Movement System Impairment Purposes Syndromes of the ...

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Movement System Impairment Syndromes of the Lumbar Spine

Shirley Sahrmann, PT, PhD, FAPTAProfessor Emerita

Program in Physical Therapy


Purposes

• Importance of promoting the movement system• Describe how movement induces/exacerbates

lumbar pain conditions• The Importance of emphasizing the role of

movement in the patient’s condition.• Movement as a cause, exacerbator, treatment, prevention

• Discuss Movement system impairment diagnoses of lumbar spine,

• Diagnostic labels are essential • Diagnoses increase efficiency and can reduce treatment variability

• Demonstrate an examination of subject with back pain


Why the Movement System?• The goal of physical therapy is to • Regain or Improve Movement for function, health,

prevention• Requires being movement and exercise experts and able to

optimize movement, • Need to consider all aspects of major component systems

• Musculoskeletal = biomechanics – muscle physiology – skeletal physiology

• Nervous = biocontrol – biobehavioral (psychosocial) - biomechanics • Activation patterns = interaction of muscle adaptions & motor learning

with gravity as major influence

• Cardiovascular, pulmonary, endocrine = bioenergetics


THE KINESIOPATHOLOGICMODEL A THEORETICAL CONSTRUCT OF THE MOVEMENT SYSTEM HOW MOVEMENT IS CAUSE AND EXACERBATOR OF PATHOLOGY

THUS HOW PHYSICAL THERAPY CAN TREAT CAUSE

APTA "THE INTEGRATION OF BODY SYSTEMS THAT

GENERATE AND MAINTAIN MOVEMENT AT ALL LEVELS OF BODILY FUNCTION”


Kinesiopathologic Model of Movement System

Musculoskeletal Nervous

Biomechanics

Repeated movementsSustained alignments

CauseINDUCERS

Personal Characteristics – intrinsicActivity Demands - extrinsic

Tissue Adaptations

Joint AccessoryHypermobility

Relative Stiffness of muscle & connective tissue

Relative FlexibilityIntra-jt + Inter-jt

Micro Macro trauma

Path of Least Resistance

Cardio-Pulmon -endocrine

Motor LearningNeural aff/efferent

Micro-instability

MSI Syndrome

Joint moves too readily


Premise for Movement System Impairment (MSI) Syndromes • LBP develops because people

• repeatedly use

• direction-specific,

• stereotypic movement and alignment patterns

• of the lumbar spine across their day.

• The patterns are characterized by segments of the lumbar spine

• moving more readily than other segments and other joints

• during performance of movements or assumption of postures.

• Use of the same patterns is proposed to contribute to sub-failure magnitude loading

• Micro-instability > Microtrauma > Macro-trauma

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Muscles =Springs in series & inparallel

Passive stretch of stiff & < stiff muscle in series elongation of least stiff muscle

Stiff m< stiff m

Most important:FLEXIBILITY ofjoint of spineNOT stiffnessor shortness ofmusclesRELATIVE

Relative Flexibility/Stiffness


Movement System Impairment Syndromes

• Named for movement direction or alignment that most consistently causes symptoms and is impaired (moves too readily).

• Correction of the movement or alignment decreases or eliminates the symptoms

Lumbar Syndromes areExtension Extension-rotationRotationFlexionFlexion-rotation

Induced by daily activities and associated movements of the hip - CAUSE


Two Major Types

Marked Motion

• Limited control of lumbopelvic region from abdominal muscles

• Movements of lower extremities cause notable lumbopelvic motion

Compression – Little Motion• Marked hypertrophy of

abdominal muscles• Subtle alignment

faults• Correction of

alignment decreases symptoms


Movement System Impairment SyndromeClassificationsOld, short, chronic conditions -usually• Extension• Extension-rotation• Rotation• Consistent with later stages

of degenerative changes in the spine

Tall, young, acute conditions -usually• Flexion• Flexion-rotation• Consistent with early stage of

degenerative changes


Effective Treatment for LBP - a Research Study

• Determine the movement direction causing symptoms

• Identify the activities that cause symptoms• Use a motor learning paradigm – for movement

correction• Guide the patient in figuring out the

symptomatic movements• Then in correcting the symptom producing

movements • Compared to stretching and strengthening

program


Effect of Motor Skill Training in Functional Activities vs Strength and Flexibility Exercise on Function in People With Chronic Low Back Pain A Randomized Clinical Trial

Linda R. van Dillen, PhD; Vanessa M. Lanier, DPT; Karen Steger-May, MA; Michael Wallendorf, PhD; Barbara J. Norton, PhD; Jesse M. Civello, DPT; Sylvia L. Czuppon, DPT; Sara J. Francois, DPT; Kristen Roles, MS; Catherine E. Lang, PhD

JAMA Neurol. doi:10.1001/jamaneurol.2020.4821 Published online December 28, 2020.

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Van Dillen et al. JAMA, Neurolo12-2020

Treatment once a week for 6 weeksSystematic increase in treatment program


Use of MST appeared to

(1) result in improved short‐term but more importantly long termOutcomes with only 6 one‐hour treatments,

(2) Promote better adherence to training for a prolonged period, and

(3) enable a person to practice the activities across the day, thus providing a means of self‐management. Such benefits could be key in a condition typically characterized by a clinical course of recurrent, fluctuating, or persistent functional limitation and pain.

Requirements for Implementation

(1) Classify the patients according to movement direction or alignment causing symptoms

(2) Guide the patient using motor learning principles in recognizing the offending movements or alignments associated with daily activities

(3) Guide the patient in learning to correct the offending movements and alignments with suitable practice of daily activities


REPEATED MOVEMENTSSUSTAINED ALIGNMENTSOF DAILY ACTIVITIES

Examples: Walking and Hip motions affecting the spineSleeping alignment


EXTENSION EXTENSION - ROTATION


Body Structure & Hip Impairments Causing Movement that Causes Back Pain

Everyday activities – impaired performance – contributing to LBP


Extension Syndromes

Optimal alignmentis important

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Gymnast with Low Back Pain –Correction Eliminates Pain - Extension Syndrome


Movement Pattern used with this AlignmentReturn From Forward Bending

Hip extension Back extension Ankle sway


Extension Syndrome - Short Hip Flexor Muscles


Extension Syndrome - Short Hip Flexors


Hip extensor muscles more flexible than Back extensor muscles

Extension Syndrome - Hypermobility

Back extensorsare cause of anteriorpelvic tilt


FLEXIONFLEXION - ROTATION

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Flexion Syndrome - UltramarathonistFAI - Stiffness of Hip Extensors and of

Abdominal Muscles (compression)


Lordotic?

Excessive flexion

Flexion Moment

Flexion Syndrome – student/diverTall – sit-up exercises (psoas flexing lumbar spine)

Hip extensors not short Relative stiffness: abdominals > back ext


Case Presentation – Lumbar Flexion 64 yo


Spinal Flexion and Rotation

DDD of entire lumbar spine: Having chronic pain and acute episodes


Quadruped Alignment

Doing all the wrong exercises


Immediate Change Post Quadruped Rocking Backward

Pre Immediate Post

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ROTATION SYNDROME

Two subclassifications:

Primary – lumbar spine is rotated (easier if flat or flexed) and is the pain generation site

Secondary – usually lower thoracic and high lumbar are rotated (fixed) pain generation is lower lumbar site -Moves more because other lumbar segments are not

moving


PRIMARY ROTATION

Rotation of lumbar spine is site of pain (primary site)Rotation must be corrected


LBP in standing. Lumbar side bend to right with shift of trunk to left.

Primary Rotation Syndrome –Radiculopathy – scheduled for surgery

Played ice hockey


Rotated Spine – flexion/rotation increases when rocking backward

Hip flexion limited – Cam hip impingement


Treatment Effect

Before Post quadruped rocking


Quadruped – Instant Effects

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Modified Quadruped


SECONDARY ROTATION SYNDROME

The examination


Alignment – low thoracic/high lumbar right rotation


Rotation – to right > to left

Hands out drugtrays to right


Hip Lateral Rotation/Abduction –lumbopelvic rotation

Wide hips –in sidebend when on side


Passive Knee Flexion – lumbopelvic rotation

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Hip Rotation – lumbopelvic rotation


Comments

• Correction of the movement impairment during daily activities –

• corrects the impaired muscle adaptions and the relative flexibility


Examination• Movement tests –

• Primary =preferred • Secondary = corrected• Note symptoms and movement if impaired

• Positions – standing, supine, side-lying, prone, quadruped, sitting, sit to stand, gait

• Most important is symptoms in a position or during a movement and change in symptoms with correction

• Alignment• Anterior pelvic tilt flex hips, lateral pelvic tilt – abduct hips,

overdeveloped abdominal muscles – lift trunk, take deep breath

• Forward bending, return, side-bending, rotation • All motions used during day with activity


Examination 2 Need to Knows• Supine – need to knows

• Femoral ante or retroversion, femoroacetabular impingement• Log roll, hip flexion• Active hip/knee flexion

• Sidelying• Getting to position • In position (primarily women) – side bending, because of

width of pelvis/hips

• Prone • Getting to position• In position• Effect on pelvis of passive knee flexion and hip rotation

• Quadruped • Getting to position • In position – preferred alignment


Examination 3

• Sitting • Symptoms – slumped, extended• Knee extension – effect on lumbar spine• Sit to stand and reverse - symptoms

• Gait• Symptoms – what phase of gait• Lumbopelvic rotation or anterior pelvic tilt

• Stairs • Symptoms – what phase?


EVIDENCE FOR CLASSIFICATION

AND

KINESIOPATHOLOGICMODEL

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Evidence from Clinical Studies

To develop evidence – for classification and the model The following were accomplished• Inter-rater reliability of exam items • Inter-rater reliability of classification• Validity of classification based on exam • Daily Activities causes symptoms• Movements of the spine and of the limbs that cause low

back symptoms, when spine movement is prevented symptoms are reduced or eliminated

• Earlier & greater (fractions of seconds, few degrees) movements of spine in LBP than No LBP with LE motion

• Spine patterns are generalized across activities• Treatment effectiveness


Validity of Classifications• Subgroup names describe the directions of lumbar

movements and alignments considered to be contributing to the LBP condition

• A number of studies have been conducted to test aspects of the validity of the proposed subgroups

Van Dillen LR et al, JOSPT, 2003; 33(3):126-142Norton BJ et al, JOSPT, 2004; 84(3):524-553Van Dillen LR et al, APMR, 2007; 88(3):351-360Gombatto SP et al, Phys Ther, 2007; 87(4):441-454Scholtes SA et al, Clin Biomech, 2009; 24(1):7-12Hoffman SL et al, PMR, 2010; 2(10):1113-1118Hoffman SL et al, Man Ther, 2011; 16(4):344-350Hoffman SL et al, Man Ther, 2012; 17(2):157-163Gombatto SP et al, Clin Biomech, 2006; 21(3):263-71


Reliability of Exam and Validity of Classification• Reliability of physical examination items used for classification of patients

with low back pain.• Van Dillen LR, et al. Phys Ther. 1998 Sep;78(9):979-88.

• Movement system impairment-based categories for low back pain: stage 1 validation.

• Van Dillen LR, et al. J Orthop Sports Phys Ther. 2003 Mar;33(3):126-42.

• Reliability of novice raters in using the movement system impairment approach to classify people with low back pain.

• Henry SM, et al. Man Ther. 2013 Feb;18(1):35-40

• The inter-tester reliability of physical therapists classifying low back pain problems based on the movement system impairment classification system.

• Harris-Hayes, et al. PM&R. 2009 Feb;12:117-26.

• Differences in measurements of lumbar curvature related to gender and low back pain.

• Norton BJ, et. al. J Orthop Sports Phys Ther. 2004 Sep;34(9):524-34.• Luomajoki H et al, BMC Musc Dis, 2007; 8:90-101• Roussell NA et al., Man Ther, 2009; 14(6):630-635


Inter-rater Reliability of Classification

• Reliability to classify is clinically acceptable• Experienced clinicians: % agreement: 78, kappa = .57

(1 study)

• Novice clinicians: average % agreement: 81 ± 4.56, average kappa = .74 ±.08 (5 studies)

Norton BJ et al., JOSPT, 2004; 34(9):524-533Trudelle-Jackson et al, JOSPT, 2008; 38(6):371-376Harris-Hayes et al, PMR, 2009; 24(1):117-126Henry SM et al, Man Ther, 2012; 92(2):136-142Kim MH et al, J Elec Kines, 2013; 23:387-393Henry SM et al, Man Ther, 2013;18(1):35-40


Correction of Symptom Producing Movement Reduces or Eliminates Symptoms

Determine relationship of movement and alignment patterns to symptom behavior

• Primary tests: Patient’s preferred strategy (symptoms and direction of movement or alignment observed)

• Secondary tests: Systematic modification of patient’s specific movement or alignment pattern

• Goal: Determine effect of secondary test on symptoms compared to symptoms with primary test

Van Dillen LR et al, APMR, 2003; 84(3):313-22Van Dillen LR et al, Man Ther, 2009; 14:52-60


EVIDENCE FOR DAILY ACTIVITIES AS CAUSE

Keep spine still during performance of basic mobility activities – Performance Training

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Randomized Control Study –Low Back Pain100 patients – Van Dillen

• All classified into Movement System Impairment syndrome categories

• Group 1 – category specific exercise; keep neutral spine during functional activities

• Group 2 – general exercise – keep neutral spine

• In PT – 1x / week for 6 weeks – programs carefully progressed

Manual Therapy, Volume 24, 2016, 52–64


Modified Oswestry Score % - both groups same

20

15

1012

INITIAL VISIT POST TX 6 MONTHS 12 MONTHS

Series 1

Modified from Van Dillen LR Manual Therapy 24;2016 52 - 64


Adherence toPerformance Training & Exercise

8075

52

41

80 80 7870

INITIAL POST TX 6 MONTHS 12 MONTHS

Exercise

Performance Training

Modified from Van Dillen LR Manual Therapy 24;2016 52 - 64


EVIDENCE FOR LUMBAR SPINE MOVING READILY DURING LOWER EXTREMITY MOTION

Low back pain subjects that played rotational sports –

Motion Capture In prone with Active Knee Flexion & Hip Rotation


Timing Difference with Knee Flexion Test in Prone

Scholtes et al., Clin Biomech, 2009

Onset of lumbopelvic motion after onset of knee flexion.


Timing Difference with Hip Lateral Rotation Test

Scholtes et al., Clin Biomech, 2009

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Repeated Movements & Sustained Alignments• Chimenti RL, Scholtes SA, Van Dillen LR. Activity characteristics and

movement patterns in people with and people without low back pain who participate in rotation-related sports. J Sport Rehabil. 2013

• Harris-Hayes M, Sahrmann SA, Van Dillen LR. Relationship between the hip and low back pain in athletes who participate in rotation-related sports. J Sport Rehabil. 2009 Feb;18(1):60-75. Review.

• Weyrauch SA, Bohall SC, Sorensen CJ, Van Dillen LR. Association between rotation-related impairments and activity type in people with and without low back pain. Arch Phys Med Rehabil. 2015

• Sorensen CJ, Johnson MB, Callaghan JP, George SZ, Van Dillen LR. Validity of a Paradigm for Low Back Pain Symptom Development During Prolonged Standing. Clin J Pain. 2015


Standing for 2 Hours Induced Back Pain

• Pain develops in 28 – 42% of subjects• Pain characteristics are the same as in people with back

pain• Have greater lumbar curve than non-pain developers• Pain developers have earlier lateral pelvic tilt with left hip

abduction in sidelying, than non pain developers

Sorensen CJ et. al., Clin J Pain. 2015


EVIDENCE FOR GENERALIZATION OF LUMBAR MOVEMENT PATTERN

Picking up an Object from Different Placements


Early Lumbar Excursion (deg)

4

7

8

8.5

9.5

4

9

9

9.5

9.5

7

14

12

13.5

16

0 5 10 15 20

HIGH

STANDARD

FAR

LOW

LOW FAR

Chart Title

LBP-high LBP-Low back health

significant

Back pain low < 20 OswestryBack pain high > 20 Marich et al Clinical Biomechanics 2017

Adapted from


One Session of Motor Skill Training to Prevent Early Lumbar Flexion Marich et al PTJ 2018

0

2

4

6

8

10

12

BackHealthy LBP Mot skill train

Early Lumbar Flexion during Pick Up an Object

91% no longerhad LBP with correction offorward bending

Degrees of Lumbar Flexion


Summary• Relative (which muscles) stiffness of the hip muscles can

contribute to increasing the relative (which direction) flexibility of the lumbar spine

• The flexibility is evident in the early movement of the spine• Elicited by movement of the hips or trunk• The movement becomes the path of least resistance and

thus occurs during daily activities• Instruction in the movement direction causing the

symptoms and learning how to correct the movement is effective treatment

• Supports the proposal that the way daily activities are performed is the cause of the problem

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