Muscle Imbalance & Exercise Prescription

• Etiology:
◦ postural adaptation to gravity
◦ joint dysfunction
◦ noxious stimuli
◦ physical demand
◦ psychological influence
• Neuromuscular imbalance: chronic adaption = re-setting of reflexes = abnormal muscle tone
• Motor system movements:
etat
◦ voluntary: degrees of freedom problem
◦ reflexes:
‣ automatic and fixed motor responses, occur on much faster time scale
‣ Some reflex loops do not require conscious control- enter only the SC
‣ other reflexes have involvement of lower brain areas but also no conscious control, can be influenced by prior instructions or intentions
◦ rhythmic: "don't worry about this"
• Principles of motor control:
◦ CNS and PNS provide dynamic stability to allow efficient and effective movement *** this is a very important concept***
‣ "qualities of dynamic stability", motor system must: etat
• convey accurately timed commands
• consider body mass and distribution
• adjust to compensate for inertia of limbs and arrangement of muscle, bone, and joints being moved.
◦ feedback mechanisms: info from joint and muscle receptors to allow for unexpected occurrences , send signals "bottom up"
etat ◦ feedforward mechanisms: intended or anticipated actions send signal "top down"
◦ repetition of movement leads to learning , less control higher levels
◦ Proprioception: *** "very important concept"
etat ‣ provided by proprioceptors in skeletal and striated muscles and in joints
‣ highly affected by somatic dysfunction
‣ need proprioception for dynamic stability etat
◦ Combo of signals from basal ganglia, cerebellum and somatosensory pathways for input
‣ cerebellum and basal ganglia - planning and initiation of movement (middle level control)
‣ somatosensory afferents - proprioceptive and tactile input
• Peripheral somatosensory system: Muscle spindles, GTO, Joint mechanoreceptors, nociceptors, cutaneous receptors
• Local control mechanisms:
◦ Interneurons: (also mediate viscerosomatic reflexes) *** very important ***
‣ integrate input from higher centers and peripheral receptors
etat
etat ‣ input to interneurons from same nearby muscles, tendons, joints and skin around muscle
◦ muscle length monitoring: muscle spindles
‣ intrafusal fibers: nuclear bag and chain, monitor length (amount of stretch) and change in length (rate). Innervation afferent sensory group Ia,
II . efferent fibers by gamma motor neurons.
‣ extrafusal fibers: bulk of fibers innervated by alpha motor neurons (efferent)
◦ lower level afferent input
◦ stretch reflex: tendons, unanticipated change . syngergistic muscles coactivation and antagonist inhibition
‣ agonist: primary mover, concentric
‣ antagonist- decelerate limb, eccentric
etat ‣ reciprocal inhibition permits smooth joint movements. can lead to joint weakness. constant contraction of agonist and inhibition of antagonist
may cause weakness in antagonist.
◦ Alpha-gamma-co activation: resting muscle tone
‣ maintains constant stretch of intrafusal fibers > muscle tone
‣ descending supra spinal fibers convergence into gamma motor neurons
◦ Tension monitoring:
‣ GTO in muscle tendon, activated by limb movement, sensory afferent Ib > inhibits agonist and synergist and activates antagonist.
• Muscle Imbalance Theories:
◦ Janda: disregulation of CNS causing tightening of certain muscles and weakness of others
fifty ‣ mobilize dysfunction and stretch hypertonic muscles before strengthening
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to
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‣ improve movement patterns
◦ Sahrmann: no mobilization or stretching
‣ work antagonist to relax tight muscle
‣ reciprocal inhibition
• Tx of muscle imbalance:
◦ proprioception training- restoration of proper muscle contraction sequences
◦ stretch tight muscle first
◦ strengthen weak muscle after stretching
• Proprioception, Dr. Janda: proprioceptive training could restore symmetrical firing patterns , if not Tx then tight
muscles will continue to be tight and weak muscles remain weak
◦ three primary afferent systems for balance (body can function w 2/3 of these)
‣ vestibular: semicircular canals and otoliths
‣ visual
‣ proprioceptive input from soles of feet and joints
◦ evaluation of proprioception: (ideally should do for 30 s)
‣ stand 1 barefoot
‣ stand 1 barefoot with arms crossed
‣ stand 1 barefoot, arms crossed, + closed eyes
◦ retraining should be done with bare feet, grasp floor with sole of foot w/out excessive toe curling , increases sensitivity of sole by shrinking medial
longitudinal arch
 • Muscle Imbalance:
◦ postural tonic muscles: continuous firing (keeps up against gravity) *** "testable" ***
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‣ respond to dysfunction by facilitation, hypertonicity and shortening

ft ◦ Dynamic/phasic muscles: fire in response to command ***"testable"***

‣ respond to dysfunction by inhibition, hypotonicity and weakness FEIG
◦ lack of variety of movement favors postural system (repetitive movements)
• upper crossed syndrome: head forward & rounded shoulders *** "you should know these well" ***

Ittf
◦ tight: levator scapulae, upper trap, SCM, pec minor
Biff ◦ weak: lower trap, deep neck flexors, serratus anterior
◦ all activities of upper extremities and C spine are dysfunctional
• lower crossed syndrome: ant pelvic tilt & increased lumbar lordosis *** " you should know these well" ***
◦ tight1: iliopsoas, rectus femoris, thoraco-lumbar extensors
◦ weak: abdominals and gluteals

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◦ hyper mobility in sagittal and frontal planes at lowest lumbar levels
◦ sitting up from supine and return to upright standing from forward bending are dysfunctional
• postural muscles respond by facilitation, hypertonicity and shortening
◦ levator, upper trap, SCM, scalenes, subscapularis, UE flexors

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◦ iliopsoas, rectus femori, TFL, quadratus lumborum, short thigh
adductors, piriformis, hamstrings, gastrocsoleus, thoracolumbar
erector spine
• dynamic muscle respond by inhibition, hypotonicity and weakness
◦ middle & lower trap, serrates ant, rhomboids, supra and infraspinatus,
deltoid, deep neck flexors, extensors of UE
◦ glut max/med/minimus, transversus abdominus, rectus abdomens,
obliques, peroneals, vasti , tibialis anterior
• identification of faulty movement patterns, lower quarter:
◦ spinal dysrhythmia * classic sign of Janda LCS
◦ pelvic clocks: most common pattern right ASIS inferior or left ASIS is
superior at 12:00 or 6:00
◦ hip ABD & ER: monitor ASIS drop on one side, imbalance between abdominal muscle and hip ADD, mostly on R assoc w/inf pubic shear
◦ supine heel slides: test abdominals , most common is inability to maintain 12:00 on R (R ASIS drops prematurely)
◦ supine curl ups
• hip extension firing pattern

Etf ◦ glut max activation: hamstrings > glut max > contralateral lumbar erector spinae > ipsilateral erector spinae (normal pattern)
◦ PSIS in hip ext: PSIS should stay still or slight sup. commonly excessive superior movement = ant rotated nominate on the R
• Identification of faulty movements upper quarter:
◦ cervical flexion : watch for chin protrusion - SCM substitution of deep neck flexors
◦ should ABD: normal firing pattern supraspinatus> deltoid > infraspinatus > middle and lower trap > contralateral quadratus lumborum (if ipsilateral
quad lumborum fires first = dysfunction)
◦ scapular stabilization: look for winging of scapula
◦ scapular depression
◦ supine shoulder flex
◦ pec minor
◦ shoulder circles
Nociceptive Facilitation Visceral & Somatic Reflexes
• Lymphatics:
◦ Extrinsic pumps: vasomotion via arterial pulsation and muscular contraction pulling on fascia
◦ Intrinsic pumps: contraction of intrinsic smooth muscle (alpha excitation, beta inhibition) , vascular tone regulation by sympathetics
• Inflammation: the lymphatic system is the only source of drainage from an inflamed tissue, the rate of blood supply = the rate of lymphatic drainage
◦ mediators can produce chemonociception
• Fascia:
◦ contraction & thickening = passive congestion of lymph
◦ passive congestion > increase in H+ (metabolic waste) > decreased pH (decreased enzyme activity as a result)
◦ post nodal efferent vessels follow fascial planes towards midline
• OMT can decongest to maintain downward hydrostatic gradient to improve lymphatic system efficacy by concentrating lymph
• Neuroendocrine immune balance:
◦ nerves release of pro inflammatory cytokines > chemonociception > increased CNS sympathetic tone
◦ stressors: illness, injury, finances, family, sleep, pain control
• Nociception: highest concentration of nociceptors in skin with second highest in joint capsules !
◦ interneurons in dorsal horn of SC gate ascending pain signals and stimulate sympathetic (assoc w/pain) & alpha motor neurons

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◦ sufficient sympathetic discharge can result in nociceptive input to the spinal cord. small-caliber primary afferent fibers can become sensitized to

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sympathetic activity.
• Segmental Facilitation: *** " this chart will be a test Q" ***
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Ap ◦ acute:
‣ increased temp
‣ increased moisture/skin drag
‣ prolonged red reflex (erythema rxn)
‣ boggy, fusiform muscular change
‣ articulate motion restriction without a firm, stiff end point
◦ chronic:
‣ thickened skin and SubQ tissue
‣ rapidly fading red reflex
‣ localized muscle contraction (increased tone)
‣ muscles are hard, tense, sensitive to palpation
‣ stiff joints w/articular motion restriction w/firm/definite end feel
Chapmans Reflexes
• chapman lesion caused by lymph stasis in viscus > dysfunction of organ
• chapman lesion is an autonomic nerve reflex and lesion/nodule is a granulation tissue rxn
• reflexes are manifested by gangliform contraction (congestion in fascia due to lymph stasis)
• Tx: 15-60 s is enough for each center
• Sequence of Tx:
◦ pelvic girdle dysfunction first
◦ Tx CR of pelvic-thyroid-adrenal (PTA) syndrome
◦ Tx Cr corresponding to organs of elimination to reduce load on body
◦ Tx specific CR
• Asses and Tx lymphatics !
• Articulation of axial spine + ribs = decreases sympathetic
activity
Intro To MF Trigger Points
• TP: focus of hyper-irritability in a tissue that, when compressed is locally tender and if sufficiently hypersensitive, gives rise to referred pain and sometimes
to referred autonomic phenomena and distortion of proprioception.
◦ Active: symptomatic w/referred pain
‣ Release of pro-inflammatory cytokines as a result of ischemia and tissue hypoxia
◦ Latent: painful only with palpation
◦ Primary: hyper-irritable focus in taut band of muscle
◦ Secondary: focus that became active because of relation to primary muscle
◦ Associated: in response to compensatory overload , shortened position of referral
◦ Satellite: in muscles in reference zone of another active trigger
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• Pathophysiology:
◦ Activation of nociceptors > motor and sensory changes in PNS and CNS =
sensitization
◦ Hyperalgia from MF TP may be due to dysfunctional stress responses
• Diagnosis:
◦ Mostly in women 17-35 , difference in gender decreases with age
◦ Most common in postural muscles and masticatory muscles (TMJD)
• History:
◦ Pain radiates w/NO dermatomal distribution
◦ Direct stimuli: trauma, cold, acute overload, chronic overwork (athletes and
office workers)
◦ Indirect stimuli: Visceral disease, arthritis, emotional stress, other triggers
• PE:
◦ Digital pressure gives pain out of proportion and reproduces pain pattern
◦ Twitch response “superficial taut band of muscle twitches when strummed”
◦ Muscle decreased ROM, pain w/stretch, weak or inhibited
◦ “Primary active trigger points should be palpable, found IN MUSCLE ,
definitive radiating pain w/expected pattern”
• Palpation:
◦ Flat palpation firm compression at right angle to fibers
◦ Pincer palpation: pincer grasp and roll muscle
◦ Snapping palpation: “plucking guitar string” > best to elicit twitch response 5
• Treatment:
◦ Ischemic compression: direct soft tissue technique , *painful*, postural
muscles such as traps, levator, errector spinae, glutes and TFL
◦ Spray and stretch: ethyl chloride
◦ Injection: procain, saline, “dry needling” , steroids, toradol
F
‣ With dry needling, acupuncture needle disrupts neurological signal keeping
muscle taut , watch for punctured lungs !
◦ Low level laser
◦ Somatic dysfunction in associated regions IS ADDRESSED FIRST > may be the cause of muscle imbalance
◦ Postural education with stretching
◦ Heat/ice/theracane
• Difference b/w Tenderpoint and Trigger point *** “good exam question” ***
◦ Tender points are located in hypershortened muscles and are often associated with specific somatic dysfunction, resolves with shortening of muscle
◦ Travell trigger points are in bands of taut muscle and produce predictable radiating pain patterns, relieved by stretching
• Fibromyalgia:
◦ Chronic medical disorder involving widespread pain and tenderness
◦ Often involved tenderness to touch/pressure over skin/joints over widespread area, bilateral and above and below waist
◦ Severe fatigue and may have stiffness
◦ Sleep problems
◦ Cognitive difficulties
◦ Dx includes combo of WPS (widespread pain index) and SS score (Sx severeity score) & Sx> 3 mo, must have 11 of 18 specific trigger points
◦ TX: Opiates rarely used
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