Saara Raatikainen

1. 26.9.2013
1
Dynamic stability of the
wrist
HandFun 2013
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) ≠ better function
• Instability ≠ muscle weakness
Saara Raatikainen 2013
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

2. 26.9.2013
2
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
– supporting factors
• previous motor learning, skills
• psychological factors
– barriers
• kinesiophobia, depression,
reluctancy, etc.
– supporting factors
• motivation
• social & environmental factors
• attitudes, external support
• tasks
Saara Raatikainen 2013
• 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
Saara Raatikainen 2013
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

3. 26.9.2013
3
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
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, independent of 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. For the hand - combined??
Saara Raatikainen 2013

4. 26.9.2013
4
’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
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)
→ proprioception
• Feedforward, feedbackward, resiprocal and
recurrent inhibition
Saara Raatikainen 2013

5. 26.9.2013
5
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
• 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

6. 26.9.2013
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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 Saara Raatikainen 2013
Facilitate
• Sensory feedback, visual feedback (cortical activation),
mimiking (mirror neurons), etc.
Saara Raatikainen 2013
Challenge
• Blindfold position sense, passive place – active replace,
blindfold active replacement of pre-determined postures
and movements, etc.
Saara Raatikainen 2013

7. 26.9.2013
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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
• Low resistance to
wrist extension +
maintain smooth
finger flexion
• Low-threshold
activation when
training
Saara Raatikainen 2013
Wrist extension
control
• Maintain wrist in
near-neutral +
extend fingers
• Low resistance to
wrist flexion +
maintain smooth
finger extension
• Low-threshold
activation when
training
Saara Raatikainen 2013

8. 26.9.2013
8
Radial deviation
control
• Maintain wrist in
near-neutral +
abduct thumb
• Low resistance to
wrist ulnar
deviation +
maintain smooth
thumb abduction
• Low-threshold
activation when
training
Saara Raatikainen 2013
Ulnar deviation
control
• Maintain wrist in
near-neutral +
abduct V finger
• Low resistance to
wrist radial
deviation +
maintain smooth
V finger abduction
• Low-threshold
activation when
training
Saara Raatikainen 2013
Dart throw
control
• Maintain wrist in
near-neutral +
grip with lV-V
fingers
• Low resistance to
wrist radial
extension +
maintain ulnar
grip
• Low-threshold
activation when
training
Saara Raatikainen 2013
Dart throw
control
• Maintain wrist in
near-neutral +
extend l-ll fingers
• Low resistance to
wrist ulnar flexion
+ maintain
smooth l-ll finger
extension
• Low-threshold
activation when
training
Saara Raatikainen 2013

9. 26.9.2013
9
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 essential!!
(for functional diagnosis and planning a suitable
treatment approach)
Saara Raatikainen 2013
Also highly important…
• understanding pain mechanisms
• the affect of pain on body perception and
motor performance, e.g.
– distorted body & movement perception
– altered processing of afferent input
– altered CNS programming for output
– protective motor mechanisms
– etc.
Saara Raatikainen 2013
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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