This document discusses dynamic stability of the wrist and motor control. It defines terms like kinetic stability and kinematic stability. It notes that structural instability does not define the therapeutic approach and that stability alone does not equal better function. The aim is adequate wrist function through conscious control of movements. It discusses hierarchies of functions and motor control, with cognition and recognition playing a role. Assessment involves analyzing wrist function in tasks and detecting abnormal movement patterns. Proprioception and enhancing active wrist control are important rehabilitation goals. Control must be assessed in relation to adjacent joints and movement directions. A gradual training approach is advocated with challenge over time.

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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 velocity
Saara 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
Saara Raatikainen 2013

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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
Saara Raatikainen 2013
Hierarchy of functions
Dynamic strength
Maximal functional
strength
Static / isometric
strength
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
– supportingfactors
• previous motor learning, skills
• psychologicalfactors
– barriers
• kinesiophobia, depression,
reluctancy, etc.
– supportingfactors
• motivation
• social & environmental factors
• attitudes, external support
• tasks
Saara Raatikainen 2013

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• INPUT
• Vision, Touch, Audition, Smell
The stages of
informtion
processing
• Stimulus indentification
• Response selection
• Response programming
The motor
program and
peripheral
motor 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
Saara Raatikainen 2013
Theoretical background
• 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)
Saara Raatikainen 2013

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Theoretical background
• Planning and controlling of muscle contraction
& recruitment, movement direction and
movement velocity
(Sahrmann; Neumann)
Saara Raatikainen 2013
Definitions
A. Active structures specific movement
assessment
– Local muscle system
• Articular translation, independentof 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)
Saara Raatikainen 2013
Definitions
B. Movement direction specific assessment
– Assessment in functional movements
– Movement behavior point of view
(Luomajoki)
C. Combined??
Saara Raatikainen 2013

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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
Saara Raatikainen 2013
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
Saara Raatikainen 2013
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
Saara Raatikainen 2013

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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
Saara Raatikainen 2013
Conscious vs unconscious
• Cognition, understanding a particular
movement & the ability to differentiate
between movements
• Perception of movements
→ ability to consciously control movements
and postures
Saara Raatikainen 2013
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
Saara Raatikainen 2013

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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
Saara Raatikainen 2013
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
Saara Raatikainen 2013
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
Saara Raatikainen 2013

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Saara Raatikainen 2013
Facilitate
• Sensory feedback, visual feedback (cortical activation),
mimiking (mirror neurons), etc.
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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
Saara Raatikainen 2013
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
direction
Saara 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
• Maintain wrist in
near-neutral +
extend fingers
• Resistance to
wrist flexion +
maintain smooth
finger extension
Radial deviation
control
• Maintain wrist in
near-neutral +
abduct thumb
• Resistance to
wrist ulnar
deviation +
maintain smooth
thumb abduction
Ulnar deviation
control
• Maintain wrist in
near-neutral +
abduct V finger
• Resistance to
wrist radial
deviation +
maintain smooth
V finger abduction

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Dart throw
control
• Maintain wrist in
near-neutral +
grip with lV-V
fingers
• Resistance to
wrist radial
extension +
maintain ulnar
grip
Dart throw
control
• Maintain wrist in
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)
Saara Raatikainen 2013

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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
Saara Raatikainen 2013
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THANK YOU
Saara Raatikainen 2013