Physio Charlie

This was the IST by my colleague Ruth: 

Kinetic Control Course Feedback

20/11/08

TOPIC: The Integrated Local Cylinder


The muscles constituting the Integrated Local Cylinder are:

1. Respiratory Diaphragm
2. Pelvic Floor
3. Posterior fasciculus of Psoas
4. Segmental Multifidus
5. Transverse Abdominis


The function of the Integrated local Cylinder is to control translation in the lumbar spine – flexion, extension and rotation.


The rationale behind testing the low threshold voluntary recruitment of these muscles is to find the ones that need to be reactivated/ rehabilitated.


When testing these muscles the following principles should be remembered:
1. Test in the neutral training position
2. VAK ( visual, auditory and kinaesthetic feedback is vital)
3. Low load, slow speed, consistent holding time


Finding the Neutral Training Region:

Gandevia et al (1992) state that proprioception relates to 3 key sensations: sensation of position and movement of joints; sensation of force, effort and heaviness of workload; and sensation of the perceived timing of muscle contraction. There are few reliable studies examining proprioceptive deficits associated with low back pain ( more so of shoulder and cervical spine): Gill and Callaghan(1998), Taimela et al (1999) and Brumagne et al (1999) report a significant decrease in repositioning ability in patients with low back pain.

Bear the above in mind when finding the neutral training region. Lots of VAK! The neutral training region is a relative region within the patient’s joint mid – range where there is minimal support or restraint of motion from the passive restraints.


Practical ( make personal notes if need to)

Respiratory Diaphragm:

Ideal recruitment
Fully elevate ribs with inspiration and maintain basal rib elevation and prevent rib depression during1/2 expiration.

Check if able to do in sitting, maintaining neutral, no substitutions. The benchmark is 15 secs x 2, feels easy, no VAK.

Substitutions to watch for – Tx flexion during expiration (using rectus abdominis); spinal extension during expiration (inefficient rib elevation); ribcage depression (external oblique dominance); breath holding (global co contraction rigidity).

Pelvic Floor:

Some prelimary studies indicate that some muscles of the pelvic floor complex may have an anticipatory recruitment pattern suggesting a stability role.

There should be sensory discrimination between high and low threshold pelvic floor recruitment strategies.

Examples of high threshold recruitment is: stopping the flow of urine midstream, the “lift”, maintaining a closed sphincter when bracing or bearing down. These high threshold strategies may be useful to train in conjunction with low threshold strategies and is sometimes the only option.

Low threshold facilitation strategies ( NB for motor control of translation of pelvic joints and continence)

1. Front to back


2. Side to side


3. 4 Points to the middle


4. Pelvic Zipper



5. Perineal lift
Ideal function:
In crook lying the patient should have a definite sensation of low force contraction of the pelvic floor. In patients with no SIjt or pelvic floor dysfunction there is usually a good sensory discrimination between being lower or higher, more anterior or posterior, consistency of the contraction, symmetry.

Posterior Fasciculus of Psoas

The Psoas has segmental attachments posteriorly to all lumbar transverse processes. Anteriorly at all lumbar vertebral bodies and to all lumbar discs except L5/S1. The posterior fasciculii fibres are approx 3 – 5cm in length.

“ It has a primary stability role at the lumbar spine for axial compression and it has minimal movement function on the lumbar spine. (Bogduk 1997)”

“It demonstrates a significant decrease in cross sectional area at a segmental level in patients with sciatica. (Dangaria and Naesh 1998)”

“ Psoas is clinically deficient in that it fails to segmentally resist displacement at the level of pain in patients who have segmental lumbar dysfunction.”

“Specific segmental psoas facilitation improves lumbar segmental control of induced displacement. (Cromerford and Emerson 1998).”

Action to facilitate:
The local stability role of the psoas is to longitudinally pull the head of the femue into the acetabulum with the spine fixed and supported in neutral alignment to produce axial compression along its line of pull.

Asess and rate voluntary low threshold recruitment: (palpation of segmental loss of translation stiffness)
VAK –describe where muscle is and its function, holding stack of books which you compress to turn on its side, sucking into socket …
Correct activation, sustained contraction, control of neutral position, benchmark 15 secs x 2, no added feedback, good symmetry.

Substitutions to watch for: pelvic hitching (QL and iliocostalis); pelvic rotation (internal and external obliques); hip MR (TFL and gracilis); PPT/Lx F (ant part of Psoas); APT/LxE (iliocostalis); knee F (hamstrings); knee hyperE (quads); co contraction rigidity.

Facilitation strategies:

No cluers – use movement and load facilitators
1. Side Lying rotation to neutral (can use “waggling” as well)


2. Hand Knee Diagonal Push (multifidus reactivation as well)


3. Sitting Manual Trunk Distraction



Some Idea – specific unloaded facilitation
1. Side Lying


2. Supine


3. Standing on step



Transversus Abdominis

“Activates prior to movement of limbs or trunk in anticipation of load to increase stiffness and stability of the spine.”

“A motor control deficit is present in all subjects with back pain.”

“The normal anticipatory activation of TA is significantly delayed in low back pain subjects.”

Action to facilitate: - hollowing of lower abdominal wall without excessive overflow to the upper abdominal wall.

Assess and rate voluntary low threshold recruitment efficiency:

Crook lying. Cough, laugh, forced expiration can demonstrate that muscles are under voluntary control, but these are phasic contractions. Describe where muscle is and its function. Corset. Moving ASIS together. Maintain control of neutral. Benchmark 15secs x 2. Good symmetry.

Substitutions to avoid – no palpable contraction (more effort); abdominal wall bulge ( internal obliques or intra abdominal pressure); spinal movement (global substitution); pelvic tilt (global muscles); ribcage depression (external obliques); bracing ( co contraction rigidity, intra abdominal pressure); breath holding (global rigidity); inspiration( passive hollowing)

No Idea at All! – sensory mechanical pre load
1. Lattisimus Dorsi Facilitation

Clues? – movement and load facilitators (these load thoraco lumbar fascia)
1. Four point kneeling
2. Prone on elbows ( not for patients with extension related pain)

Some Idea – specific unloaded facilitation
1. Tactile feedback
2. Low abdominal sling
3. Counting