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11th October 2014


Physiotherapy UK Conference 2014

10th October: Session on exercise for the older MSK patient

Overview of lecture:

Movement control impairments have been shown to be a contributing factor in chronic and recurrent musculoskeletal pain and in limiting functional ability. This presentation will focus on the assessment of movement impairments using movement control tests.

Movement control tests identify the site and direction of uncontrolled movement (movement control impairments) and this classification can direct effective exercise and retraining programmes to improve function. Common movement impairments in older people will be linked to functional tasks.

Proposed learning outcomes:

1. To review the concept of using movement control tests to identify movement impairments. 2. To consider the influence of uncontrolled movement (movement impairments) on chronic and recurrent musculoskeletal pain and in limiting functional ability. 3. To discuss common movement impairments in older people and how these link to functional limitations.

Lecture Notes:

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)

Movement impairments can:

• impact on the development of movement disorders and pain

• contribute to recurrent pain

• influence function

The scientific support for identifying movement impairments comes from studies in people with pain

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

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: Cognitive Movement Control Test

• 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

1. Shoulder Flexion Scapular Movement Control 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)

2. Sitting: chest drop test

• To test for control of lumbar flexion

• Control the low back and pelvis

• Reliability (Elgueta-Cancino et al 2014)

3. Sitting to standing

• Test control of hip flexion

• Low back extension

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)

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

Movement Retraining: Control • Repetition of task following improving awareness and understanding

• Cues to suit individual

• Functional relevance

• Targeting impairment in movement system

• Alignment & function

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

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


APTA Mission Statement 2013

Elgueta-Cancino et al 2014 A clinical test of lumbopelvic control: Development and reliability of a clinical test of dissociation of lumbopelvic and thoracolumbar motion Manual Therapy 19:5 418-424

Hodges 2011 Pain and motor control: From the laboratory to rehabilitation Journal of Electromyography and Kinesiology 21 220–228

Ludewig P & Cook T 2000 Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Physical Therapy 80:276-91

Luomajoki H et al 2010 Improvement in low back movement control, decreased pain and disability, resulting from specific exercise intervention Sports Med Arthrosc Rehabil Ther Technol. 2: 11.

Mottram S et al 2012 Comparison of Clinical and Objective Measurements of Scapula Orientation during a Test of Motor Control IFOMPT Quebec, Canada

Nijs J 2014 Cognition-targeted motor control training pain: combining pain neuroscience education with a modern neuroscience approach to chronic spinal Physical Therapy 94:730-738.

Sahrmann SA 2002 Diagnosis & treatment of movement impairment syndromes. Ist ed. Missouri: Mosby

Sahrmann 2014 The human movement system: Our professional identity Physical Therapy 94:7 1034-1042

Tsao H et al Driving plasticity in the motor cortex in recurrent low back pain. Eur J Pain. 2010;14:832–839

Dankaerts W et al 2006 The inter-examiner reliability of a classification method for non-specific chronic low back pain patients with motor control impairment. Manual Therapy Feb;11(1):28-39.

Enoch et al. BMC Musculoskeletal Disorders 2011, 12:114

Monnier et al BMC Musculoskeletal Disorders 2012, 13:263

Morrissey D et al 2008 Manual landmark identification and tracking during the medial rotation test of the shoulder: An accuracy study using three dimensional ultrasound and motion analysis measures. Manual Therapy 13:6: 529-535

Roussel N et al 2009 Altered lumbopelvic movement control but not generalised joint hypermobility is associated with increased injury in dancers. A prospective study 2009 14:6 630-635

Van Dillen LR Reliability of physical examination items used for classification of patients with low back pain. Physical Therapy 78:9 979-88.

Worsley, P et al 2013 Motor control retraining exercises for shoulder impingement: effects on function, muscle activation and biomechanics in young adults. Journal of Shoulder and Elbow Surgery 22:4, e11-e19


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