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Sensory-Motor Control of the Upper Limb: Effects of Chronic Pain

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Sensory-Motor Control of the Upper Limb: Effects of Chronic Pain SensorySensory--MotorMotor ControlControl ofof thethe UpperUpper Limb:Limb: EffectsEffects ofof ChronicChronic PainPain Dr.Dr. VictoriaVictoria Galea,Galea, PhDPhD AssociateAssociate ProfessorProfessor SchoolSchool ofof RehabilitationRehabilitation ScienceScience McMasterMcMaster University,University, CANADACANADA ObjectivesObjectives •• ReviewReview ofof neuralneural innervationinnervation ofof thethe upperupper limblimb (UL)(UL) –– BrachialBrachial Plexus.Plexus. •• SensorySensory--motormotor connectionsconnections betweenbetween thethe centralcentral nervousnervous systemsystem andand upperupper limb.limb. •• InternalInternal ModelsModels ofof motormotor control:control: ForwardForward Models.Models. BasisBasis forfor MotorMotor Coordination.Coordination. •• FunctionalFunctional compromisecompromise ofof thethe ULUL duedue toto chronicchronic neckneck pain.pain. – Recent studies on Upper Limb coordination during a functional task. ReviewReview ofof neuralneural innervationinnervation ofof thethe upperupper limblimb (UL)(UL) –– BrachialBrachial Plexus.Plexus. NeuralNeural InnervationInnervation •• TheThe brachialbrachial plexusplexus isis formedformed fromfrom 55 ventralventral ramirami (C5(C5 -- T1)T1) •• 66 divisionsdivisions – 3 anterior divisions – 3 posterior divisions •• 33 TrunksTrunks •• 33 CordsCords •• 55 PeripheralPeripheral NervesNerves – Branches • Important neural structures for shoulder girdle and joint: – Dorsal Scapular N. • Levator S; Rhomboids – Suprascapular • Supraspinatus, Infraspinatus – Long Thoracic N. • Serratus Anterior – U and L Subscapular N. • Subscapularis, Teres Major – Thoracodorsal N. • Lat. Dorsi – Lat and Med Pectoral • Pec. Major (LP), Pec Minor (LP, MP) • Important Neural structures for the arm: – Axillary N. • Deltoid; Teres Minor – Musculocutaneous N. • Coracobrachialis; Biceps, Brachialis – Radial (P. Cord) • Triceps, brachioradialis, supinoator, all extrinsic extensors – Median (Med & Lat Cord) • Pronator Teres, Most Extrinsic Flexors, Thenar muscles and 1st 2 lumbricals – Ulnar (Med. Cord) • Flexor Carpi Ulnaris, FDP III & IV, all other intrinsic hand muscles. SensorySensory--motormotor connectionsconnections betweenbetween thethe centralcentral nervousnervous systemsystem andand upperupper limblimb MotorMotor SystemsSystems StructuralStructural ReminderReminder From “Raise MR Peripheral nerve injuries in the dog, Part II Compendium on Continuing Education for the Small Animal Practitioner 1 269 276, 1979) CorticospinalCorticospinal TractTract ((AKAAKA PPyramidalyramidal Tract)Tract) •• TwoTwo groupsgroups ofof fibersfibers – Corticospinal tract – Corticobulbar tract •• FibresFibres originateoriginate inin bothboth thethe frontalfrontal andand parietalparietal lobeslobes •• LateralLateral CSPtCSPt decussatesdecussates atat thethe medullarymedullary pyramidspyramids SensorySensory SystemsSystems StructuralStructural ReminderReminder From “Raise MR Peripheral nerve injuries in the dog, Part II Compendium on Continuing Education for the Small Animal Practitioner 1 269 276, 1979) AfferentAfferent EventsEvents ImportantImportant toto thethe ControlControl ofof MovementMovement •• ExteroceptionExteroception •• ProprioceptionProprioception ExteroceptionExteroception CutaneousCutaneous MechanoreceptorsMechanoreceptors SegmentalSegmental signalingsignaling ofof sensorysensory ReceptorsReceptors •• AfferentAfferent informationinformation isis carriedcarried viavia myelinatedmyelinated fibersfibers toto thethe dorsaldorsal hornhorn •• AxonsAxons havehave varyingvarying propertiesproperties ProprioceptionProprioception ProprioceptionProprioception •• Proprioception, is mediated via proprioceptors. •• Proprioceptive feedback provides information from stimuli generated by the system itself. Examples are the mechanical variables associated with activation of muscle (length, velocity, tension). •• Proprioceptors are involved in the moment-to- moment control of movement and include, muscle spindles, tendon organs and joint receptors (e.g. deep joint receptors in cervical vertebral joints). TheThe StretchStretch ReflexReflex •• TheThe stretchstretch reflexreflex isis aa reflectionreflection ofof thethe ““phasicphasic”” componentscomponents ofof musclemuscle spindlesspindles •• TonicTonic componentscomponents conveyconvey importantimportant staticstatic informationinformation aboutabout musclemuscle lengthlength TheThe DorsalDorsal ColumnsColumns MajorMajor PathwayPathway forfor TouchTouch andand ProprioceptionProprioception TheThe CNSCNS knowsknows whatwhat aa musclemuscle isis actuallyactually doingdoing fromfrom decodeddecoded informationinformation fromfrom fourfour inputinput sources:sources: •• The peripheral sensing of the joint angles and skin deformation. •• The peripheral sensing of muscle lengths and their changes by muscle spindles. •• The peripheral sensing of muscle forces generated by Golgi tendon organs. •• The reference (corollary) copies of the instructions sent by the CNS middle level to alpha and gamma motor neurons. CorticalCortical StructuresStructures InvolvedInvolved inin MotorMotor CoordinationCoordination AreasAreas ofof BrainBrain involvedinvolved inin MotorMotor ControlControl • Lots of “traffic” involved in the planning, execution and shaping of movement • Areas of the frontal lobe are involved in the planning and execution of movement . Areas of the parietal lobe are involved in the ongoing performance and shaping of movement. • Many sources of communication between cortical areas and sub- cortical areas such as the cerebellum. InternalInternal ModelsModels ofof MotorMotor Control.Control. ForwardForward Models:Models: BasisBasis forfor MotorMotor CoordinationCoordination InternalInternal ModelsModels ofof MotorMotor ControlControl TheThe acquisitionacquisition ofof complexcomplex motormotor skillsskills isis facilitatedfacilitated byby thethe formationformation ofof internalinternal modelsmodels whichwhich areare neuralneural representationsrepresentations ofof thethe inputinput-- outputoutput characteristicscharacteristics ofof thethe motormotor systems.systems. TheThe cerebellumcerebellum containscontains inverseinverse oror forwardforward modelsmodels ofof thethe motormotor system.system. InternalInternal ModelsModels ofof MotorMotor ControlControl • Mathematically, the term internal model refers to two transformations: – Forward model – the set of operations that change a motor command into motor behaviour. • Forward Internal Models can predict sensory consequences from efference copies of issued motor commands – Inverse Model – The set of operations needed to retrieve a motor command from motor behaviour. • Inverse Internal Models – Can calculate necessary feedforward motor commands from desired trajectory information CoordinationCoordination ofof GripGrip--ForceForce LoadLoad--ForceForce CouplingCoupling • When holding an object with the tips of the fingers there is a frictional force exerted to keep the object from slipping. • This is precisely controlled so that it is just slightly greater than the minimum force needed to prevent slip. • This coupling is explained by a framework that contains both inverse and forward models of the arm. InternalInternal ModelsModels ofof MotorMotor ControlControl fMRIfMRI studiesstudies havehave revealedrevealed cerebellarcerebellar activityactivity specificspecific toto gripgrip--forceforce –– loadload--forceforce coupling,coupling, suggestingsuggesting thethe existenceexistence ofof forwardforward modelsmodels inin thethe cerebellumcerebellum CervicalCervical MuscleMuscle CoordinationCoordination WhiplashWhiplash AssociatedAssociated DisorderDisorder NeuromuscularNeuromuscular ActivationActivation ModelModel •• TheThe presencepresence ofof pain:pain: – Alters the activity of muscles during functional movement. – Specifically – inhibition or delayed activation of muscles. – There are suggestions that this occurs in the deep muscles involved in joint stability. – The action of the superficial muscles is reflective of a compensation for loss of joint stability. – SterlSterling,ing, Jull & Wright, 2001 DisruptionDisruption inin MuscleMuscle ActivationActivation withwith NeckNeck PainPain duringduring ULUL Flexion/Extension.Flexion/Extension. •• Note pattern of activation in controls. – This is a feedforward neural strategy pre-planned by CNS structures. •• Note delayed activation in Neck Pain Patients. •• Automatic Neuromuscular control may not be optimal. – Falla et al, 2004 ClinicalClinical ImplicationsImplications •• DeepDeep CervicalCervical FlexorsFlexors havehave toto bebe broughtbrought backback ““onon--lineline”” forfor properproper posturalpostural adjustmentsadjustments toto taketake place.place. •• TheThe actionaction ofof thethe superficialsuperficial neckneck flexorsflexors andand extensorsextensors isis notnot sufficientlysufficiently ““finefine”” forfor stabilitystability ofof thethe cervicalcervical spinespine duringduring upperupper limblimb movements.movements. TestTest forfor CervicoKinestheticCervicoKinesthetic Ability:Ability: ““TheThe FlyFly””.. Kristjanssen et al, 2004 ClinicalClinical ImplicationsImplications •• ProprioceptiveProprioceptive acuityacuity isis disrupted.disrupted. •• FurtherFurther compoundingcompounding thethe problemproblem inin motormotor controlcontrol ofof thethe neckneck andand armarm •• TheseThese teststests maymay bebe usedused toto traintrain proprioceptiveproprioceptive functionfunction inin patientspatients withwith Neck/ArmNeck/Arm painpain andand functionalfunctional disability.disability.
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