alignment is necessary for optimal movement. The function of the coracoclavicular ligaments is to stabilise the clavicle at the scapula.
• The conoid ligament primarily prevents the anterior and superior clavicular displacement.
• The trapezoid ligament is the primary constraint against compression of the distal clavicle into the acromion.
The optimal kinetic chain alignment is necessary for optimal movement. The function of the coracoclavicular ligaments is to stabilise the clavicle at the scapula.
• The conoid ligament primarily prevents the anterior and superior clavicular displacement.
• The trapezoid ligament is the primary constraint against compression of the distal clavicle into the acromion.
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SubAcromial Space & its Tenseactive Relationships with forward shoulders SubAcromial Space & its Tenseactive
Relationships with forward shoulders
The increased tenseactive coupling action to either the conoid and trapezoid ligaments in forward shoulders avoid the coracoclavicular separation during the arm elevation and limit the clavicular posterior rotation
The superior coracoclavicular ligament is more tense in forward shoulder increasing the closing forces and the joint friction in the AC-C
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The Acromioclacivular Angle & Scapular Orientaton
The Acromioclacivular Angle & Scapular Orientaton
Hebert LJ, Moffet H, McFadyen BJ, Dionne CE. Scapular behavior in shoulder impingement syndrome. Arch Phys Med Rehabil. 2002;83: 60–69Lukasiewicz AC, McClure P, Michener L, et al. Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement. J Orthop Sports Phys Ther. 1999;29: 574–583
Normally the pectoralis minor muscle elongates during arm elevation.Kebatse et al. 1999 have shown that excessive scapular protraction, decreases maximum rotator cuff activation by 23%. (Arch Phys Med rehab).
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Shortened Pectoralis Minor Shortened Pectoralis Minor
The coupling forces created by trapezius, Serratus and Pectoralis Minor are neccessary to positioning the scapula on the thoracic wall.
The adaptative shortening of the pectoralis minor would increase the opposite & passive tension forces during arm elevation.
Smith et al. 2006 reported that maximal rotator cuff strength is optimal when the position is “neutral of scapular retraction/protraction” (Jour, Elb Should Surgery)
Physical Therapy . Volume 86 . Number 4 . April 2006
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Whiplash and Shoulder Impingement
Abbasian et Als examined 220 patients who reported whiplash injury. Only the 5% presented impingement syndrome. Journal of Orthopaedic Surgery and Research 2008, 3:25
Chauhan and colleagues examined 102 cases of shoulder pain after whiplash and found to be 22% syntomatic but only 9% had subacromial impingement. J Bone Joint Surg Br 2003, 85(3):408-10.
Direct seatbelt trauma to the shoulder is one possible explanation for its aetiology. Acta Orthop. Belg., 2005, 71, 385-387
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Influences on the fusimotor-muscle spindle system from chemosensitive nerve endings in cervical facet joints in the cat: possible implications for whiplash induced disorders.Thunberg J, Hellström F, Sjölander P, Bergenheim M, Wenngren B, Johansson H. Pain. Mar;91(1-2):15-22, 2001
Capsular, Facetary & Ligamentous Damage Related To Motor Dysfunction % Cervical Pain
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Kinematic Alterations and Muscle Dysfunctions in the Shoulder
The decreased serratus anterior muscle function in the subjects with shoulder impingement have been demonstrated by a deficitary control of the inferior angle of the scapula against the thorax. Ludewig and Cook , Physical Therapy . Volume 80 . Number 3 . March 2000
In other pathologies as idiopatic shoulder frozen the humeral ROM deficits relative to the trunk and scapula have been confirmed but this was not determinant in relation to a pattern of muscle dysfunction. Rundquist P. et Als. Arch Phys Med Rehabil Vol 84, October 2003
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Posture Changes and muscle activation
Posture Changes and muscle activation
(1) Mc Lean L, 2005 and (2) Schuldt 1996 coincidently found that the corrected posture in sitting produce a statistically significant reduction in muscle activation amplitudes in the neck and shoulder regions compared to forward head posture and, Corrected posture in standing required more muscle activity than habitual or forward head posture.
(1)The effect of postural correction on muscle activation amplitudes recorded from the cervicobrachial region. Linda McLean Journal of Electromyography and Kinesiology, 2005 Vol. 15, 527-535(2)Effects of changes in sitting work posture on static neck and shoulder muscle activity. Kristina Schuldt el Als. Ergonomics, Vol. 29, 1986, 1525 - 1537
Villanueva M. Found similar findings Industrial Health 1997, 35, 330-336. Ceneviz and other authors have related the cervical muscle activation to the mandibular position Cranio. 2006 Oct;24(4):237-44.
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Shoulder Pain: ¿Motor Control reorganization?
Shoulder Pain: ¿Motor Control reorganization?
Falla D. et Als. Below experimental muscle nociceptive stimuluation Differents responses among trapezius muscle subdivisions during repetitive shoulder flexion. (1)
Recently Diederichsen L. et Als, 2009 confirmed that induced pain in the supraspinatus muscle caused a significant decrease in activity of the anterior deltoid, upper trapezius and the infraspinatus and an increase in activity of lower trapezius and latissimus dorsi muscles. (2)
After the subacromial injection they observed also an increased muscle activity in the lower trapezius, the serratus anterior and the latissimus dorsi muscles. (2)
(1)Experimental Brain Research, Volume 178, Number 3 / 2007 (2) Experimental Brain Research Volume 194, Number 3 / 2009
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Cognitive problems Associated to Shoulder Pain
Cognitive problems Associated to Shoulder Pain
Zanette G. et Als. (1997) found reversible changes of motor cortical outputs following immobilization of the upper limb. (1)
Exist abundant evidence that cortical representation of body parts is continuously modulated in response to activity, behavior and skill acquisition. (2)
Reorganization of the sensory and motor systems following peripheral injury occurs in multiple levels including the spinal cord, brainstem, thalamus and cortex. (2)
(1) Electroencephalography and Clinical Neurophysiology / Electromyography and Motor Control Volume 105, Issue 4, August 1997, Pages 269-279 (2) Neuroscience Volume 111, Issue 4, 6 June 2002, Pages 761-773
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Evidenciated Functional Plasticity By Neuroimaging
Where are we?
Evidenciated Functional Plasticity By Neuroimaging
Where are we?
M.E.P.s (EMG)
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Synapsis
Dendritic Spines
CONDUCT
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TrainedHand
ControlHand
Work Memory (WM) The amount of WM is directly related to excitable cortex.Pascual-Leone 2005. While increase the difficulty task increase also the Motor Evoked Potentials (MEPs/EMG) signal in the working hand.
The Plastic Human Brain Cortex. Alvaro Pascual-Leone, Amir Amedi, Felipe Fregni, and Lotfi B. Merabet. Annu Rev Neurosci 28: 377-401, 2005
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Cognitive ability must be qualified with respect to elicited task employed. The mental exercise practice increased similarly the motor cortex (MEPs/EMG) representation of the trained hand. Then Could be the motion a cortical meaning?.
The Plastic Human Brain Cortex. Alvaro Pascual-Leone, Amir Amedi, Felipe Fregni, and Lotfi B. Merabet. Annu Rev Neurosci 28: 377-401, 2005
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A,Areas activated during listening to the untrained-same-notes-music contrasted against rest (p < 0.05, FDR corrected). B, Contrasted image of group mean activation is presented in areas that were significantly more active during listening to trained-music compared with untrained-same-notes-music.
The Journal of Neuroscience 10 January 2007 vol. 27 no. 2 308-314
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Motion Process: A Motor Meaning
The movement is an experience, an acquired motor meaning.
The somatosensory information as space, length, and velocity of the muscles, tension and pressure acting over the joints, tendons and ligaments, etc. are fundamental to build up the motor action.
• In summary we are moving based in the assimilated sensation along all the life in ours cognitive-levels.
• Clinical Application: The erectus posture is developed according our normalized concept of the erectus position, according our feel and experiences, our beliefs, emotions and fears, etc. David López PT, DC.
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Shoulder Muscle Strengthen Without Tense Length Normalization and Whatever Posture?
Hides: Spine 2001; Mannion: Spine 2001; Solomonow: Spine 98; O”sullivan: Spine 97; Hodges: J. Spinal Disord. 98; Richardson et al: Spine, 96-97; Magnusson: Eur.Spine J. 96; Panjabi et al: J. S. Disorders 90,92.
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Cognition and Emotion Substrate(Motor learning & adaptative motor strategies , fear to pain,
beliefs, affective experiences, etc.)
Motor Control(specific timing of neuromuscular function & strength,
& tense-length variation)
Shoulder Dysfunction:Applied
Tense Active Approrach
XIVth FESSH Congress 3rd to 6th of June 2009
Poznan, Poland
Moto-Tense-Active Coupling
(muscle forces and its vectiorial action)
Elastic-Tense-active
Coupling (connective structures
& joint shapes)
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Thank You
David López Sánchez PT DCXIVth FESSH Congress 3rd to 6th of June 2009
Poznan, Poland