dynamic stability of the wrist

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Dynamic stability of the wrist

Saara Raatikainen

Saara Raatikainen 2013

Terms

• Kinetic stability

• capability to bear physiologic load without

yielding

• Kinematic stability

• capability to move smoothly without sudden

bone/joint displacement

• Movement control

• planning and motor control of movement

direction, muscle contraction amplitude and

movement velocitySaara Raatikainen 2013

Concept

• Specific patho-anatomic diagnosis ≠ functional therapeutic hypothesis

• Structural instability does not define the

approach for gaining dynamic stability

• Strength (alone) ≠ stability

• Stability (alone) ≠ be'er func(on

• Instability ≠ muscle weakness / muscle insuffiency


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The aim? - Adequate wrist function

→ Conscious control of movements and postures required, with gradual integration into an automatic control during meaningful movement/functions


Hierarchy of functions

Dynamic strength

Maximal functional strength

Static / isometricstrength

Control of postures & movements

CNS processing / Cognition / Recognition / Postural sense / Proprioception / Kinesthesia

/ Cortical representation / etc.Saara Raatikainen 2013

Motor control

• CNS processing of information,

cognition, recognition, cortical

representation, proprioceptive

properties, etc.

• postural & movement control

• physiological & anatomical

properties for movement

– structures (tissues), strength,

ROM, velocity, stamina, etc.

– barriers

• injuries, impairments

– supporting factors

• previous motor learning, skills

• psychological factors

– barriers

• kinesiophobia, depression,

reluctancy, etc.

– supporting factors

• motivation

• social & environmental factors

• attitudes, external support

• tasks


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• INPUT

• Vision, Touch, Audition, Smell

The stages of informtionprocessing

• Stimulus indentification

• Response selection

• Response programming

The motorprogram and

peripheralmotor system

• Motor program

• Spinal cord

• Muscles

• OUTPUT

Theoretical background

• Currently few different concepts that vary

slightly in the practical approach but are based

on the same theoretical aspects:

– Biomechanics

– Movement patterns

– Function of kinetic chains

– Muscle recruitment patterns

– CNS muscle recruitment programming



• CNS modulation of efficient low-threshold

recruitment of local & global muscle systems

– Low-threshold co-contraction for posture and

alignment control

– Coordinated patterns of muscle recruitment to

produce ROM

– Decelerate motion & control excessive ROM

– Control articular neutral zone

(Gibbons et al 2001)


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• Planning and controlling of muscle contraction

& recruitment, movement direction and

movement velocity

(Sahrmann; Neumann)


Definitions

A. Active structures specific movement

assessment

– Local muscle system

• Articular translation, independent of direction,

anticipatory activation to produce protective stiffness,

no significant change in muscle length

– Global muscle system

• Alighnment & ROM, direction dependent which is

influenced by antagonist activation, length change in

functional movements

(Comerford et al)


Definitions

B. Movement direction specific assessment

– Assessment in functional movements

– Movement behavior point of view

(Luomajoki)

C. Combined??


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’The give’

• Presents as a result of

– Compensation for movement restriction

– Active habitual overuse / misuse (mobilizer

muscles)

– More rarely, due to an extrinsic trauma w/ no

restriction

– Restriction without compensation is rare

→ presents w/ loss of ROM


Definitions – ’the give’,

a common presentation

A. Absent or abnormal muscle recruitment

pattern, or

B. Lack of active control in a certain joint /

movement segment / functional unit towards

a physiological movement direction


A software issue

• Focus on how movements occur

• Assessment of how one aspect of the CNS

processing of movements works

• Important to differentiate from hardware

assessment

– Clinical case presentation can be very similar to a

structure based problem, essential to define and

reason between software & hardware problems


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Conscious vs unconscious?

• Input to the CNS and information processing

within the CNS

• Afferent input from various sources

• Joint position sense, movement sense

(kinesthesia), reflex reactions to extraneous

stimuli (neuromuscular control)

→ propriocep(on

• Feedforward, feedbackward, resiprocal and

recurrent inhibition


Conscious vs unconscious

• Cognition, understanding a particular

movement & the ability to differentiate

between movements

• Perception of movements

→ ability to consciously control movements

and postures


Contents of the approach

• Maintain / resume functional ROM

• Proprioception

• Enhance active wrist alignments and dynamic

control

• Muscle synergy and kinetic chains

• Functional isometric muscle recruitment,

functional dynamic strength


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• Analysis of wrist function in relation to adjacent

joints

• Analysis of wrist function in relation to a task or

a meaningful action

• Most symptoms related to functional, multi-joint

activities

• Detection of any abnormal or uncontrolled

biomechanical movement patterns that might

contribute to negative loading of the wrist /

tissues


Proprioception

• Joint position sense, movement sense

(kinesthesia), reflex reactions to extranous

stimuli (neuromuscular control)

• conscious, unconscious

• Afferent input from various sources

• Muscle spindels, ligament/intra-articular

mechanoreceptors, cutaneous receptors

• Visual input

• Afferent input may be diminished or destroyed

due to trauma or surgery

• PIN, soft tissues

Enforce the remaining sources in rehabilitation


Proprioception

• Joint position and movement sense training

• Include / exclude visual and/or sensory feed back

according to individual level of performance

• Balance and reaction (speed) training,

neuromuscular training

• Various equipment, surfaces, etc.

• Notice the kinetic chains of the whole upper

limb, especially in weigh-bearing functions

• Optimize the loading of wrist structures


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Facilitate

• Sensory feedback, visual feedback (cortical activation),

mimiking (mirror neurons), etc.


Challenge

• Blindfold position sense, passive place – active replace,

blindfold active replacement of pre-determined postures

and movements


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Gradual approach of training

• Recognise the movement

• Facilitate when necessary

• Always exercise with attention

• Challenge with progression


Assessment

• Ability to maintain a near-neutral position

during a movement in an adjacent joint /

functional unit

• Control of the wrist in relation to adjacent

joint movements

• Fingers

• According to extrinsic muscle synergy

• Testing according to wrist movement

directionSaara Raatikainen 2013

Wrist flexion

control

• Maintain wrist in

near-neutral + flex

fingers

• Resistance to wrist

extension +

maintain smooth

finger flexion

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Wrist extension

control


near-neutral +

extend fingers

• Resistance to

wrist flexion +

maintain smooth

finger extension

Radial deviation

control


near-neutral +

abduct thumb

• Resistance to

wrist ulnar

deviation +

maintain smooth

thumb abduction

Ulnar deviation

control


near-neutral +

abduct V finger

• Resistance to

wrist radial

deviation +

maintain smooth

V finger abduction

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Dart throw

control


near-neutral +

grip with lV-V

fingers

• Resistance to

wrist radial

extension +

maintain ulnar

grip

Dart throw

control


near-neutral +

extend l-ll fingers

• Resistance to

wrist ulnar flexion

+ maintain

smooth l-ll finger

extension

But remember..

• No single test is reliable to make a judgement

• Several pieces will make the whole puzzle

• Detect any compensatory movements within a

kinetic chain

– Differentiate between primary and secondary

findings

→ clinical reasoning skills are essen3al!!

(for functional diagnosis and planning a suitable

treatment approach)


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Conclusions• Current research is taking the baby steps into

understanding movement control & dynamic

stability, and it’s different aspects

• No evidence or set guidelines for the hand

• Clinical reasoning skills are outmost essential

when analysing movement control, motor

skills and motor performance and their

relevence with clinical symptoms


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THANK YOU


dynamic stability of the wrist

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