plan implicaons of biomechanics for analysis and interven0on · implicaons of biomechanics for...

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TheTrunk

Implica0onsofbiomechanicsfor

analysisandinterven0onKarlSchurr

MemberoftheStrokeCollabora0onwww.StrokeEd.com

2018Copenhagen

Plan•  Defini0on•  Biomechanicsofthetrunk

•  Implica0onsforanalysisofsiKngandstanding

•  Examplesofevidencebasedclinicalinterven0on

•  Implica0onsofevidencebasedprac0ceforourclinicalprac0ce

Why is this man falling? Why is this man falling?

Wherewouldyoustart?Observedproblem Possiblecause? What/Howtotest?

Fallingtothele>andforward

Poortrunkcontrol?Decreasedstrengthinwhichtrunkmuscles?Decreased/absentleOlegextensorstrength:Hip,Knee,AnkleDecreased/absentleOhipabductorstrength

Pushingtothele>withrighthand

Decreasedsenseofver0cality?

Le>footnotontheground

Decreasedsensa0oninleOleg?

Decreased/absentleOlegextensorstrength?

Wherewouldyoustart?

Whatproblemswouldyoupriori0se?

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Observedproblem Possiblecause? Priority

Fallingtothele>andforward

Poortrunkcontrol?Decreasedstrengthinwhichtrunkmuscles?

Decreased/absentleOlegextensorstrength?Hip,Knee,Ankle

Decreased/absentleOhipabductorstrength?

Pushingtothele>withrighthand

Decreasedsenseofver0cality?

Le>footnotontheground

Decreasedsensa0oninleOleg?

Decreased/absentleOlegextensorstrength?

KeyMessages•  TheessenBalroleofthetrunkistoprotectvitalorgans•  Trunkmusclesarebilaterallyinnervated

UnlikelytobesignificantlyaffectedaOerstroke•  Uprightbalanceofthetrunkisdependentonthestrengthandco-ordina0onofthemusclesofthebaseofsupport:

InsiKng=thighs&feet Instanding=feet

•  Analysisandinterven0onstrategiesneedtofocusontheessen0alcomponentsforskillssuchassiKng&standing(iethemusclesofthebaseofsupport)

•  Useevidencetoinformourclinicaldecisionmaking

Thetrunk–whatdoweknow? Whatisthetrunk?

Defini0on:Ø  Thepartofthebodytowhichtheheadand

limbsarea]ached=torso–  Includes:chest,abdomen&back

Comprises:•  Skeleton•  Muscles•  Vitalorgans

Trunkanatomy:Skeleton

Ø  Consistsof:

Ø  Vertebralcolumn

Ø  Ribs

Ø  Pelvis

Vertebralcolumn

Essen0alAnatomy5by3D4Medical

Stablerela0onshipofcloselyar0cula0ngvertebra,ligaments&connec0ve0ssue

Providesprotec0onforthespinalcord

Exitpointsfornervestocommunicatewithmusclesandorgans

Spinousprocessesformusclestoa]ach:EgIntervertebralShoulder:Rhomboids,Trapezius,La0ssimusdorsiHip:Iliopsoas

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Ø  Consistsof:

Ø  Vertebralcolumn

Ø  Ribs

Ø  Pelvis

Trunkanatomy:Skeleton

Ribs

Essen0alAnatomy5by3D4Medical

Protec0onofheartandlungs

Combinewithdiaphragmandintervertebralmusclesforthenega0ve&posi0vepressuresforinhala0onandexhala0on

Ø  Consistsof:

Ø  Vertebralcolumn

Ø  Ribs

Ø  Pelvis

Trunkanatomy:Skeleton

Pelvis

Essen0alAnatomy5by3D4Medical

Helpscontainthecontentsofthetrunk

•  Legs:GlutmaxGlutmedius/MinimusIliacusBicepsfemorisRectusfemoris

•  Trunk:Abdominals,PelvicfloorQuadratuslumborumTrunkextensors

•  Shoulder:La0ssimusdorsi

Providesalargesurfaceareafora]achmentoflargemuscles:

TrunkskeletonSummary:

Ø  Stable:Ø  Ver0callyØ Horizontally•  allowssomemovement•  butnottoomuchtoprevent

damagetothevitalorgans!Ø  A]achmentofmuscles:

trunk,legs&armsEssen0alAnatomy5by3D4Medical

Protec0on

Ø  Vitalorgans:•  Spinalcord• Heart•  Lungs•  Stomach/diges0vesystem

•  Liver•  Kidneys,etc

Essen0alAnatomy5by3D4Medical

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Howmuchcanyourtrunkmove?

Allowyourtrunkto:

1.   Flex

2.   Extend

3.   Side-flex

4.   Rotate

Structureofthetrunkskeletonlimitsmovement

Essen0allyastablestructure

Trunkanatomy:

Muscles

MusclesAnteriortrunk

Essen0alAnatomy5by3D4MedicalEssen0alAnatomy5by3D4Medical

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Essen0alAnatomy5by3D4Medical

Diaphragm

Essen0alAnatomy5by3D4Medical

IntercostalsQuadratuslumborum

Essen0alAnatomy5by3D4Medical

Vitalorgans

Transversusabdominus

Essen0alAnatomy5by3D4Medical

Rectusabdominus

Essen0alAnatomy5by3D4Medical

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Internalobliques

Essen0alAnatomy5by3D4Medical

Externalobliques

Essen0alAnatomy5by3D4Medical

MusclesPosteriortrunk

Essen0alAnatomy5by3D4Medical

Trunkwithvitalorgans

Diaphragm

Smallintervertebralmuscles

Intercostals

Mul0fidi

Quadratuslumborum

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LongissimusLongintercostals

Essen0alAnatomy5by3D4Medical

UpperandlowerSerratusposterior

Essen0alAnatomy5by3D4Medical

Whatcanyourtrunkmusclesdo?

Exercise

Timetocontractyourtrunkmusclesasmuchasyoucan!

– Flexors:

– Extensors:

– SideFlexors:

– Rotators:

Howmuchmoredoyoumoveincomparisontoyour

passiveflexion,extension,rotaBon&sideflexion?

Exercise

–  Pressure:Squeezeyourabdominalmusclesashardasyoucan!

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Trunkmuscles:Summary

•  Containvitalorgans

•  Contributetomovementpermi]edbythestableskeletalstructure

•  Arecontainedwithinthetrunk

•  Providepressure:–  Breathing–  Coughingetc

Innerva0onofmuscles

•  Trunk: Bilaterallyinnervated

•  Limbs:

Unilaterallyinnervated

Innerva0onofTrunkvsLimbs

Onesideofthebrains0mulatedusingfocalmagne0cs0mula0on-innormalpeople

–  Results:•  Bilaterals0mula0onof:

Ø  DiaphragmØ  Rectusabdominus1Ø  LumbarParaspinalmuscles2

•  Unilaterals0mula0onofupperlimbmuscles1Carr1992

2Marsden1999

Focaltransmagne0cs0mula0onofLeOhemisphere1

1Carr1992

Transmagne0cs0mula0onLeOhemisphere1

Ø  UpperLimbmuscles:FDI=Firstdorsalinterosseus

Ø  ConsistentforallUpperLimbmusclesinallsubjects

1Carr1992

AnatomySummary-Trunk

•  Skeleton:–  Intrinsicallystable:ribs,vertebraeandpelvis–  Protec0onandcontainmentofvitalorgans–  A]achmentofmusclesof:Trunk,Legs&Arms

•  Muscles:Ø  Providepressure:

•  Breathing:nega0veandposi0vepressures•  Coughing,Vomi0ng,Defeca0on:assistperistalsis

Ø  Contain/protectorgans

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AnatomySummary-Trunk

•  Muscles:

Ø  Providemovement:

•  Flexion,extension,sideflexion&rota0onofthetorsowithinlimitsoftheskeleton

•  Providelinkagebetweenarmsandlegs

(egswimming,golf,bowling,rowing,choppingwood)

Ø  BilaterallyinnervatedExtentoflossaOerstrokeisminimised

Anatomy

LegmusclesPosterior

Largeandextensivemusculaturea]achestothepelvis

AdductorsGluteusminimus

GluteusmaximusGluteusmedius

Anatomy

LegmusclesAnterior

IlliacusPsoasmajorAdductors

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Rectusfemoris

Large,powerful&extensivelegmusculaturea]achedtothepelvis

Summarysofar…..

•  Pelvisprovidesalargea]achmentareaforlarge,powerfullegmuscleswhichflex,extendabductandadductthehip

•  Trunkmusclesarecontainedwithinthetrunk

Anatomyimplica0ons

SiTng

Centreofmass

Ischialtuberosi0es Essen0alAnatomy5by3D4Medical

Whichmusclescancontrolthetrunkposi0oninsiKng?

Trunk,arms&head=2/3bodyweight!

Ischialtuberosi0es

Whichmusclescanstopthetrunkfromfallingforward?

Essen0alAnatomy5by3D4Medical

Centreofmass

SiTng

Trunkextensors?Othermuscles?

SiTng:analysisofmuscleac0vity

=CentreofGravity

Centreofmass

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SiTng:analysisofmuscleac0vity

Ø  Trunkmuscles?

Ø  Musclesexternaltothetrunk?

Whichmusclescanstopthetrunkfromfallingforward?

Thighsupport

SiTng:analysisofmuscleac0vity

Femur

HipExtensors:GluteusmaximusHamstrings?

SiTng:analysisofmuscleac0vity

HipExtensors:GluteusmaximusHamstrings

Feetontheground:

•  KneeExtensorsQuadriceps:MedialisIntermediusLateralisRectusfemoris

•  Plantarflexors:GastrocnemiusSoleus

SiTng:analysisofmuscleac0vity

Howfarcanyoureach?

1.  Withyourfeetofftheground?

2.  Withyourfeetontheground?

3.  Isthereadifference?

4.  Why?

Summary….Keypoints:

Trunkmuscles:

ü  Flex,extend,sideflex&rotatethetrunk✗Donotcrossthehipjoint

✗Cannotstopthetrunkfromfallingforwardorbackward

✗ Cannotpreventthetrunkfromfallingsidewayswithoutlegmuscleac0vity

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Summary….Keypoints:

•  Legmuscles:Hipextensors/flexorsabductors

ü  Crossthehipjoint&controlhipflexion,extension,abduc0on

ü  Arelargeandpowerful

ü  Controltheposi0onofthetrunkoverthighsinsiKng

Standing

Whichmusclescancontrolthetrunkposi0oninstanding?

Standing

•  Simplemodel–  Invertedpendulum:

CentreofMass2/3ofbodymassabovepelvis

Wholesystemrotatesaroundankle

Standing

StandingMul0plemuscles:–  Singlejoint:primarilylarge-legs

•  Ankle:soleus•  Knee:extensors•  Hip:extensors,flexors,ab/adductors•  Trunk?

–  Two-joint:•  Linkagemuscleswhichtransmitforcesfromlargemusclestootherjoints–  Primarilyinthelegs:Gastrocnemius,Biceps

femoris,Rectusfemoris,Gracilus,Sartorius

Summary…...

•  Legmusclesarebigandpowerfulforagoodreason

•  Theyhaveabigjobtodo!

•  Theyhavetokeepusuprightagainstgravity– SiKngreaching– Standing– Walking– Runningetc

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SoleusGastrocnemius

Plantarflexors

Standing:Baseofsupport=Feet

Howstrongareyoursoleusmuscles?

Inpartners:TestyoursoleusmusclesOnepersonkeepstheirheeloffthegroundwiththeirsoleus

Theotherpersontriestopushtheheeldown(ashardasyoupossiblycan!)

Howac0veareourmusclesinquietstanding?

Standing

•  Canyouallstandup?

•  Staystanding

•  Nowcloseyoureyes

Quiet standing

Eyes open Eyes closed

Krishnamoorthy (2002)

Standing:muscleac0vityPanzeretal:BiomechanicalAssessmentofQuietStandingandChangesAssociatedWithAging.

ArchPhysMedRehabilVol76,February1995

•  24subjects21-78•  KinemaBc&KineBcdata(video&forceplatedata)

–  Centreofgravity(COG)–  Centreofpressure(COP)

•  Electromyographic(EMG)ac0vityinallsubjects:–  Legmuscles:TibialisAnterior,Gatrocnemius,VastusLateralis,BicepsFemoris

–  SoleusandVastusMedialis(infivesubjects)–  Trunkmuscles:RectusAbdominus,ErectorSpinae

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Muscle %MVC Range%

Rectusabdominus 1% 1-23

Erectorspinae 6% 1-45

Bicepsfemoris,lateralhead 1% 1-38

Vastuslateralis 4% 1-25

Vastusmedialis* 7% 1-25

Gastrocnemius 1% 1-34

Soleus 10% 9-32

Tibialisanterior 1% 1-28

1Panzeretal1995ArchPhysMedRehabil1995;76:15

10% 9-32%

Standing:EMGmuscleac0vity Belief:“Roleofthecore”

Core“stability”:

–  Mythologyarisenaboutthetrunkmuscles:

?“Helpspreventfalls”

?“corestabilisesyourbodyallowingyoutomoveinanydirec0onevenonthebumpiestterrainorstandinonespotwithoutlosingyourbalance”

Roleofthe“core”

ü  Organcontainmentandprotec0on

ü  Contributetoflexion/extension/rota0onofthetrunk

ü  Providepressure

ü  Linkarms&legsintasks(egswimming)

ü  Minimalac0vityinquietstanding11Panzeretal1995ArchPhysMedRehabil1995;76:151-7.

Aposi0onwhentrunk/coremusclesmayhaveanessen0alroleinremainingupright?

SummaryKeyPoints

•  Gravityistheconstantdeterminantofmuscleac0vityrequiredtoperformanytask

•  Trunkmusclesprovideprotec0onforvitalorgans&movementallowedbytheskeleton

•  Musclesatthebaseofsupportarethefirsttobeac0vatedinanytaskrequiringselfini0atedbalance:Ø SiKng:thighsandfeetØ Standing:feet

Howtousethisinforma0on?

Whataretheimplica0onsfor:

–  Analysisofmovement?

• WhichmusclesareessenBalforsiKng?

• WhichmusclesstopyourtrunkfromfallingforwardsorbackwardsorsidewaysinsiKng?

–  IntervenBon?• WhichmusclestotargetforsiKng,standing-up,walkingetc?

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Analysis

Implica0onsforsiKnganalysis

Why is this man falling?

Why is this man falling? Whatarethepriori0esObservedproblem Possiblecause? Priority IntervenBon

Fallingtothele>andforward

Poortrunkcontrol?Decreasedstrengthinwhichtrunkmuscles?

No No

Decreased/absentleOlegextensorstrength:Hip,Knee,Ankle

Yes Yes

Decreased/absentleOhipabductorstrength Yes Yes

Pushingtothele>withrighthand

Decreasedsenseofver0cality? Possibly ?

Le>footnotontheground

Decreasedsensa0on/propriocep0oninleOleg? Possibly ?

Decreased/absentleOlegextensorstrength? Yes Yes

Possibleplacetobegin:alignmentcue

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Whatarethepriori0esObservedproblem Possiblecause? Priority IntervenBon

Fallingtothele>andforward

Poortrunkcontrol?Decreasedstrengthinwhichtrunkmuscles?

No No

Decreased/absentleOlegextensorstrength:Hip,Knee,Ankle

Yes Yes

Decreased/absentleOhipabductorstrength Yes Yes

Pushingtothele>withrighthand

Decreasedsenseofver0cality? Possibly ?

Le>footnotontheground

Decreasedsensa0on/propriocep0oninleOleg? Possibly ?

Decreased/absentleOlegextensorstrength? Yes Yes

Interven0onideas

Weaklegextensormuscles

SittoStandandStandingVery weak muscles: Leg extensors Impairment training – strength & co-ordination

Sliding tilt-table

Extendingagainsttheendofthebed

Very weak muscles: Leg extensors Books/scales

Hospitalbedcanbe0ltedtoincreasedifficulty

Pressurefeedback

Weak

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Pressurefeedback

Weak Forcefeedback-weak

SteppingTile:sBertBongersUniversityofTechnology,Sydney

Reaching in sitting1,2,3 – wall on intact side

1,2Dean1997,200732017AustralianNa0onalStrokeGuidelines

Reaching in sitting1,2 – wall on intact side

1,2Dean1997,2007

TrainingSiKngLoadingtheaffectedleg

1,2Dean1997,200732017AustralianNa0onalStrokeGuidelines

TrainingSiKng

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EvidenceBasedPrac0ce

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EvidenceBasedPrac0ce

•  Whatdoesitmean?

•  Whataretheimplica0onsforallhealthcaretherapists?

Qualityofinterven0on

How likely are you to receive the best current interventions, which are implemented appropriately for

your presenting problems in a health care service?

A.  60-80%?

B.  40-60%?

C.  20-40%?

D.  10-20%?

E.  Do you know?

EvidencevsOpinion

Ø Weareallbiased!

ü  Humanrealitytoseetheworldthroughourowneyesandindividualexperiences

ü  Weseekinforma0on/evidencethatsupportsandconfirmsourbiases

✗  Ourbiasesmaystopusfromprovidingthebestcurrentinterven0ons

ü  Needstrategiestominimisetheinfluenceofourbiaseswhenconsideringresearchoutcomes

EvidencevsOpinion

•  Research:Ø  Randomisedcontrolledtrials

•  Specificmethodologytominimisebiasoftheresearcher/s

Ø  Aimtodeterminetheeffec0venessofaninterven0onbyminimisingthepoten0alofthepersonalbiasesoftheresearchersfrominfluencingtheoutcomes

“Doingtherightthings,right”Glasziou 2011

EvidenceBasedPrac0ce“Doingtherightthings” Glasziou 2011

1. What are the right things?

Ø  Interventions informed by research:

Randomised Controlled Trials:

Determine the effectiveness (or not) of interventions

Ø  Systematic reviews

= EVIDENCE

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“Doingtherightthings,right” Glasziou 2011

2. How to do things right?

Ø  Intervention protocols from randomised controlled trials & systematic reviews

Ø  High quality clinical guidelines based on current evidence

Ø  Ongoing evaluation of our clinical practice to see if

interventions are being carried out & with fidelity to the

research

= INTERVENTION

Therapists/Clinicians•  Attitudes/beliefs/habits:

Difficult to change!

Ø  Particularly when evidence challenges our beliefs

Ø  “Cognitive dissonance”

•  Evidence will continue to challenge our biases

Ø  Need strategies which help us overcome our biases

and enable us to

“do the right things, right”

What to do with evidence that challenges our biases?

Burnthemessenger?

Centre of Evidence-Based Physiotherapy (CEBP)

Year

1930 1940 1950 1960 1970 1980 1990 2000 2010

Cum

ulative number of records

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000Randomised controlled trialsSystematic reviewsEvidence-based clinical practice guidelines

Graduated

Current

40,000+ records

8,000+ Sys rev

32,000+ RCT’s

PEDro www.PEDro.org.au

2018

Whatisthelikelihoodthatyouwillreceivethebestqualitycare?

Inthehealthservicesthathaveachievedthehigheststandards?

45%45%

WhatisthecurrentdelayingeKnghighqualityinterven0onsinto

clinicalprac0ce?

17+years!

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Implications for clinicians

•  Be aware of current evidence

•  Acknowledge that changing our habits and practice is hard

•  Our biases will continue to be challenged by evidence

•  Be prepared to change our practice when evidence is of high quality

•  Enjoy being challenged!

KeyMessages•  TheessenBalroleofthetrunkistoprotectvitalorgans•  Trunkmusclesarebilaterallyinnervated

UnlikelytobesignificantlyaffectedaOerstroke•  Uprightbalanceofthetrunkisdependentonthestrengthandco-ordina0onofthemusclesofthebaseofsupport:

InsiKng=thighs&feet Instanding=feet

•  Analysisandinterven0onstrategiesneedtofocusontheessen0alcomponentsforskillssuchassiKng&standing(iethemusclesofthebaseofsupport)

•  Useevidencetoinformourclinicaldecisionmaking

Thankyou