The Lumbo/pelvic/hip complex

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1 The Lumbo/pelvic/hip complex Optimising intervention to maximise dynamic function. Trish Wisbey-Roth Masters Sports Physio. ( AIS/UC) Sports/Olympic Physio. Active Rehabilitation Consultant Incidence of low back pain 85% of people experience Low back pain (LBP) in life. 5% become chronic and unremitting. 70% have recurrent back problems. ( Garofalo and Polatin 1999) Approx 20% of chronic LBP patients have SIJ (synovial portion) as a pain generator. (Schwarzer et al 1995) Groin surgical intervention Why? & How much is enough? More than 25% sports hernias asymptomatic (Paajaren 2007). Adductor tendon surgery, obturator nerve entrapment. Hip labral repairs and Guans lesion removal. Pubic symphysis curettage (Radic 2007). Blood, dextrose injections. (Gaston 2005) Muscular system - A major dynamic support Hides, Hodges, 2000; O Sullivan,1997;2001. Panjabi, 1994; Richardson et al, 1992; Holmich, 1999, Vleeming, 2000 McGill, 2004 Mens,, Solving the puzzle Underlying causes of injury. Diagnose source of dysfunction:- - Motor control L/S, SIJ and hip. - Passive stability L/S, SIJ and hip. - Neural compromise/tethering. - Bone,ligament,tendon compromise. Comprehensive proprioceptive rehab. 1

2 In this Lecture Changes in virtual body:-feed forward CNS engrams from motor cortex. How L/S and SIJ pain can lead to hip dysfunction. A functional and proprioceptive stability program for the L/S, SIJ and hip. Irreversible changes in passive structures. Proprioception in muscle control Muscle receptors play a primary role in joint position sense. (Taimela et al, 1999). Body sway important to balance reactions. Postural sway initially opposite direction to the reactive motion (Hodges 2004). 9 Pain adaptation model (Lund et al,1991) With pain, motor control will limit movement (McGill, 2007). Limitation of velocity and greater co contraction. Co contraction:- spine compressive forces spinal stiffness (Hodges and Mosley 2003). Changes in balance reactions Inaccurate virtual body creates changes in muscle recruitment and decreased preprogramming. Decreased ability to perform reposition tasks and increased reaction time ( Mok et al 2007). Changes in motor planning with pain Changes continue despite :-: resolution of pain, anticipation of pain. Resolver/non resolver personality personality (Mosley et al 2004). Invariable motor recruitment pattern (Mosley and Hodges 2006). Stimulating postural equilibrium If absent, forces and co-contraction contraction in the spine and harder to control dynamic stability. (Mok 2004; Hodges 2004) Induced LBP, L/S Movt compensated by hip and ankle movement. (M M Smith 2004; Hodges 2004) 2

3 Compensation in postural sway Hip strategy is complex CNS task. dependency but also disturbance of visual cues. Hip strategy poor balance with small base and eyes closed (Mok et al 2004 & 2007). Gluteal amnesia (Cholewicki & McGill 1992, McGill 2004) Occurs with L/S & SIJ dysfunction and results in SIJ compression. (Vleeming 1998) With Hams, psoas/iliacus activity to resist reaction forces (McGill 2004). Lumbo pelvic link to groin pain Delayed onset of TrA in chronic groin subjects ( Cowan et al 2004). Passive compression of SIJ adductor force in 39%, isometric adductor pain in 68% (Mens 2006). 89% athletes with pubic bone oedema returned to sport with lumbo pelvic program. (Verrall et al 2007). Resting supine ASLR ASLR with compression SIJ Compression driving muscle recruitment (O Sullivan et al 2002) Resting supine ASLR ASLR with compression Groin pain and stability rehab 1999, Holmich: Active training for chronic Groin pain. 2006, Wollin and Lovell: Osteitis pubis in Footballers. 2007, Verrall et al: Outcome of conservative management of chronic groin injury ( AFL). 2007, Holmich: Long standing Groin pain (66% football, 18% runners). Dynamic stability is not rigidity Traditional models ignored the importance of movement. spinal stiffness may stimulate further trauma. displacement of the whole body during reactive movements from the limbs. (Mosley and Hodges 2006) 3

4 Pilates as a motor control rehab strategy Lack of sound evidence on Pilates (Bernanrdo 2006). (Herrington and Davies 2005). Lack of defined method of Pilates. Changes in movement patterns with changes in speed (Saunders et al 2005). Abdominal stability test:- 58% Pilates group failed. Walking:- increasing speed lumbopelvic movt, abdo and Mult. activity Running+3m/s:- hip flexion, decreased hip extn. (Schache et al 1999). Changes in motor programming with running speed Running +3m/s: TrA phasic while airborne, increased RA and EO activity. EO concentric in walking, eccentric in running (Saunders et al 2004 & 2005). A functional dynamic graded stability system (Wisbey-Roth, 1996) Retraining must be movt. 23 and speed specific. Functional training goals Generate quick appropriate strength in environ that preserves balance.(mcgill 1) Intra muscular (I & II) fibre coordination. 2) Intermuscular coordination b/w muscle groups. McGill 2004) Functional training goals (contd) 3) Train the neuromuscular control systems via facilitatory and/or inhibitory reflexive pathways. 4) Encoding motor patterns for ability to react to changing environment. 4

5 Grade 1 Tonic and independent contraction of key stabilising muscles. Exercises performed in static and stable postures. Grade 2 Progress proprioceptive control of core stabilisers. Endurance of stabilisers while slowly moving arms or legs. Grade 3 Dynamic 3D stability of the spine and Hypertrophy muscle fibers. Retrain eccentric contraction of stabilisers working in dynamic slings. Grade 4 Dynamic stability of limbs in joint angle and speed specific patterns. Grade 5 Dynamic core stability in speed specific, whole body functional postures. Eccentric and dynamic movement retraining. 5

6 Activation pattern fine tuning Optimal dynamic function 35 Functional Integration Module (Lee & Vleeming 1998) Pelvic form closure for optimal L/S, hip function (Kapandji,, 1974; Vleeming 1998; Lee,2001) Form Closure Bones, joints, ligaments Force closure Muscles, fasciae FUNCTION Motor control Neural recruiting patterns Emotions Awareness Changes in passive stability Changes to joint compression alters recruitment pattern (O Sullivan 2002). Failure of form closure may make optimal dynamic function unachievable, without medical intervention The inner unit muscles affecting pelvic form closure Abdominals works with pubococcygeus, to stiffen the pubic symphasis (Avery + O Sullivan, O 2001). Multifidus works with levator ani to position sacrum (Hodges, 2000; Vleeming and Lee, 2000). All loading requires compression of sacrum against ilia to prevent viscoelastic creep of ligs (Cusi,, Saunders, Hungerford and Wisbey-Roth 2007). 39 (Richardson et al, 2002). 6

7 SIJ compression aiding muscle recruitment Tension of pelvic belt is sufficient to obtain required SIJ compression. (Richardson et al 2002; Mens et al 2006) Pelvic stability taping - Posterior If no firm Anchor for muscles to attach to. compression/form closure at the SIJ compromised. ( Cusi et al 2007) Pelvic stability taping - Anterior Prolotherapy improves form closure in SIJ instability (Cusi,, Saunders, Hungerford and Wisbey-Roth 2007) Dextrose 18.5% in Marcain 0.5%, with dash of Dye Diagnostic criteria Measurements. History 6 months minimum Increased by loading Standing, walking Sitting Stairs Comprehensive stability ex program and other Rx failed Examination Stork ASLR+/- mm activity ASLR+/- compression SIJ glide +/-mm activity PPPP Muscle recruitment of local system Clinical assessment Sports physician Physiotherapist Independently Questionnaires Quebec Rol/Morris 24 Rol/Morris 24 multi 7

8 Subjects Profile N = 25 Clinical scores. 9 Clinical assessment tests. Maximum score = 9 t-test for matched pairs Male 5 Female 20 N = 25 Age (years) Average F/U (months) Range Private 20 W/C 5 Mean p< Initial 3 months p= p= year 2 years Quebec Disability Questionnaire 160 Roland Morris 24 Multi Initial 3 months p<0.001 p=0.002 p= year 2 years p= p=0.016 p= Initial 3 months 1 year 2 years Conclusion Address proprioceptive changes occurring with L/S and SIJ pain. A focus on rigid stability may incidence of hip issues result in training for failure Irreversible changes in passive structures may need to be addressed. 8

The One-Leg Standing Test and the Active Straight Leg Raise Test: A Clinical Interpretation of Two Tests of Load Transfer through the Pelvic Girdle

The One-Leg Standing Test and the Active Straight Leg Raise Test: A Clinical Interpretation of Two Tests of Load Transfer through the Pelvic Girdle Diane Lee BSR, FCAMT, CGIMS Published in the Orthopaedic Division Review 2005 I read with interest and some concern the discussion in the last issue of the Orthopaedic Division Review on evidence based