plan implicaons of biomechanics for analysis and interven0on · implicaons of biomechanics for...
TRANSCRIPT
27/09/18
1
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?
27/09/18
2
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
27/09/18
3
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
27/09/18
4
Howmuchcanyourtrunkmove?
Allowyourtrunkto:
1. Flex
2. Extend
3. Side-flex
4. Rotate
Structureofthetrunkskeletonlimitsmovement
Essen0allyastablestructure
Trunkanatomy:
Muscles
MusclesAnteriortrunk
Essen0alAnatomy5by3D4MedicalEssen0alAnatomy5by3D4Medical
27/09/18
5
Essen0alAnatomy5by3D4Medical
Diaphragm
Essen0alAnatomy5by3D4Medical
IntercostalsQuadratuslumborum
Essen0alAnatomy5by3D4Medical
Vitalorgans
Transversusabdominus
Essen0alAnatomy5by3D4Medical
Rectusabdominus
Essen0alAnatomy5by3D4Medical
27/09/18
6
Internalobliques
Essen0alAnatomy5by3D4Medical
Externalobliques
Essen0alAnatomy5by3D4Medical
MusclesPosteriortrunk
Essen0alAnatomy5by3D4Medical
Trunkwithvitalorgans
Diaphragm
Smallintervertebralmuscles
Intercostals
Mul0fidi
Quadratuslumborum
27/09/18
7
LongissimusLongintercostals
Essen0alAnatomy5by3D4Medical
UpperandlowerSerratusposterior
Essen0alAnatomy5by3D4Medical
Whatcanyourtrunkmusclesdo?
Exercise
Timetocontractyourtrunkmusclesasmuchasyoucan!
– Flexors:
– Extensors:
– SideFlexors:
– Rotators:
Howmuchmoredoyoumoveincomparisontoyour
passiveflexion,extension,rotaBon&sideflexion?
Exercise
– Pressure:Squeezeyourabdominalmusclesashardasyoucan!
27/09/18
8
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
27/09/18
9
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
27/09/18
10
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
27/09/18
11
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
27/09/18
12
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
27/09/18
13
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
27/09/18
14
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?
27/09/18
15
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
27/09/18
16
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
27/09/18
17
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
27/09/18
18
EvidenceBasedPrac0ce
27/09/18
19
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
27/09/18
20
“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!
27/09/18
21
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