26.9.

2013

Terms

Dynamic stability of the

wrist

Kinetic stability

Kinematic stability

HandFun 2013
Saara Raatikainen

Concept
Specific patho-anatomic diagnosis
functional therapeutic hypothesis
Structural instability does not define the
approach for gaining dynamic stability
Strength (alone) stability

capability to move smoothly without sudden

bone/joint displacement

Movement control

Saara Raatikainen 2013

capability to bear physiologic load without

yielding

planning and motor control of movement

direction, muscle contraction amplitude and
movement velocity
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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

Stability (alone) better function

Instability muscle weakness

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Hierarchy of functions
Maximal functional
strength
Dynamic strength
Static / isometric
strength
Control of
postures & movements

CNS processing / Cognition / Recognition /

Postural sense / Proprioception / Kinesthesia
/ Cortical representation / etc.
Saara Raatikainen 2013

INPUT
Vision, Touch, Audition, Smell

The stages of
informtion
processing

The motor
program and
peripheral
motor system

Stimulus indentification
Response selection
Response programming

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

psychological factors
barriers
kinesiophobia, depression,
reluctancy, etc.

supporting factors
motivation

social & environmental factors

attitudes, external support
tasks

injuries, impairments

supporting factors
previous motor learning, skills
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

Motor program
Spinal cord
Muscles

OUTPUT

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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

Theoretical background
Planning and controlling of muscle contraction
& recruitment, movement direction and
movement velocity
(Sahrmann; Neumann)

(Gibbons et al 2001)
Saara Raatikainen 2013

Saara Raatikainen 2013

Definitions

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

B. Movement direction specific assessment

Assessment in functional movements
Movement behavior point of view
(Luomajoki)

C. For the hand - combined??

(Comerford et al)
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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

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

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

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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)
proprioception
Feedforward, feedbackward, resiprocal and
recurrent inhibition
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Contents of the approach

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

Maintain / resume functional ROM

Proprioception
Enhance active wrist alignments and dynamic
control
Muscle synergy and kinetic chains
Functional isometric muscle recruitment,
functional dynamic strength
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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

Proprioception

Joint position sense, movement sense

(kinesthesia), reflex reactions to extranous
stimuli (neuromuscular control)

Muscle spindels, ligament/intra-articular

mechanoreceptors, cutaneous receptors
Visual input

Afferent input may be diminished or destroyed due

to trauma or surgery

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conscious, unconscious

Afferent input from various sources

PIN, soft tissues

Enforce the remaining sources in rehabilitation
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Proprioception

Joint position and movement sense training

Balance and reaction (speed) training,

neuromuscular training

Include / exclude visual and/or sensory feed back

according to individual level of performance

Various equipment, surfaces, etc.

Notice the kinetic chains of the whole upper

limb, especially in weigh-bearing functions

Optimize the loading of wrist structures

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Saara Raatikainen 2013

Facilitate

Challenge

Sensory feedback, visual feedback (cortical activation),

mimiking (mirror neurons), etc.

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Blindfold position sense, passive place active replace,

blindfold active replacement of pre-determined postures
and movements, etc.

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Assessment

Gradual approach of training

Recognise the movement

Facilitate when necessary
Always exercise with attention
Challenge with progression

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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
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Wrist flexion
control

Wrist extension
control

Maintain wrist in
near-neutral + flex
fingers
Low resistance to
wrist extension +
maintain smooth
finger flexion
Low-threshold
activation when
training

Maintain wrist in
near-neutral +
extend fingers
Low resistance to
wrist flexion +
maintain smooth
finger extension
Low-threshold
activation when
training

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Radial deviation
control

Ulnar deviation
control

Maintain wrist in
near-neutral +
abduct thumb
Low resistance to
wrist ulnar
deviation +
maintain smooth
thumb abduction
Low-threshold
activation when
training

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

Saara Raatikainen 2013

Dart throw
control

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

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
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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

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.

Differentiate between primary and secondary

findings
clinical reasoning skills are essential!!
(for functional diagnosis and planning a suitable
treatment approach)
Saara Raatikainen 2013

Conclusions
Current research is taking the baby steps into
understanding movement control & dynamic
stability, and its 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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