Kinetic Control This page intentionally left blank Kinetic Control The Management of Uncontrolled Movement Mark Comerford, BPhty, MCSP, MAPA Director, Movement Performance Solutions Sarah Mottram, MSc, MCSP, MMACP Director, Movement Performance Solutions Edinburghâ•… Londonâ•… New Yorkâ•… Oxfordâ•… Philadelphiaâ•… St Louisâ•… Sydneyâ•… Toronto Churchill Livingstone is an imprint of Elsevier Elsevier Australia. ACN 001 002 357 (a division of Reed International Books Australia Pty Ltd) Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067 © 2012 Elsevier Australia This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher. Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible.
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National Library of Australia Cataloguing-in-Publication Data Comerford, Mark â•… Kinetic control: the management of uncontrolled movement â•…â•…â•…â•…â•… /Mark Comerford, Sarah Mottram. â•… Movement disorders – Classification. â•… Movement disorders – Diagnosis. â•… Movement disorders – Treatment.8 Publisher: Melinda McEvoy Developmental Editor: Rebecca Cornell Publishing Services Manager: Helena Klijn Project Coordinators: Natalie Hamad and Karthikeyan Murthy Edited by Stephanie Pickering Proofread by Forsyth Publishing Services Cover design by Lisa Petroff Illustrations by Rod McClean Index by Robert Swanson Typeset by Toppan Best-set Premedia Limited Printed by CTPS Contents Preface.
vii Section 2 Foreword. ix 5 The lumbopelvic region. xi 6 The cervical spine. 218 Section 1 7 The thoracic spine.
3 8 The shoulder girdle. 362 2 Muscle function and physiology. 505 3 Assessment and classification of uncontrolled movement. 43 4 Retraining strategies for uncontrolled movement.
63 v This page intentionally left blank Preface Preface This book presents a comprehensive system for the assessment and retraining of movement control. It has been in evolution for the last 25 years. Uncontrolled movement has a significant impact on the development of move- ment disorders and pain. The scientific support for the process of the assessment and retraining of uncontrolled movement has been steadily expanding particularly in the last 10 years.
The influence of uncontrolled movement on symptoms, especially pain, movement function, recurrence of symptoms and disability is now well established. We believe that in the next 10 years the literature will support that the presence of uncontrolled movement will also be recognised as a predictor of injury risk and as having an influence on performance. Uncontrolled movement can be identified by movement control tests. People with pain demonstrate aberrant movement patterns during the performance of these movement control tests.
A growing body of evidence supports the use of movement control tests in the assessment and management of chronic and recurrent pain. The identification of uncontrolled movement in terms of the site, direction and threshold of movement impairment is a unique subclassification system of musculoskeletal disorders and pain. The movement testing process proposed enables the classification of uncontrolled movement into diagnostic subgroups that can be used to develop client-specific retraining programs. This process can determine management priori- ties and optimise the management of musculoskeletal pain and injury recurrence.
Subclassification is now recognised as being the cornerstone of movement assess- ment and the evidence for subclassification of site, direction and threshold is growing. This book details a structured system of testing, clinical reasoning and specific retrain- ing. This system does not preclude other interventions as it is designed to enhance the management of musculoskeletal disorders. The Kinetic Control process has come a long way in last 25 years.
The motivation for the development of the Kinetic Control process was to find a way to blend the new and exciting concepts in movement dysfunction into an integrated clinical process, built on the foundation of a solid clinical reasoning framework. Our aim is to gain a better understanding into the inter-relationship between the restrictions of movement function and movement compensations. The breakthrough came with the realisation that some compensation strategies are normal adaptive coping mecha- nisms and do not demonstrate uncontrolled movement, while others are maladap- tive compensation strategies that present with uncontrolled movement. This led us to develop the structured assessment process detailed in this text including the Move- ment Control Rating System (Chapter 3).
This clinical assessment tool can identify movement control deficiencies and be valuable for reassessing improvements in motor control efficiency. vii Preface Recurrent musculoskeletal pain has a significant impact on health care costs, employment productivity and quality of life. Uncontrolled movement can be identi- fied by observation, and corrective retraining of this uncontrolled movement may have an influence on onset and recurrence of symptoms. To date, outcome measures in terms of changes in range and strength, have not influenced the onset and recur- rence of injury.
The ability to assess for uncontrolled movement and to retrain move- ment control is an essential skill for all clinicians involved in the management of musculoskeletal pain, rehabilitation, injury prevention, and those working in health promotion, sport and occupational environments. Preventing the recurrence of mus- culoskeletal pain can both influence quality of life and have an economic impact. Movement control dysfunction represents multifaceted problems in the movement system. Skills are required to analyse movement, make a clinical diagnosis of move- ment faults and develop and apply a patient-specific retraining program and manage- ment plan to deal with pain, disability, recurrence of pain and dysfunction.
The mechanisms of aberrant movement patterns can be complex, so a sound clinical reasoning framework is essential to determine management goals and priorities. We present an assessment framework which will provide the option to consider four key criteria relevant to dysfunctional movement: the diagnosis of movement faults (site and direction of uncontrolled movement), the diagnosis of pain-sensitive tissues (patho-anatomical structure), the diagnosis of pain mechanisms and identifying relevant contextual factors (environmental and personal). This clinical reasoning framework can help identify priorities for rehabilitation, where to start retraining and how to be very specific and effective in exercise prescription to develop indi- vidual retaining programs. Uncontrolled movement can be reliably indentified in a clinical environment and related to the presence of musculoskeletal pain, to the recurrence of musculoskeletal pain and to the prediction of musculoskeletal pain.
We hope this text will enable clinicians worldwide to effectively identify and retrain uncontrolled movement and help people move better, feel better and do more. Mark Comerford Sarah Mottram 2011 viii Preface Foreword Comerford and Mottram are to be commended for their extensive and comprehen- sive presentation of factors involved in movement dysfunctions. This book shares several of my own strong beliefs that have implications for the management of mus- culoskeletal pain conditions. Those beliefs are: 1) recognising and defining the movement system; 2) identifying and describing pain syndromes based on move- ment direction; 3) identifying the primary underlying movement dysfunction; 4) describing the various tissue adaptations contributing to the movement dysfunction; and 5) developing a treatment program that is comprehensive and based on the identified contributing tissue adaptations.
I also share with the authors a belief that the treatment program requires the patient’s active participation, which can range from control of precise, small, low force requiring movements to total body large force requiring movements. Historically – and still prevalent – is the belief that tissues become pathological as an inevitable outcome of trauma, overuse and ageing. The result is a focus on identifying the patho-anatomical structure that is painful rather than on identifying the possible contributing factors, or even how movement faults can be an inducer. We are all aware that movement is necessary to maintain the viability of tissues and bodily systems.
Almost daily, studies are demonstrating the essential role of movement, in the form of exercise or activity, in achieving or maintaining health. Yet there is very little recognition that there are optimal ways of moving individual joints and limb segments as well as the total body. Similarly there is little recognition that painful conditions can be treated by correcting the move- ment rather than resorting to symptom-alleviating modalities, drugs or surgery. Optimal alignment when maintaining prolonged postures, such as sitting, is not considered to be necessary.
I believe the situation is analogous to that of diet. For many years, no one worried about the effect on a person’s health of the type or amount of food that was consumed. Indeed, more money is still spent on the align- ment of the teeth than on the alignment of the body, though the function of the body is more affected by alignment faults than eating is by poor alignment of the teeth. This book serves to reinforce and define the characteristics of the movement system and how they contribute to movement dysfunctions associated with pain syndromes.
The authors have done an extensive review of the relevant literature describing the dysfunctions of the nervous and muscular systems. They have provided a detailed description of a key underlying factor, designated as uncontrolled movement, which then provides a basis for the treatment program. The detailed descriptions of the syndromes, key observations and examination forms should be most helpful in guiding the clinician. Building upon the information taken from the examination, the treatment program is also described in detail.
What is particularly noteworthy is the incorporation of most of the perspectives and methods used by the best known ix Foreword approaches to musculoskeletal pain. The authors have organised the rationale and methods from these varying approaches into a comprehensive approach. Comerford and Mottram have done a thorough job of describing all aspects of what could be considered the ‘psychobiosocial’ model of analysis and treatment of musculoskeletal pain. The timeliness of this book is reflected by the incorporation of their concepts to the International Classification of Functioning, Disability, and Health.
As stated previously this book has its particular value in the comprehensiveness and detailed descriptions of possible tissue dysfunctions as reported in the literature, methods of analysis and treatment. The reader will be truly impressed by the many complexities of the movement system and the rigorous analysis that is required to understand, diagnose and treat the dysfunctions that can develop and contribute to pain syn- dromes. The authors have truly provided an outstanding text in its inclusive and thorough discussion of the topic of movement dysfunction. Shirley Sahrmann, PT, PhD, FAPTA Professor Physical Therapy, Neurology, Cell Biology and Physiology Washington University School of Medicine – St.
Louis x Acknowledgements The content of this book has been a work in progress since 1988. The background to the development of the assessment and retraining of uncontrolled movement has been influenced by the work of Shirley Sahrmann, Vladamir Janda, Gwendolyn Jull, Paul Hodges, Carolyn Richardson and Maria Stokes. Since 1995 many colleagues within Kinetic Control and Performance Stability have helped with the development of the clinical tests and the consolidation of theoretical frameworks. Erik Thoomes contributed to the clinical reasoning process in Chapter 1.
We would very much like to thank all these people for their contribution through inspiration, advice, support or feedback. We both appreciate the support of our family and friends and in par- ticular Mark’s wife Selina, without whom he would not have found the time to devote to this project. Reviewers Technical Reviewer Philippa Tindle BSc. MCSP Prue Morgan M.