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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.

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muscle imbalance evaluation and treatment for the low back and hip areas

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
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
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
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
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
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)
muscle imbalance theory
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
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.
slide9

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

understanding motor control
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
sit up straight please
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
functional disturbance
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
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
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
road map1
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
functional disturbance1
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
slow twitch fiber type
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
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
stand up please
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
road map2
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
causes of muscle imbalance
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 imbalance1
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
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
muscle function disturbance1
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.
slide30

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

functional capacity
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
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
road map3
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
diagnosis of muscle imbalances three specific types of clinical testing
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
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
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 sequence1
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
road map4
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
treating impaired proprioception
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
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 proprioception1
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.
road map5
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
pelvic clocks
PELVIC CLOCKS
  • Three dimensional evaluation of function of the lumbar spine and pelvis.
  • Used diagnostically and therapeutically.
testing pelvic clocks
Testing: PELVIC CLOCKS

Clock Orientation

Start Position

testing pelvic clocks1
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

testing pelvic clocks2
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

testing hip extension firing pattern1
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
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
road map6
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
slide55

Evaluating and Treating

Muscle Length Asymmetry

of Lower Quarter Muscles

manual stretching of muscles
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: 20-30 secs, 2 or 3 reps.
  • Muscle Energy: Post-isometric Relaxation and Stretch
stretching psoas prone
Stretching: PSOAS PRONE
  • Anterior Hip Capsule Stretch
stretching piriformis1
Stretching: PIRIFORMIS
  • Above 90 degrees
self stretch piriformis
Self Stretch: PIRIFORMIS

Above 90 degrees

Below 90 degrees

road map7
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
strengthening retraining gluteus maximus
Strengthening/Retraining: GLUTEUS MAXIMUS
  • Prone hip extension.
  • Bridging.
strengthening retraining gluteus maximus1
Strengthening/Retraining: GLUTEUS MAXIMUS

2. Contract Gluteus & hold knee.

1. Contract Gluteus.

strengthening retraining gluteus maximus2
Strengthening/Retraining: GLUTEUS MAXIMUS

3. Isometric hold.

4.Concentric contraction.

strengthening retraining gluteus maximus bridging
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 abdominals
Strengthening/Retraining: ABDOMINALS
  • Sit backs.
  • Curl ups.
  • Supine leg slides with stable transversus or posterior pelvic tilt.
  • Norwegian exercise.
strengthening retraining abdominals1
Strengthening/Retraining: ABDOMINALS

Rectus abdominus

Transversus abdominus

strengthening retraining abdominals sit backs
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.
road map8
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