Moving Well: Identifying &

retraining movement impairments to optimise function Sarah Mottram MSc

Visiting Research Fellow University of Southampton

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Managing Movement

• ‘Transforming society by optimizing movement to improve the human experience’ vision statement for Physical Therapy Profession’ (APTA Mission Statement 2013)

• Movement is a key to optimal living and quality of life

• Health

• Activity Participation

• Physiotherapists should address kinesiopathological conditions – be life-span practitioners (Sahrmann 2014)

• This lecture will explore how managing movement impairments can direct training to optimise movement and function

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Aims:

• Review the concept of using movement control tests to identify movement impairments (uncontrolled movement)

• Consider the influence of uncontrolled movement on chronic and recurrent musculoskeletal pain and in limiting functional ability

• Discuss common movement impairments in older people and how these link to functional limitations.

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Movement Impairments

• Movement impairments

• impact on the development of movement disorders and pain

• contribute to recurrent pain

• influence function

• Scientific support for identifying movement impairments comes from studies in people with pain

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Movement Control Impairments: Pain ‘Movement is changed in pain and is the target of clinical

interventions’ (Hodges 2011)

• Pain leads to redistribution of activity within and between muscles

• Modifies the mechanical behaviour, protective response

• Adaptation to pain involves changes at multiple levels of the motor system

• Adaptation to pain has short-term benefit, but with potential long-term consequences

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• Individuals with pain present with aberrant movement patterns

(Falla et al 2004, Ludewig & Cook 2000, Luomajoki et al 2008)

Common pattern: • Use patterns associated for high load tasks e.g. pushing

pulling, lifting weights i.e. a bracing strategy for postural tasks, co-ordination and alignment tasks

Motor adaptation to pain (Hodges)

Bracing / rigidity pattern of movement!

Movement Control Impairments: Pain

Changes in Central Nervous System

• Abnormal Brain Structure & Function in Patients with Chronic Pain (Nijs 2014)

• Brain atrophy, especially decrease in brain gray matter, density and volume (containing neural cell bodies seen in people with CLBP)

• Suggest reversible consequence of chronic pain

• Pain influences motor control & capacity to control movement

• Motor control training can reverse reorganization of motor cortex (Tsao 2010)

• People with low back pain fail movement control tests (Luomajoki 2008)

Identifying Movement Impairments

Comerford Mottram Kinetic Control The Management of Uncontrolled Movement Elsevier 2012

• A person is asked to control movement cognitively at a specific joint (e.g. the scapula) whilst challenging the ability to maintain this control with a movement at an adjacent joint

(Comerford & Mottram 2012, Sahrmann

2002)

• Uncontrolled movement: a person demonstrates an inability to cognitively control movement to benchmark standards

• Identifies site and direction of uncontrolled movement

Cognitive Movement Control Test

To identify a movement control impairment

Shoulder Flexion Scapular Movement Control Test

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• Single joint test

• Test of scapula control alignment and coordination e.g. scapula downward rotation

• The clinical SFSMC test to assess uncontrolled scapular motion during arm movement confirmed by motion analysis showing preliminary construct validity (Mottram 2012)

Sitting: chest drop test

• To test for control of lumbar flexion

• Control the low back and pelvis

• Reliability (Elgueta-Cancino et al 2014)

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Sitting to standing

• Test control of hip flexion

• Low back extension

• Control the low back and pelvis

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Short lunge: trunk rotation

• Maintain the hip in extension in upright stance

• Maintain optimal femur-foot alignment in stance to control the hip from rolling into excessive medial rotation / adduction

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Functionally Relevant: multi-joint

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Movement Control Tests

Evidence to support the clinical utility of and reliability of movement control tests

Dankaerts et al 2006, Elgueta-Cancino et al 2014 Enoch et al 2011, Luomajoki et al 2010,

Monnier et al 2012, Mottram et al 2009, Morrissey et al 2008, Roussel et al 2009, van Dillen et al 1998, Worsley et al 2012

Adapted Sahrmann

Linking UCM to functional ability

• Movement control tests are designed to identify those movement impairments which limit functional ability

• 10 week motor control retraining for shoulder impingement improved The Shoulder Pain and Disability Index (SPADI) scores and reduced pain

(Worsley 2014)

• Patient-specific functional complaints and disability improved following specific individual exercise programmes

(Luomajoki 2010) 16

Classifying Uncontrolled Movement to Direct Training • Testing identifies the site and direction of uncontrolled

movement

• Training:

1. To change movement patterns (control work)

2. Target specific muscle recruitment and strength

• Cognitive motor control retraining

• Awareness of impairment

• Relate to function

• Improve task performance based on errors identified

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Movement Retraining: Control

• Repetition of task following improving awareness and understanding

• Cues to suit individual

• Functional relevance

• Targeting impairment in movement system

• Alignment & function

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Movement Retraining: Muscle

• Uncontrolled hip flexion

• Relevance: influence the ability maintain the hip in extension in upright stance

• Target muscle: deep glut max

• Keep it simple

• Movement retraining vs exercise

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In Summary: Movement Control Tests

• Identify site & direction of uncontrolled movement

• Links impairments to function

• Guide effective movement retraining programmes

• Encourages engagement and understanding of movement health

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Thank you

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