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Understanding Movement Evaluation of The Low Back

Hip and Knee

Dr. Kevin Kerchansky DC, DACRB, CSCS, CICE

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Science Research

Anecdotal Clinical

Philosophy Dogma

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Fast Medicine

New Symptoms

Treatment

Side Effects

Treatment

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Trends and Fads Or GoodScience?

Gingko Biloba, Ginseng, Acai Berry Magnetic Bracelets, Copper Sleeves

Green Coffee, Creatine,Multivitamin

EMS, Ultrasound, Cold Laser

HCG, Atkins, Low-Fat, Paleo, Keto Spinal Manipulation, MRT

Vegetarian, Vegan, Lacto-Ovo Meniscus Surgery, Carpal Tunnel Surgery, Spinal Fusion

Statins, PPI’s, NSAID’s, Opioids, SSRI

Microdiscectomy, Medial Branch Block, Radiofrequency Ablation

Juicing, Cleanses, Intermittent Fasting

Acupuncture, Dry Needling

Detoxifications Stretching, Yoga

STRUCTURE VS FUNCTION

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Structure = Pictures

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Structural Approach

“Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear”

– “One year after the procedures, patients in both groups reported similar improvements in pain and quality of life.”

– “Researchers concluded the actual procedure did not provide any additional benefit over the sham surgery.”

– New England Journal of Medicine, Dec. 26, 2013

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Structure = Pictures

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Structural Approach

“A review of more than 3200 cases of acute low back pain suggests that for similar patient presentations, those who had MRI’s early on in their care had a worse outcome, more surgeries, higher costs and greater disability.”

- Journal of Occupational and Environmental Medicine. 2010 Sep;52(9):900-7

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Structure v. Function

• Movement Approach Includes:

– Load/Gravity

– Posture

– Position

– Muscle Activation

– Stabilization

– Compensation

• Leads to Compression and Shearing Forces

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Structure vs. Function

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Neurodevelopmental Model

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Movement

• “First Move Well and Then Move Often.” - G. Cook

• Requirements for Movement– Arthrokinetic Capacity

– Tissue Flexibility

– Motor Control

– Strength (Under Increasing Load)

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Motor Control

“The ability to actively utilize the vast majority of available passive range of motion with biomechanical efficiency.”

• Uncompensated Movement

• Efficient Movement

• Stable Movement

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Joint By Joint Approach

- Cervical – S

- Thoracic – M

- Scapula – S

- Glenohumeral – M

- Lumbar – S

- Hip – M

- Knee – S

- Ankle – M

- Foot – SS = Stable

M = Mobile

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Spinal Stabilization

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Inner Core: Transverse Abdominis, Pelvic Floor, Multifidus, Internal Obliques,

DiaphragmOuter Core:

External Obliques, Rectus Abdominis, Latissimus Dorsi, Quadratus Lumborum, Psoas, Gluteals etc

Core Concepts

• Feed-Forward Mechanism

• 360 Effect

• Pressure Cooker Analogy

• Spinal Stability

• Proximal Stability Before Distal Mobility

• The Search for Stability

• One-Joint Theory

• Two-Hand Rule/Ribs to ASIS - Kinesthetic

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Diaphragm Importance

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� Creates Top of Inner Core

� Acts as Postural and Respiratory Muscle

� Stress Breathing (Apical Breathing) is Improper

� Stress Breathing Inhibits Re-education

of the Nervous System

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Default Positions

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Default Positions

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Injury Risk and Functional Tolerance

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Breakdowns In Movement

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Range of Motion

Joint Tissues

Motor Control

Full Movement

Stable

Uncompensated

Efficient

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Range of Motion Elements

Joints

• Thoracic Spine

• Sacroiliac

• Hip

• Ankle

Treatments

• Manipulation

• Mobilization

• Mulligan Mobilizations

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Range of Motion Elements

Tissues

• Quadriceps

• Rectus Femoris

• Psoas

• Adductors

• Hamstrings

• Gastroc/Soleus

• Piriformis

• Quadratus Lumborum

• Erector Spinae

• Capsules

Treatments

• Myofascial Release

• Active Release Technique

• Graston

• PNF

• Mashing

• Foam Rolls

• Lacrosse Balls

• Various Soft Tissue Tools

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Motor Control Elements

Motor Control

• Altered Movement Patterns

• Dyskinesia

• Overactive/Inactive

• Shortened/Lengthened

• Tonic/Phasic

• Compensation Patterns

• Joint Imbalances

Treatments

• Active Rehabilitation

• Incorporate Increasing Postural Load

• SFMA 4x4 Matrix

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Mobility FirstAllows Expression of

Ideal Fit

• Increased Human Performance

• Injury Prevention

• Injury Resolution

• Attenuation of Injury (Ghosting)

Improves Areas of Fitness

• Strength

• Power

• Endurance

• Cardiorespiratory Capacity

• Balance

• Agility

• Speed

• Stamina

• Accuracy

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The Importance of Optimal Mobility

Quality Stability Is Driven By Quality Proprioception

Quality Proprioception Is Not Possible With Limitations In Mobility

Excessive Mobility Require Excessive Control

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Evaluation Algorithm

• Movement Evaluations Under Load

• Breakout Dysfunctional Movement Under Decreased Load

• Evaluate If Active and/or Passive Range of Motion Is Full

• If Active or Passive Range of Motion Is Full Under No Load A Motor Control Deficit Exists

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Sample Tests

• Standing Toe Touch (Multisegmental Flexion)

• Single Leg Stand

• Overhead Squat

• Global Extension (Multisegmental Extension)

• Lunge Test

• Step Up/Step Down Tests

• Single Leg Squat

• DeadLift Test (Hip Hinge Test)

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Treatment Algorithm

• Restore Passive Range of Motion Deficits

– Joints and Tissues

• Cement New PROM With Active Exercises

– If Stretch Psoas to Full Length Follow With Active Hip Extension Exercise

• Correct Motor Control Deficits ^^^

• Restore Movement Patterns

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Treatment Algorithms

“Rehabilitation of The Spine” – C. Liebenson

• Mobilize Stiff joints

• Relax Overactive Muscles

• Facilitate Inactive Muscles

• Restore Functional Movement Patterns at Subcortical Level

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Treatment Algorithms

• Functional Exercise Progression – P. Page

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Soft TissueProprioception and Posture

Pain and Inflammation

Balance/StabilityMuscle Activation/

StrengthFlexibility/ROM

SkillMovement

Synergy

The Range of Motion/Motor Control Continuum

“Improving PROM decreases motor control.”

“Improving PROM does not improve AROM in the hip.”

“Core or proximal stiffening provides a base for the limb movement. However, this increased prom does not transfer to function; in order for new motor patterns to be adopted, old patterns must be overcome.”

Lower Extremity Review, Nov 13, Vol 5

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Recommended References

• Movement – Gray Cook

• Anatomy Trains – Tom Myers

• Assessment and Treatment of Muscle Imbalance – Phil Page et al

• Kelly Starrett – www.mobilitywod.com

• Functional Movement Systems

• Selective Functional Movement Assessment (SFMA)

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