Pain is the prevailing symptom of musculoskeletal disorders and most often that symptom is increased by movement. The pain is attributed to tissue injury usually arising from trauma or activity often as the result of cumulative trauma that develops over long periods of time. What has become relatively clear over the past 15 to 20 years is that the pain associated with movement can be modified by altering the movement. For many years, low back pain has been treated by limiting motion through back braces and even surgical fusion. Thus one of the evolving general strategies for addressing low back pain is by “stability” exercises. Similarly injury to the knee joint has been shown to be associated with a movement impairment of adduction and rotation. Recent studies have also shown that a similar pattern of hip adduction and medial rotation is associated with the anterior groin pain of young individuals who are active in sports. Furthermore, motions of the scapula and humerus have been shown to be impaired in individuals with shoulder impingement syndromes. Movement system impairment exercises are based on the concept that imprecise joint movement is the prevailing cause of joint microtrauma that eventually becomes macrotrauma.
The working hypothesis is that these early musculoskeletal pain problems are the first steps toward the development of osteoarthritis. Just as lifestyle issues of diet and general exercise are major factors in the development of systemic diseases of the cardiovascular and endocrine systems so are the precision, magnitude, and repetitions of joint movement affected by lifestyle which becomes a major factor in musculoskeletal system disorders. Thus these exercises are designed to address the active performance of precise joint movement including intra and inter-joint, within limb segments and total body motion. Consistent with kinesiology one part of the body cannot move during activity without being impacted by other parts or without impacting other parts of the body.
Acceptance of the Movement Pattern Training
Unfortunately the prevailing belief except for highly trained athletes is that you can move any way you want and that is acceptable. A similar belief about eating has resulted in the epidemic of obesity. Another naïve belief is that any form of strengthening or flexibility exercise is desirable. Actually strengthening does not improve movement unless there is marked weakness which is usually not the case and strengthening can contribute to imprecise joint movement. Also excessive joint flexibility can clearly compromise joint integrity. These exercises can be considered movement pattern training with the focus on not only the joint that is painful but also on the body region to which the joint belongs and to total body movement during functional, work, fitness, and sports activities.
The exercises and movement pattern training address both stability and mobility. In other words, if the patient has pain with forward bending that is associated with lumbar flexion, correction of bending to limit the flexion addresses the need for stability of the lumbar spine. Teaching the patient to flex the hips rather than the lumbar spine addresses mobility as well as reducing or alleviating the symptoms. Additional exercises for improving abdominal muscle performance further enhance the stability control. The patient is also instructed in correct spinal motion or prevention of motion during functional activities. Most of the exercises are actually used as tests as part of the examination and the general rule is that when the patient fails the test, it becomes one of the exercises in the program.
General Concepts Regarding Mechanisms
A critical guideline is that the body takes the path of least resistance for motion and that the factors that contribute to that path are the relative flexibility of the joints involved in the motion, both intra and inter-joint, and the relative stiffness of the surrounding muscle and connective tissues. All joints have intrinsic accessory motion. With repetition of daily activity, 1 or 2 of the accessory motions may become imprecise and develop increased range. The more frequent the imprecise motion occurs the more likely the joint will develop micro-instability. A factor contributing to the relative flexibility is the relative stiffness (change in tension/change in length) of the muscles and connective tissues about the joint and other joints usually in series with the painful joint. Based on the behavior of the symptoms during the examination the joint motion that is painful whether physiological or accessory is identified as the movement system impairment diagnosis. Movement of the painful joint has to be corrected by movement pattern training. For example, with knee or hip pain the motion of the affected joint has to be corrected such as hip adduction and medial rotation during going up or down stairs or even sit to stand. In the case of back pain, most often the movement of the spine has to be restricted and the patient taught to move in the hips.
General Differences Compared to Other Programs
The primary difference of this approach is the emphasis on both stability and mobility through precise training of movement patterns during active motion. Though many of these exercises can be considered “open chain” that is to enable the patient to learn to find and use the deficient muscles. The belief being that impaired movement patterns do not use all muscles optimally and that if the muscle cannot be activated under optimal conditions, such as during the specific exercise, it will not participate during general movements. The muscle re-education exercises are not considered sufficient but only one early step in the rehabilitation process. At the same time the patient is instructed in precise or correct performance of basic movement patterns of daily activities. Because treatment involves active participation, the patient is learning the motions that cause pain and how to correct those motions. This puts the patient in charge of the pain which is an important step in dealing with excessive reaction to symptoms.
Factors Leading to the Development of Movement System Impairment Exercises
After spending 9 years treating patients with central nervous system lesions, observations of patterns of movement became almost an obsession. A similar question arises from being able to recognize someone at a distance by how they move, if we all have a “normal” gait pattern. Questions about why people move differently peaked my interest in the movement patterns evident in patients with musculoskeletal pain. As a therapist starting practice at the end of the polio era and when treatment of patients with shoulder pain involved optimizing scapula-humeral motion, addressing movement patterns seemed more than appropriate. Being asked to participate in examining runners and cyclists with lower extremity and back pain, I addressed their movement impairments by instruction in correct movements and did tests of muscle length and strength to identify what I considered contributing factors. Over a period of years, using a set exam, the underlying mechanisms and the evident loss of precise joint movement became apparent.
Information obtained from 40 years of patient care, research by colleagues, and findings in the literature have further clarified the concept. The interest in movement and movement pattern training by physiotherapists has been escalating over the past 10 years. Though hard for many patients to deal with treatment using subtle retraining methods, rather than a challenging strength training and stretching program can be difficult and counterintuitive, the major selling factor is the effect on their symptoms and the long-term results from the program. Patients can be reassured that once they are moving precisely they can add strength training to their exercise programs.
About the author Shirley Sahrmann
Dr. Shirley Sahrmann, Ph.D, P.T., F.A.P.T.A, is Professor Emerita of Physical Therapy at Washington University School of Medicine, St. Louis, Missouri. She received her bachelor’s degree in Physical Therapy, masters and doctorate degrees in Neurobiology from Washington University. She has served on the APTA Board of Directors and has received considerable number of awards. Dr. Sahrmann’s research interests are in development and validation of classification schemes for movement impairment syndromes as well as in exercise based interventions for these syndromes.
Corrective Exercises for Movement System Impairment
PhysioTools has launched an exercise module Corrective Exercises for Movement System Impairment (PX64) in co-operation with Shirley Sahrmann.