The Shoulder Dysfunction: A Tense Active model of motor control


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Conference of the Tense Active Motor Control in the Shoulder. XIVth Federation of European Societies for Surgery of the Hand, FESSH Congress 3rd to 6th of June 2009 Poznan, Poland. The author explain how the connective system is determinant to control the motions in the shoulder, an special joint deeply dependent of the tissue deformation of the connective and sof tissues to build the adequate movements. Are the connective tissues a passive sub system? Dr. López proposed a new vision how understand the role of Fascias, ligaments, Capsules and other connective tissues during the movements and posture.

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The Shoulder Dysfunction: A Tense Active model of motor control

  1. 1. Shoulder Dysfunction:A Tense Active AnalysisDavid López Sánchez, P.T., D.C.XIVth FESSH Congress3rd to 6th of June 2009Poznan, Poland
  2. 2. Shoulder Pain The shoulder pain represent the thirdmost common cause ofmusculoskeletal consultation inprimary care. BMJ 2005;331:1124-1128 Near 40 to 50% of people who consultwith a new episode of shoulder pain inprimary care report persistentsymptoms after 6 to 12 months.Rheumatology 1999, 38:160-3. The severity of the impingementsyndrome affects the diagnostic valuesof the commonly used clinical testsand those shows low specificity.Rheumatology 2008;47:679–683
  3. 3. The cervicothoracic spine function & head posture havebeen related to shoulder dysfunction. Forward Head Diminished Suboccipital Space &increased thoracic kyphosis Bruxism Cervicothoractic Hypomobility Forward Shoulder (Scapular Protraction) Humeral Internal Rotation•Lewis JS, Green A, Wright C. Subacromial impingement syndrome: the role of posture and muscle imbalance. J ShoulderElbow Surg. 2005;14:385–392.•Finley MA, Lee RY. Effect of sitting posture on 3-dimensional scapular kinematics measured by skin mountedelectromagnetic tracking sensors. Arch Phys Med Rehabil. 2003;84:563–568.•Kebaetse M, McClure P, Pratt NA. Thoracic position effect on shoulder range of motion, strength, and three-dimensionalscapular kinematics. Arch Phys Med Rehabil. 1999;80:945–950.Shoulder Dysfunction and PostureDysfunctions?
  4. 4. Integrated TenseActive ModelAndry Vleeming PhD&David López DCPoland, November 2008MOTORCONTROLTense-ActivityPassive- DynamicNeural ActivityMoto-ActivityVoluntary, in Restingand Automatic(Reflex)Tense - LengthVariation
  5. 5. Functional Sensory-Motor Integration, propioceptive & kinestheticJournal of Athletic Training 2002; 37(1):71–79.The Sensorimotor System, PartI:ThePhysiologic Basis of Functional JointStability. BryanL.Riemann; Scott M. Lephart
  6. 6. Fascies-capsules-tendons-ligaments-perineural layers-cartilages, conective tissues (Static & Dynamic Behavorial)TENSEACTIVE SYSTEMMuscle Activity Neural ActivityFunctional Sensory-Motor Integration, propioceptive & kinestheticJoint MovementDavid López SánchezXII LatinoamericanCongress of Physiotherapy& Kinesiology CLAFK,Bogotá, Colombia. 2006TenseActive ConceptSpinal Motor ControlFUNCTIONAL MOTOR COMPLEX
  7. 7. Integrated TenseActive ModelThe connective tissue damage could produce corruptionof the propioceptive and kinestethic afferents signalsManohar Panjabi: XVI Chilean Congress of Kinesiology, Sept. 2005
  8. 8. The Passive Sub System: it is? The main stimulus for themechanoreceptors is deformationof their differentiatedmicroarchitecture by compressionfor the lamellated bodies andtraction and torsion for the spray-like type. My conviction is No: “TheConnective System actually is aTenseActive System totallyintegrated to the Sensory MotorFunction”. D.L.
  9. 9. The Assessment of theAnterior Head TranslationThe suboccipital space distance, Cobb’s method, craniovertebralangle, sagittal shoulder posture and anterior head translation line arecommonly used by clinicians assess the anterior head translation.Harrison, 2002: AHT 15 mm (10mm or up to 1.0 inch) and found that30 mm of AHT will increase the compressive and bending loadsacting on the lower cervical spine by a factor of 1.25- 4.25.Spine 2000, 25(16):2072–2078; Eur Spine J (2007) 16:669–678; Australian Journal of Physiotherapy 2001, Vol. 47;
  10. 10. Shoulder TenseActive COREThe optimal kinetic chain alignment is necessary for optimalmovement. The function of the coracoclavicular ligaments is tostabilise the clavicle at the scapula.•The conoid ligament primarily prevents the anterior and superiorclavicular displacement.•The trapezoid ligament is the primary constraint againstcompression of the distal clavicle into the acromion.
  11. 11. SubAcromial Space & its TenseactiveRelationships with forward shoulders The increased tenseactive couplingaction to either the conoid andtrapezoid ligaments in forwardshoulders avoid the coracoclavicularseparation during the arm elevationand limit the clavicular posteriorrotation The superior coracoclavicular ligamentis more tense in forward shoulderincreasing the closing forces and thejoint friction in the AC-C
  12. 12. The Acromioclacivular Angle & ScapularOrientatonHebert LJ, Moffet H, McFadyen BJ, Dionne CE. Scapular behavior in shoulder impingement syndrome. Arch Phys Med Rehabil. 2002;83:60–69Lukasiewicz AC, McClure P, Michener L, et al. Comparison of 3-dimensional scapular position and orientation between subjects with andwithout shoulder impingement. J Orthop Sports Phys Ther. 1999;29: 574–583Normally the pectoralis minor muscle elongates during armelevation.Kebatse et al. 1999 have shown that excessive scapular protraction,decreases maximum rotator cuff activation by 23%. (Arch Phys Medrehab).
  13. 13. Shortened Pectoralis MinorThe coupling forces created bytrapezius, Serratus and Pectoralis Minorare neccessary to positioning the scapulaon the thoracic wall.The adaptative shortening of the pectoralisminor would increase the opposite &passive tension forces during armelevation.Smith et al. 2006 reported that maximalrotator cuff strength is optimal when theposition is “neutral of scapularretraction/protraction” (Jour, Elb ShouldSurgery)Physical Therapy . Volume 86 . Number 4 . April 2006
  14. 14. Whiplash and Shoulder ImpingementAbbasian et Als examined 220 patients whoreported whiplash injury. Only the 5%presented impingement syndrome. Journal ofOrthopaedic Surgery and Research 2008, 3:25Chauhan and colleagues examined 102 casesof shoulder pain after whiplash and found to be22% syntomatic but only 9% had subacromialimpingement. J Bone Joint Surg Br 2003, 85(3):408-10.Direct seatbelt trauma to the shoulder is onepossible explanation for its aetiology. Acta Orthop.Belg., 2005, 71, 385-387
  15. 15. Influences on the fusimotor-muscle spindle system fromchemosensitive nerve endings in cervical facet joints in the cat:possible implications for whiplash induced disorders.ThunbergJ, Hellström F, Sjölander P, Bergenheim M, Wenngren B,Johansson H. Pain. Mar;91(1-2):15-22, 2001Capsular, Facetary & Ligamentous DamageRelated To Motor Dysfunction % Cervical Pain
  16. 16. Kinematic Alterations and MuscleDysfunctions in the ShoulderThe decreased serratus anterior musclefunction in the subjects with shoulderimpingement have been demonstratedby a deficitary control of the inferiorangle of the scapula against the thorax.Ludewig and Cook , Physical Therapy . Volume 80 .Number 3 . March 2000In other pathologies as idiopaticshoulder frozen the humeral ROMdeficits relative to the trunk and scapulahave been confirmed but this was notdeterminant in relation to a pattern ofmuscle dysfunction. Rundquist P. et Als. ArchPhys Med Rehabil Vol 84, October 2003
  17. 17. Posture Changes andmuscle activation(1) Mc Lean L, 2005 and (2) Schuldt 1996 coincidently found that thecorrected posture in sitting produce a statistically significantreduction in muscle activation amplitudes in the neck andshoulder regions compared to forward head posture and,Corrected posture in standing required more muscle activity thanhabitual or forward head posture.(1)The effect of postural correction on muscle activation amplitudes recorded from the cervicobrachial region. Linda McLean Journalof Electromyography and Kinesiology, 2005 Vol. 15, 527-535(2)Effects of changes in sitting work posture on static neck and shoulder muscle activity. Kristina Schuldt el Als. Ergonomics, Vol. 29,1986, 1525 - 1537Villanueva M. Found similar findingsIndustrial Health 1997, 35, 330-336.Ceneviz and other authors have related thecervical muscle activation to themandibular position Cranio. 2006Oct;24(4):237-44.
  18. 18. Shoulder Pain:¿Motor Control reorganization?Falla D. et Als. Below experimental musclenociceptive stimuluation Differents responsesamong trapezius muscle subdivisions duringrepetitive shoulder flexion. (1)Recently Diederichsen L. et Als, 2009 confirmedthat induced pain in the supraspinatus musclecaused a significant decrease in activity of theanterior deltoid, upper trapezius and theinfraspinatus and an increase in activity of lowertrapezius and latissimus dorsi muscles. (2)After the subacromial injection they observed also an increasedmuscle activity in the lower trapezius, the serratus anterior and thelatissimus dorsi muscles. (2)(1)Experimental Brain Research, Volume 178, Number 3 / 2007(2) Experimental Brain Research Volume 194, Number 3 / 2009
  19. 19. Cognitive problemsAssociated to Shoulder PainZanette G. et Als. (1997) found reversiblechanges of motor cortical outputs followingimmobilization of the upper limb. (1)Exist abundant evidence that corticalrepresentation of body parts iscontinuously modulated in response toactivity, behavior and skill acquisition. (2)Reorganization of the sensory and motorsystems following peripheral injury occursin multiple levels including the spinal cord,brainstem, thalamus and cortex. (2)(1) Electroencephalography and Clinical Neurophysiology / Electromyography and Motor Control Volume 105, Issue 4,August 1997, Pages 269-279(2) Neuroscience Volume 111, Issue 4, 6 June 2002, Pages 761-773
  20. 20. Evidenciated Functional Plasticity ByNeuroimagingWhere are we?M.E.P.s (EMG)
  21. 21. SynapsisDendritic SpinesCONDUCT
  22. 22. TrainedHandControlHandWork Memory (WM)The amount of WM is directly related toexcitable cortex.Pascual-Leone 2005. While increasethe difficulty task increase also theMotor Evoked Potentials (MEPs/EMG)signal in the working hand.The Plastic Human Brain Cortex. Alvaro Pascual-Leone, Amir Amedi, Felipe Fregni, and Lotfi B. Merabet.Annu Rev Neurosci 28: 377-401, 2005
  23. 23. Cognitive ability must be qualified with respect to elicited taskemployed. The mental exercise practice increased similarly the motorcortex (MEPs/EMG) representation of the trained hand.Then Could be the motion a cortical meaning?.The Plastic Human Brain Cortex. Alvaro Pascual-Leone, Amir Amedi, Felipe Fregni, and Lotfi B. Merabet.Annu Rev Neurosci 28: 377-401, 2005
  24. 24. A,Areas activated during listening to the untrained-same-notes-music contrasted against rest (p < 0.05, FDR corrected). B,Contrasted image of group mean activation is presented in areasthat were significantly more active during listening to trained-music compared with untrained-same-notes-music.The Journal of Neuroscience 10 January 2007 vol. 27 no. 2 308-314
  25. 25. Motion Process: A Motor MeaningThe movement is an experience, an acquiredmotor meaning.The somatosensory information as space,length, and velocity of the muscles, tensionand pressure acting over the joints, tendonsand ligaments, etc. are fundamental to build upthe motor action.• In summary we are moving based in theassimilated sensation along all the life in ourscognitive-levels.• Clinical Application: The erectus posture isdeveloped according our normalized conceptof the erectus position, according our feel andexperiences, our beliefs, emotions and fears,etc. David López PT, DC.
  26. 26. Shoulder Muscle Strengthen Without Tense LengthNormalization and Whatever Posture?Hides: Spine 2001; Mannion: Spine 2001; Solomonow: Spine 98; O”sullivan: Spine 97; Hodges: J. Spinal Disord. 98;Richardson et al: Spine, 96-97; Magnusson: Eur.Spine J. 96; Panjabi et al: J. S. Disorders 90,92.
  27. 27. Cognition and Emotion Substrate(Motor learning & adaptative motor strategies , fear to pain,beliefs, affective experiences, etc.)Motor Control(specific timing of neuromuscular function & strength,& tense-length variation)Shoulder Dysfunction:AppliedTense Active ApprorachXIVth FESSH Congress3rd to 6th of June 2009Poznan, PolandMoto-Tense-ActiveCoupling(muscle forces and its vectiorial action)Elastic-Tense-activeCoupling(connective structures& joint shapes)
  28. 28. Thank Youconsultas@dolordeespalda.clDavid López Sánchez PT DCXIVth FESSH Congress3rd to 6th of June 2009Poznan, Poland