Re establishing neuromuscular control
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Re-establishing Neuromuscular Control. Why is it critical to the rehabilitation process?. Refocuses the athlete’s awareness of peripheral sensation & guides them into more coordinated motor strategies Required to: Protect joints from excessive strain

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Re-establishing Neuromuscular Control

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Re-establishing Neuromuscular Control

Why is it critical to the rehabilitation process?

  • Refocuses the athlete’s awareness of peripheral sensation & guides them into more coordinated motor strategies

  • Required to:

    • Protect joints from excessive strain

    • Provide prophylactic mechanism to recurrent injury

  • Complements traditional components of rehabilitation

  • We rely on sensory information from the periphery from our visual, vestibular, & somatosensory systems.

  • Primary role of articular structures

    • Stabilize & guide body segments

    • Provide mechanical restraint to abnormal joint motion

    • Dynamic restraint system

    • Capsuloligamentous tissue & musculotendon receptor sensory role

      • Detect joint motion & position

      • Detect changes in muscle length

      • Implicated in regulating muscle stiffness prior to loading

  • Injury results in damage to microscopic nerves associated with peripheral mechanoreceptors

    • Disrupts sensory feedback

    • Alters reflexive joint stabilization & neuromuscular coordination

  • Four critical elements of neuromuscular control in rehab

    • Joint sensation (position, motion, force)

    • Dynamic stability

    • Preparatory & reactive muscle characteristics

    • Conscious & unconscious functional motor patterns

  • Rehabilitation should address feedback systems

    • Preparatory (feed-forward)

    • Reactive (feed-back)

  • Muscle sense is divided into 4 sensory functions:

    • Sensation of passive movement

    • Sensation of active movement

    • Sensation of position

    • Sensations of heaviness & resistance

What is neuromuscular control?

  • Signal transmission through afferent sensory pathways

  • Proprioception

    • Conscious & unconscious appreciation of joint position

    • Awareness of position & movement

    • Any postural, positional or kinetic info provided to the CNS by sensory receptors in muscles, tendons or joints

  • Kinesthesia

    • Sensation of joint motion or acceleration

    • Sensation of ACTIVEmovement (contracting muscle)

  • Neuromuscular control

    • Efferent motor response to sensory information

    • Proprioception & kinesthesia

  • Motor control mechanisms

    • Feed-forward neuromuscular control

      • Planning movements based on sensory information from past experiences

      • Preparatory muscle activity

      • Operates on premise of initiating a motor response in anticipation of a load or activity

    • Feed-back neuromuscular control

      • Continuously regulates muscle activity through reflexive pathways

      • Reactive muscle activity

      • Operates directly in response to a potentially destabilizing event, using a normal reference point

  • Muscle stiffness

    • Ratio in change of force to change in length

    • Stiffer muscles resist stretching = more effective restraint to joint displacement

    • Modified by muscle activation

Activities for Inducing Adaptations

  • Open & closed kinetic chain activities

  • Balance training

  • Eccentric & high repetition low load exercises

  • Reflex facilitation

  • Stretch-shortening

  • Biofeedback training

  • Controlled positions of vulnerability

Physiology of Mechanoreceptors

  • Articular Mechanoreceptors

    • Specialized nerve endings that transduce mechanical tissue deformation into frequency modulated neural signals

      • Increased tissue deformation results in increased afferent firing rate or rise in quantity of mechanoreceptors activated

    • Types

      • Pacinian corpuscles – (Type II) sensitive to high-frequency vibration; compression sensitive

      • Ruffini endings – (Type I) sensitive to stretching of the joint capsule

      • Golgi-Mazzoni corpuscles – (Type III) sensitive to joint compression, not joint motion

      • Free nerve endings – (Type IV) stimulated by pain & inflammation when a joint is placed in an end position

        • Normally not active in normal joint movement

Articular Mechanoreceptors

  • Quick adapting (QA)

    • Cease discharging shortly after onset of stimulus

    • Provide conscious & unconscious kinesthetic sensation in response to joint movement/acceleration

    • Type II

  • Slow adapting (SA)

    • Continue to discharge as long as stimulus is present

    • Continuous feedback & proprioceptive information relative to joint position

    • Type I, III

Musculotendon Mechanoreceptors

  • Muscle spindles – located in the muscle

    • Responds to stretch of a muscle

      • Detects length & rate of length changes

    • Its stimulation leads to a contraction

    • Transmit information via afferent nerves

    • Innervated by small motor fibers (gamma efferents)

    • Project directly on motoneurons (monosynaptic reflexes)

    • Stretch reflex

      • Stimulation results in reflex contraction

      • Continued stimulation (gamma motor nerves) heighten stretch sensitivity

      • Muscle activity mediation

Musculotendon Mechanoreceptors

  • Golgi Tendon Organs (GTO) – located in tendon & musculotendon junction

    • Detects tension within a muscle & responds to both the contraction & stretching of a muscle

      • Regulate muscle activity & tension

    • Its stimulation results in muscle relaxation

  • GTO’s have opposite effect of muscle spindles by producing a relaxation in the muscle being loaded

Neural Pathways of Peripheral Afferents

  • Encoded signals - transmitted from peripheral receptors via afferent pathways (interneurons) to CNS

  • Brain Stem = Balance

    • Primary proprioceptive correlation center

  • Cerebral Cortex – location of conscious movement

  • Monosynaptic reflex pathway - links muscle spindles directly to motor nerves

  • Balance

    • Influenced by peripheral afferent mechanism mediating joint proprioception

    • Partially dependent on inherent ability to integrate joint position sense, vision & vestibular apparatus with neuromuscular control

Re-establishing Neuromuscular Control

  • Injuries result in decreases in neuromuscular control

  • Pathoetiology

    • Injury results in deafferentation of ligament & capsular mechanoreceptors

    • Joint inflammation & pain compound sensory deficits

    • Congenital/pathological joint laxity have diminished ability to detect joint motion & position

      • Proprioceptive, kinesthetic deficits & mechanical instability lead to functional instability

  • Objectives for Neuromuscular Rehabilitation

    • Develop/re-establish afferent & efferent characteristics that enhance dynamic stability

    • Elements

      • Proprioceptive & kinesthetic sensation

      • Dynamic joint stabilization

      • Reactive neuromuscular control

      • Functional motor patterns

  • Afferent & Efferent Characteristics

    • Sensitivity of peripheral receptors

    • Facilitation of afferent pathways

    • Muscle stiffness

    • Onset rate & magnitude of muscle activity

    • Simultaneous activation of agonist/antagonist

    • Reflexive & discriminatory muscle activation

Neuromuscular Characteristics

  • Peripheral Afferent Receptors

    • Altered peripheral afferent information may disrupt motor control & functional stability

    • Repetitious athletic activity enhances proprioceptive & kinesthetic acuity = facilitated afferent pathways

    • Enhanced joint motion awareness improves feed-forward & feedback mechanisms

  • Muscle Stiffness

    • Significant role in preparatory & reactive dynamic restraints

    • Exercises that encourage muscle stiffness should be incorporated into rehabilitation programs

      • Eccentric exercises

      • Chronic overload results in connective tissue proliferation, desensitizing GTO’s & increase muscle spindle activity

    • Power trained vs. Endurance trained athletes

      • Power athlete = Faster muscle pre-activation (EMG)

      • Endurance athlete = Increased baseline motor tone

  • Reflexive Muscle Activation

    • Reflex latency times may be dependent on types of training (endurance vs. power)

    • Preparatory & reactive muscle activation might improve dynamic stability & function if muscle stiffness is enhanced in deficient joints

    • Decreasing electromechanical delay between joint loading & protective muscle activation can increase stability & function

  • Discriminate Muscle Activation

    • Unconscious control of muscle activity is critical in balance & coordination

    • May initially require conscious activation prior to unconscious control

    • Use of biofeedback can aid in this process

      • Help eliminate imbalances & re-establish preparatory & reactive muscle activity

Elements for Neuromuscular Control

  • Proprioception & Kinesthesia Training

    • Restore neurosensory properties

    • Enhance sensitivity of uninvolved peripheral afferents

    • Joint compression is believed to maximally stimulate articular receptors

      • Closed chain exercises through available ROM

    • Early repositioning tasks are critical

      • Conscious to unconscious joint awareness

    • Applying neoprene sleeve or ace wrap stimulates cutaneous receptors – additional proprioception & kinesthesia

  • Dynamic Stabilization

    • Encourage preparatory agonist/antagonist coactivation

    • Restores force couples & balances joint forces

      • Results in decreased loads on static structures

    • Activities that require anticipatory & reactive adjustments to imposed loads

    • Combination of balance & stretch shortening exercises

      • Encourages preparatory & reactive muscle activity

    • Closed chain exercises induce coactivation & compression

  • Reactive Neuromuscular Control

    • Stimulates reflex pathways

    • Object is to impose perturbations that stimulate reflex stabilization

      • Can resultin decreased response time & develop reactive strategies to unexpected joint loads

      • Perturbations should be unexpected in order to facilitate reflexive activity

  • Functional Activities

    • Objective is to return athlete to pre-injury activity

    • Involves sports specific movement patterns designed to restore functional ability

    • Can be utilized to assess readiness for return to play

    • Stresses peripheral afferents, simultaneous muscle activation, reflexive activity

    • Progress from conscious to unconscious

    • Develop functionally specific movement patterns, ultimately decreasing risk of injury

Lower Extremity Techniques

  • Techniques should focus on muscle groups that require attention

    • Progress from no weight to weight assisted

  • Use of closed-chain activities is encouraged

    • Replicates environmental demands

    • Plays on principles of neuromuscular control

  • Joint stabilization exercises

    • Balance & partial weight bearing activities

    • Progress non-weight bearing to full weight-bearing

    • Balance on unstable surfaces can begin once full-weight bearing

  • Slide board exercises

    • Stimulates coactivation with increasing muscle force & endurance

    • Stimulating dynamic stability & stiffness

  • Stair climbing (forward & backward)

    • Emphasis on eccentric strength

  • Biofeedback

    • Used to develop agonist/antagonist coactivation

    • Encourages voluntary muscle activation

  • Stretch-shortening exercises

    • Eccentric deceleration & explosive concentric contractions

    • Incorporate early in process (modified loads)

    • Involves preparatory & reactive muscle activity

    • Hopping progression

      • Double  Single leg

      • Sagittal  Lateral  Rotational hopping

      • Surface modification

Rhythmic stabilization

React to joint perturbations preparatory & reactive muscle activity

Alterations in loads & displacement

Unstable surfaces

Linear & angular perturbations, altering center of gravity

Facilitate reflexive activity

Ball toss

Disrupt concentration, induce unconscious response & reactive adaptation

Trampoline Hopping

Hopping & landing (double support, single support, rotation)

Challenge athlete

Hopping & catching

Hopping & landing on varying surfaces

Functional activities

Restore normal gait

Athlete must internalize normal kinematics (swing & stance)

Utilize retro walking (hamstring activity), pool or unloading devices

Cross over walking, figure 8’s, cutting, carioca, changes in speed

Functional activities that simulate demands of sport

Upper Extremity Techniques

  • Work to maintain joint congruency & functional stability

    • Requires dynamic restraint via coordinated muscle activation

  • Injury to static stabilizers

  • Failure of dynamic restraint system

    • Could result in repetitive loads, compromising joint integrity & predisposing athlete to re-injury

  • Adapt lower extremity exercise for upper extremity

  • Muscle stiffness

    • Enhance using elastic resistance (focus on eccentrics)

    • High repetitions & low resistance

    • Upper extremity ergometers should be incorporated for endurance

  • Dynamic stabilization

    • Stability platforms

    • Push-ups, horizontal abduction, tracing circles on slide board with dominant & non-dominant arms

    • Plyometric exercise

  • Reactive Neuromuscular Exercises

    • Manual perturbations

    • Rhythmic stabilization with gradual progression

    • Placing joint in inherently unstable positions

  • Functional Training

    • Developing motor patterns in overhead position

    • Reproduce demands of activity

    • Emphasis on technique

    • Re-education of functional patterns

    • Speed & complexity in movement require rapid integration of sensory information

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