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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 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 Copyright Elsevier 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 Copyright Elsevier 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. Copyright Elsevier