NEUROMUSCULAR EVALUATION IN L.B.P.

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NEUROMUSCULAR EVALUATION IN L.B.P.
By Dr. Samia Abdel Hamied.
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This work can provide new insight into sensory
and neuromusculoskeletal function associated with
lumber disorders.
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Health and Health- related states. Health
condition is the interact between functions ,
environmental and personal factors.
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Health condition is the interact between
functions , environmental and personal
factors. WHO 2001 has developed ICF as a
description of health and health- related states.
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• Low Back Pain is the most common musculoskeletal
  disorders.
• 60 -90 .
• 5 10 become chronic.
• Multidimensional problems.
• Pain.
• Neuromuscular control.
• Disability.
• Functional disorders in L.B.P. vary
• in respect to
• Stages .
• Duration of illness
• Physical and psychological stress.
• Nerve- root symptoms occur in 1 of acute Low
  Back Pain.
• The most common cause of sciatica is a herniated
  disc , but in aging population spinal stenosis
  considered as a cause of sciatica
  ( Frymyer 1988 ).

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• Nerve- root symptoms occur in 1 of acute Low
  Back Pain.
• The most common cause of sciatica is a herniated
  disc , but in aging population spinal stenosis
  considered as a cause of sciatica
  ( Frymyer 1988 ).

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Claude et al 2003, Solomonow et al 2003 reported
that spatial or temporal overloading of
spinal structure leads to micro injuries ,
inflammation , pain and neuromuscular
dysfunction. Static lumber flexion develop micro
injuries of the collagenous structure of the
ligaments , acute inflammation, hyperexcitability
of the multifidus muscles.
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The Mechanism of Low Back Pain. spatial or
temporal overloading of spinal structure leads
to micro injuries , inflammation , pain and
neuromuscular dysfunction. Claude et al 2003,
Solomonow et al 2003
Mechanical
Inflammatory stimulus
Sciatic Pain

• MICROINJURY
• Macrophages and Neutrophil accumulation
• and
• Inflammation.
• ( Burke et al 2002)

• muscle fatigue.
• Dorsal ramous neuropathy
• Inappropriate neural control of the muscle
  disposing them to overload and injury.

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The Mechanism of Low Back Pain.

• MICROINJURY
• Macrophages and Neutrophil accumulation
• and
• Inflammation.
• ( Burke et al 2002)

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• Reactive Oxygen Species contribute to muscle
  fatigue.
• Dorsal ramous neuropathy is a potential cause of
  LBP.
• Inappropriate neural control of the muscle bring
  compensatory changes in neighboring muscles
  disposing them to overload and injury.

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• Pain can lead to pathological activation of the
  paraspinal muscles at the same time and adjacent
  segment.
• Chronic pain may lead to reconditioning of the
  muscles and neural modulation of the CNS.( pain
  mode).
• The
  link between pain and altered movement is
  skeletal muscle.

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Pain intensity rating
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• The motor output of the muscle during pain.
• Change the motor patterns of the trunk, due to
  activity of a- motorneurones.
• Travell Simons, 1983 described trunk muscle
  response to painful stimulus.
• Decreased lumber spindle input.
• Increased paraspinal and gluteus muscles
  fatigability.
• Painful input to the CNS leads to Muscular
  hypertonus
• Increased spindle sensitivity to stretch.
• Increased gain to central transmition.
• Decreased range of movement and the velocity of
  motion of painful muscles.
• The reflexive muscle stiffness protect the
  injured structure and enabling tissue healing.

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• The motor output of the muscle during pain.
• Change the motor patterns of the trunk, due to
  activity of a- motorneurones.
• Decreased range of movement and the velocity of
  motion of painful muscles.
• The reflexive muscle stiffness protect the
  injured structure and enabling tissue healing.

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Travell Simons, 1983 described trunk muscle
response to painful stimulus. Zedka 1999
described the modulation depth of ES EMG
activity. He concluded that deep back pain
does not influence the stretch reflex in the back
muscles but modulates the voluntary activation of
these muscles.

• Travell Simons, 1983 described trunk muscle
  response to painful stimulus.
• Lumber spindle input decreased in lumber pain.
• CLBP patients exhibit an increased paraspinal and
  gluteus muscles fatigability.
• Painful input to the CNS leads to
• Muscular hypertonus
• Increased spindle sensitivity to stretch.
• Increased gain to central transmition.

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• Allen (1948) notice the flexion relaxation
  phenomenon
• The ES ceased between 80 and 100 of flexion .
• In the static flexed position no ES activity (
  relaxation ).
• Trunk re extension strong ES activation which
  started before the movement and continued until
  the upright position was reached.
• Absence of the flexion relaxation phenomenon
  indicates that the injured ligaments cannot
  sustain the force and have to be protected by ES
  contraction.
• Zedka (1999 ) described the modulation depth of
  ES EMG activity.
• He concluded that deep back pain does not
  influence the stretch reflex in the back muscles
  but modulates the voluntary activation of these
  muscles.
• Paraspinal muscle spindles are important in
  correct positioning of the lumbosacral spine. (
  Leinonen 2004)

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• Zedka 1999 described the modulation depth of ES
  EMG activity.
• He concluded that deep back pain does not
  influence the stretch reflex in the back muscles
  but modulates the voluntary activation of these
  muscles.

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• During trunk flexion- extension ,Paraspinal
  muscle activity increased when acting as
  antagonist, and decreased when acting as agonist.
  i.e. increased paraspinal muscle activity in the
  normally silent period ,and decreased activity in
  the normal active period of gait.
• ( Leinonen 2004)
• Paraspinal muscle spindles are important in
  correct positioning of the lumbosacral spine.

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• Allen (1948) notice the flexion relaxation
  phenomenon
• The ES ceased between 80 and 100 of flexion .
• In the static flexed position no ES activity
  ( relaxation ).
• Trunk re extension strong ES activation which
  started before the movement and continued until
  the upright position was reached.
• Absence of the flexion relaxation phenomenon
  indicates that the injured ligaments cannot
  sustain the force and have to be protected by ES
  contraction.

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• There are three different co- operating levels
  for human control .
• The highest level, is planning for the movement.
• Voluntary movement.
• The lowest level, is the spinal reflexes
• Automatic motor programs.
• The intermediate levels,
• For the execution of the task.

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Age after the 5th decade of life have
detrimental effects on postural control
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• Body position in relation to gravity is detected
  by sensory input
• Balance movements involve a number of joints
• Ankle
• Knee
• Hip
• Coordinated movement along kinetic chain

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The equilibrium of the body is essential for
locomotion and performing limb movement
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METHODS
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• Voluntary movement
• Subjects performed trunk flexion and extension in
  the standing position with knee extended and the
  feet 10 cm apart.
• They were instructed to forward flexion and
  extension lasting from 5-10 seconds.
• The muscle activation amplitude were calculated
  from 1 sec period during the flexion , full
  flexion and extension movement .
• The range of motion was determined by goniometr
  placed on the T6 vertebra.
• The pattern of movement was described by
• lumbar to hip extension ratios for each 25
  interval of total extension.
• Lumber flexion ratios.

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• Voluntary movement.
• Subjects performed sagittal trunk flexion and
  extension in the standing position with knee
  extended and the feet 10 cm apart.
• They were instructed to flex their body to the
  limit of full flexion and to extend back to the
  upright position ( forward flexion and extension
  lasting from 5-10 seconds)
• The muscle activation amplitude were calculated
  from 1 sec period during the flexion , full
  flexion and extension movement .
• The range of motion was determined by goniometr
  placed on the T6 vertebra.

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• The pattern of movement was described by
  calculating
• lumbar to hip extension ratios for each 25
  interval of total extension.
• Lumber flexion ratios.
• The mean lumbar to hip extension ratios were
• 0.26 for 0-25 of extension,
• 0.61 for 25-50,
• 0.81 for 50-75, and
• 2.3 for 75-100.

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• sEMG.
• Bipolar surface electromyography was recorded
  bilaterally over the paraspinal muscles at T12-L1
  and L5 S1.
• The electrodes were placed on the erector
  spinae(T12-L1 level) and multifidus(L5-S1 level)

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• The postural was evaluated during eight 20 sec
  trials.
• One two footed trial with eyes open and one
  with eyes closed.
• Six one footed trials, of which three were
  performed while standing with the right foot and
  three while standing with the left foot.
• The center point of force velocity was calculated
  for each trial (CPFV) . i.e. The location of the
  resultant ground reaction force from the foot .

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RESULTS
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• Flexion-relaxation phenomenon was seen to occur
  in all at
• 57 of the maximum hip flexion and at
• 84 of the maximum vertebral flexion .
• Abrupt of the activity was seen at almost similar
  flexion angle while coming back to erect
  position.
• The lumbar to hip ratios were different in each
  25 interval.

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• A short latency response was observed in the
  paraspinal muscles.

• Angular displacement during flexion-extension,
  increase spinal stability and represent
  compensation mechanism.

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• Sudden onset of electrical silence called the
  flexion-relaxation phenomenon was seen to occur
  in all at 57 of the maximum hip flexion and at
  84 of the maximum vertebral flexion .
• Abrupt re-commencement of the activity was seen
  at almost similar flexion angle while coming back
  to erect position.

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Mean EMG responses of the right and left lumbar
ES A short latency response was observed in the
paraspinal muscles.
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the angular displacement found in lumbar vertebra
and EMG recruitment patterns from the back
muscles during flexion-extension increase spinal
stability and represent compensation mechanism.
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EMG amplitudes during three phases of movement
(flexion, relaxation, extension) under painless
and painful conditions
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• The average paraspinal muscle activations during
  full flexion were 60 at T12-L1, and 65 at L5-
  S1.
• The relative extension activation in T12-L1 was
  smaller .
• The poor flexion- extension function is due to
• Denervation.
• poor muscle endurance .
• Pain.
• disability.

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• Patients exhibited larger CPFV values
• in the two footed stance with eyes open and
  closed, and in one footed balance test.
• Motor weakness was larger related to two- footed
  CPFV with eyes open ,and Limited rang of movement
  with larger CPFV with eyes closed at baseline.
• Motor weakness, and Limited range of movement
  have larger one footed CPFV.

Unilateral stance test
Left eye open (EO)
Left eye closed (EC)
Right eye open (EO)
Right eye closed (EC)
Mean COG sway velocity (eye open)
Mean COG sway velocity ( eye closed)
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Unilateral stance test
Left eye open (EO)
Left eye closed (EC)
Right eye open (EO)
Right eye closed (EC)
Mean COG sway velocity (eye open)
Mean COG sway velocity ( eye closed)
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• The two footed body sway was increased due to
  motor weakness and limited range of motion.
• The two footed postural stability was weaker with
  eyes open.
• One footed body sway was not associated with the
  side of sciatica pain.

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• The lumbar to hip ratios were different in each
  25 interval.
• When lumbar to hip extension ratios were compared
  with corresponding intervals of flexion, three of
  four were positively correlated to flexion
  ratios, demonstrating a reversible lumbo-pelvic
  rhythm.

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CONCLUSION
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• Both reflex and voluntary mechanism
• are responsible for the absence of flexion
  relaxation .
• In lumber disorder there is slow psychomotor
  reaction time in association with BP.
• It is not yet known whether the poor postural
  control is a consequence of pain or
  neuromuscular impairment.
• Impaired postural control is a potential major
  source of the disorder.

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• The impaired postural stability in CLBP is due to
• Poor balance performance.
• Delayed trunk muscle response time during quick
  force release .
• Impaired proprioception.

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• Factors impacting balance
• Muscular weakness
• Proprioceptive deficits
• ROM deficits

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• The prolonged sciatic pain can impair the lumber
  feed-forward control of the trunk muscles in
  CLBP.
• In CLBP patients the impaired lumber
  proprioception is a reversal phenomenon due to
  feedback error as a result of sensory loss and
  deficit in information processing.
• CLBP patients failed to sense the direction of
  lumber rotation correctly , localize the movement
  sensation else where than lumber region, results
  in segmental instability.
• CLBP and related depression interfere with
  voluntary motor control.

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• Pain decrease the muscle activation amplitude
  during voluntary contraction and increase the
  muscle activation during the automatic
  contraction based on fear-avoidance behaviour.
• Pain-related fear is significantly associated
  with
• Reduced lumbar flexion.
• Greater EMG in full flexion. due to
  musculoskeletal abnormalities.

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• The prolonged sciatic pain can impair the lumber
  feed-forward control of the trunk muscles in
  CLBP.
• CLBP and related depression interfere with
  voluntary motor control.

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• In CLBP patients the impaired lumber
  proprioception is a reversal phenomenon due to
  feedback error as a result of sensory loss and
  deficit in information processing.
• CLBP patients failed to sense the direction of
  lumber rotation correctly , localize the movement
  sensation else where than lumber region, results
  in segmental instability.

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• Pain decrease the muscle activation amplitude
  during voluntary contraction and increase the
  muscle activation during the automatic
  contraction based on fear-avoidance behaviour.
• Pain-related fear is significantly associated
  with reduced lumbar flexion, greater EMG in full
  flexion, due to musculoskeletal abnormalities

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• The impaired postural stability in CLBP is due
  to
• Poor balance performance.
• Delayed trunk muscle response time during quick
  force release .
• Impaired proprioception.

• These musculoskeletal abnormalities as well as
  limited movement may be involved in the
  development and maintenance of chronic low back
  pain.

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• These musculoskeletal abnormalities as well as
  limited movement may be involved in the
  development and maintenance of chronic low back
  pain.

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This work can provide new insight into sensory
and neuromusculoskeletal function associated with
lumber disorders, and the effect of
rehabilitation in muscular function by improving
the muscle control.
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THANK YOU