Download Distributed with permission from Elsevier.

From: Movement System Impairment Sydromes of the Extremities,
cervical, and thoracic spine.
Elsevier publisher 2010 Editor; S. Sahrmann, PT, PhD, PT
Distributed with permission from Elsevier.
Introduction to Volume 2
Chapter 1
Introduction:
Update of concepts underlying Movement System Impairment Syndromes.
General concepts:
Optimizing the health of the system during growth and development
Role of degeneration
Balancing optimal use versus disuse vs overuse or misuse
Pain – tissue injury is from what is moving
Path of least resistance
Relative flexibility
Muscle Adaptations
Motor Control Adaptations
Biomechanical Influences
Nancy Bloom and Shirley Sahrmann
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From: Movement System Impairment Sydromes of the Extremities,
cervical, and thoracic spine.
Elsevier publisher 2010 Editor; S. Sahrmann, PT, PhD, PT
The Key Concepts
The following statements encapsulate the primary factors underlying movement
system dysfunctions that contribute to the syndromes associated with the development
of musculoskeletal pain conditions. A full understanding of these key concepts and their
application to patients with musculoskeletal pain will enable the practitioner to develop
the appropriate movement system (MS) diagnosis and treatment program.
1. The majority of musculoskeletal pain syndromes are the result of cumulative
microtrauma from the stress induced by repeated movements or sustained
alignment in a specific direction.
a. Musculoskeletal pain is the result of a progressive condition that is related
to lifestyle.
b. The transition from tissue microtrauma to macrotrauma is influenced by a
variety of intrinsic (genetic, sex, age) and extrinsic (amount and type of
fitness, work activity) factors,
2. The site (joint region) that is moving or stressed in a specific direction is the site
of pain generation
3. The trauma inducing stress occurs most often during the initiation or earliest
phase of the motion rather than at the end of the physiological motion
4. Hypermobility, most often accessory motion hypermobility, is the cause of the
pain. Therefore the offending motions are most often very subtle and the more
chronic the condition or the older the subject, the more subtle the motion.
5. The body follows the law of physics and takes the path of least resistance for
motion, which is a contributing factor to the hypermobility
6. One of the factors influencing the path of least resistance is variation in the
stiffness or relative flexibility of tissues attached to adjoining joints. Most
activities involve movement across several contiguous joints that are arranged in
series and one of these joints moves more readily in a specific direction than the
other joints.
7. The predisposition of a joint to move readily in a specific direction contributes to
the development of a movement pattern
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From: Movement System Impairment Sydromes of the Extremities,
cervical, and thoracic spine.
Elsevier publisher 2010 Editor; S. Sahrmann, PT, PhD, PT
8. Insufficient muscle stiffness (because of relative flexibility) and increased resting
muscle length are the more problematic adaptations than specific muscle
weakness and shortness.
9. The way everyday activities are performed is the critical issue. For efficiency, the
body establishes a pattern of motion that reinforces the relative participation of
specific joints including the joint that moves the most readily in a specific
direction.
10. The relative participation of some muscle groups (disuse or overuse) is the result
of movement patterns and biomechanical influences.
a. For example, in the swayback posture if the pelvis is tilted posteriorly and
the hip is extended, the use of the gluteus maximus is minimized.
b. The kyphotic posture without a posterior sway posture can reduce the
participation of the abdominal muscles because they are not periodically
working against gravity. In contrast a kyphotic posture in the sway back
position can be the result of abdominal muscle shortness or stiffness
because they are the antigravity muscle of the trunk during standing.
11. Muscle performance reflects the pattern of movement but correction is best
achieved by training the correct pattern and not by isolated “strengthening” of a
muscle.
12. Though the human body is highly capable of motor equivalency, the repertoire of
variability becomes limited over time. Stopping the offending motion at the joint
that moves the most readily and redistributing the motion to other adjoining
segments enhances the repertoire for motor equivalency.
a. Motor equivalency is the ability to realize the same motor outcome with
different effectors.
13. The most important treatment is correcting the movement pattern that is causing
the tissue to become painful or irritated and rather than directly treating the
affected tissue.
14. There is no magic in an exercise unless the exercise is limiting or correcting the
movement at the painful joint and producing the desired appropriate movement
at adjoining joints.
Copyright Elsevier
From: Movement System Impairment Sydromes of the Extremities,
cervical, and thoracic spine.
Elsevier publisher 2010 Editor; S. Sahrmann, PT, PhD, PT
a. The same exercise can be used for contrasting problems depending upon
the instruction and performance (quadruped rocking to either increase or
decrease lumbar flexion)
15. Stretching a muscle or soft tissue will not stop the compensatory motion causing
pain but stopping the motion will stretch the muscle.
16. Training movement patterns using motor control principles will induce appropriate
muscular and biomechanical adaptations that will reinforce the development of
optimal neuromuscular action.
17. All neuromuscular adaptations can contribute to as well as correct problems.
Thus “indiscriminate” core strengthening exercises can become a cause of pain
as readily as a lack of muscle strength can contribute to pain problems.
18. The movement system needs periodic examination from childhood to old age to
optimize tissue development and slow the progression of degeneration as well as
guiding exercise to maintain the health of the cardiovascular and metabolic
systems.
a. guide appropriate use, thus preventing disuse, misuse or overuse.
Copyright Elsevier
From: Movement System Impairment Sydromes of the Extremities,
cervical, and thoracic spine.
Elsevier publisher 2010 Editor; S. Sahrmann, PT, PhD, PT
The General Premise: Movement System Impairments a Cause of Pain Syndromes
Ten years have passed since publication of the first volume of this book,
Diagnosis and Treatment of Movement Impairment Syndromes. The purpose of the first
book was to describe a generic model for organizing musculoskeletal pain conditions
into syndromes that constitute diagnostic categories that direct treatment of the
biomechanical aspects of the problem. The belief is that correction or modification of
the biomechanical factors altering the precision of motion (accessory) alleviates or
reduces the tissue irritation and thus the painful condition. The model also described the
key contributing factors to the various diagnostic groups. A major premise of the model
is that the pain most often arises from tissues that are stressed by subtle impairments in
movement or alignment and that key factors are contributing to these particular
impairments. One important factor is that the body, following the laws of physics, takes
the path of least resistance for movement. The activities an individual performs require
movements of multiple joints that are contiguous and in the same kinematic chain, i.e.,
in serial arrangement, and all of which have different flexibility characteristics. Thus one
joint of those that are anatomically arranged in series moves the most easily and the
most readily when an individual performs an activity. Our research supports the
premise (ref) that how readily a joint moves is a more important factor in a movement
pattern associated with pain than muscle shortness, soft tissue restrictions or limited
range of motion of an adjoining joint.
These latter factors may have contributed to the initial development of the flexibility of
the joint causing the pain but once established the offending motion has to be
addressed primarily and the tissue adaptations secondarily. Clearly stretching muscles
or soft tissues will NOT stop the offending motion. But when the offending motion is
stopped or controlled the appropriate tissues will be stretched.
The motion causing the pain occurs during the first few degrees of motion with
performance of an activity. The impairment is believed to be an accessory rather than a
physiological motion, which is consistent with the problem arising during the first few
Copyright Elsevier
From: Movement System Impairment Sydromes of the Extremities,
cervical, and thoracic spine.
Elsevier publisher 2010 Editor; S. Sahrmann, PT, PhD, PT
degrees of movement. Accessory motion hypermobility is an underlying characteristic
of degenerative joint disease. Lumbopelvic motion in patients with low back pain is an
example of abnormal early onset joint motion. In the prone position, lumbopelvic
rotation occurs earlier and to a greater extent during the first few degrees of knee
flexion in patients with low back pain than in control subjects(ref). The predisposition of
these joints to move readily, contributes to the frequency of their movement and just
furthers the tendency for motion. Thus the joint or joints, the lumbar spine in this
example, develop a tendency or susceptibility to move readily in a specific direction
(directional susceptibility to movement, DSM) during all activities. In most joints, the
accessory motion impairment is not clinically observable, thus the physiological motion
associated with the pain is most often designated as the DSM.
Clarification of the meaning of hypermobility is essential. There are 3 possible
meanings: 1) The range of joint movement exceeds the ideal. The term can be applied
to a physiological (osteokinematic) movement. For example, if the degrees of rotation,
a physiological motion, between 2 cervical vertebrae is ideally 4 degrees or less, then 6
degrees of motion is hypermobility. 2) The amount of accessory motion, for example
translation between cervical vertebrae is 2 mm, then 3 mm of translation, is
hypermobility. Accessory motion hypermobility can occur even though the joint’s
physiological motion is less than normal. 3) The frequency of movement of a specific
joint in a specific direction occurs more often than is considered ideal. If an individual,
has a habit of constantly moving the head and neck when talking, the cervical vertebrae
that move the most readily will also be moving the most frequently. Also to be noted is
that excessive frequency of motion can occur in the presence of hypomobility. In the
cervical spine with degenerative disc disease and exostosis, motion at some joints may
be markedly restricted but limited to a lesser extent at other joints. As the individual
attempts to rotate the head and neck, though the range of motion of every joint is less
than normal there will still be some joints that move the most readily and thus will move
more frequently than optimal. Probably the accessory motion will occur the most readily
and will be greater than normal though the physiological motion is less than normal. The
attempt to achieve maximum voluntary motion will cause tissue stress and pain.
Copyright Elsevier
From: Movement System Impairment Sydromes of the Extremities,
cervical, and thoracic spine.
Elsevier publisher 2010 Editor; S. Sahrmann, PT, PhD, PT
As might be suspected, when a joint moves more readily than other joints in the
same kinetic chain the repeated movements and prolonged postures associated with
everyday activities can be the precipitating as well as the perpetuating factors of the
joint’s DSM. The repeated movements cause tissue microtrauma that eventually results
in macrotrauma and pain. Thus movement in the offending direction has been
associated with pain and is often impaired (deviates from the kinesiological standard,
usually arthrokinematic). Therefore when the movement is corrected the symptoms
decrease or are eliminated. Based on the premise that the diagnosis should direct
treatment, the DSM is most often also the diagnosis. Correcting the pattern or stopping
the movement in the painful direction is the focus of treatment because the symptoms
are decreased or eliminated by this action.
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