12th September 2018
FRAMING THE CLINICAL PICTURE
There is increasing awareness of the multifactorial nature of any presentation. Indeed, all clinical presentations are complex; they are the result of the dynamic interactions of multiple factors; for example, the presence of pain, previous injury, fatigue, or changes in morphology. However, many presentations possess a ‘movement’ element; something in the person’s movement has changed as a result of their presentations or is contributing to them.
The Kinetic Control clinical reasoning framework supplies a systemized process to consider this outcome through the assessment and subsequent retraining of movement, whilst taking into account the other factors influencing the bigger clinical picture.
NOTATING CLINICALLY RELEVANT CHANGES IN MOVEMENT
In acknowledgment of the need to consider movement with respect to any presentation, the Kinetic Control framework places focus upon specific characteristics of how individuals move; during assessment, during retraining interventions and, ultimately, during the demands of function and sport. The assessment of these characteristics of movement informs on the presence of uncontrolled movement (UCM). Uncontrolled movement (UCM) is defined as “an inability to cognitively control movement at a specific site and direction, while moving elsewhere to benchmark standards” (Comerford & Mottram, 2012). Any one UCM can be identified as possessing a site (joint/region at which the movement occurs), a direction (the motion path in which the movement happens) and a threshold (the level of muscle recruitment at which this movement is observed).
WHY DOES UNCONTROLLED MOVEMENT MATTER?
The notation of the site, direction and threshold ® of UCM, allows movements the individual cannot observably ‘prevent’ from happening to be profiled;
for example, a person may be unable to prevent the hip from medially rotating as they transition from sitting to standing. If this pattern of movement, cannot be prevented it can be suggested to occur with a high frequency during the day. This may lead to stress and strain on tissues local to this region. Uncontrolled movement may then significantly impact quality of life; this may be due to this movement’s association to symptom provocation, risk of recurrence, or injury; all factors potentially leading to activity limitation and participation restriction. The identification of UCM supplies the clinician with valuable insight on which movement patterns may be contributing to this presentation.
However, the identification of UCM represents only the first of the four elements of the Kinetic Control framework identified below.
The clinical reasoning process:
Evaluation of Movement Health in terms of Site, Direction and Threshold of UCM ® Evaluation of syndrome, pathology, clinical signs and imaging findings
Consideration of pain mechanism
Consideration of individual, environmental and task constraints
1 Evaluation of Movement Health in terms of Site, Direction and Threshold of UCM
As highlighted above, the initial priority is to identify the site and direction of UCM that best correlates with the patient's presentation. It is to be acknowledged that there is often more than one site of UCM. The clinical reasoning process links the UCM to the symptoms, activity limitation and participant restriction, recurrence, risk of injury and performance. This helps guide retraining intervention as a priority as implicated.
2 Evaluation of syndrome, pathology, clinical signs and imaging findings
Valuable insight can also be gained from other assessment or imaging techniques. In respect to these findings, there is the need to consider the influence of a variety of pain-sensitive tissues, a knowledge of the mechanism of injury (if there is one), and an understanding of the typical responses of different tissues to stress and strain and injury. Contemporary clinical reasoning in patients with chronic pain, suggests it may be more appropriate to explore factors affecting impairment of function and participation than to attempt to diagnose specific structures or tissues as a source of nociception.
3 Consideration of pain management
Cognitive behavioural approaches clearly have a significant role to play for optimal patient outcomes.
The value of patient education, including pain education is crucial for patient outcomes
4 Consideration of individual, environmental and task constraints
Alongside these first three elements, the therapist should also consider the influence of contextual factors – both personal and environmental – on the patient's signs and symptoms and explore how these might relate to UCM. Any one of these factors can classified as belonging to the domain of task, individual or environment (Dingenen et al., 2018). Examples of each are identified:
Task; speed or distance of walking
Individual; previous injury or age
Environment: footwear, protective equipment
Only once all elements are considered, can the clinical picture come in full view. The Kinetic Control framework.
Comerford, M., & Mottram, S. (2012). Kinetic Control: The Management of Uncontrolled Movement. Elsevier Health Sciences.
Dingenen, B., Blandford, L., Comerford, M., Staes, F., & Mottram, S. (2018). The assessment of movement health in clinical practice: A multidimensional perspective. Physical Therapy in Sport.