Update of Concepts Underlying Movement System Syndromes

Presented by: Zinat Ashnagar

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An important physiological system of the body is the movement system and that

dysfunctions of this system can be classified into syndromes.

These syndromes provide direction for diagnosis, treatment, and pursuing

underlying kinesiopathology.

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The syndromes for orthopedic conditions causing musculoskeletal pain are:

(1) based on the movement directions or alignments that cause pain

(2) associated with movement impairments

(3) improved by correction of the movement impairment that decreases or eliminates the symptoms.

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Key concepts of the movement system that

contribute to the development of pain syndromes are proposed.

Understanding key concepts and their application to patients with musculoskeletal

pain will enable the practitioner to develop an appropriate movement system (MS) diagnosis

and treatment program.

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1. The majority of musculoskeletal pain syndromes both acute and chronic are the

result of cumulative microtrauma from stress induced by repeated movements in a specific

direction or from sustained alignments, usually in a nonideal position.

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• Musculoskeletal pain is the result of a progressive condition that is related to lifestyle and

degenerative changes in tissues.

• The transition from tissue microtrauma to macrotrauma is influenced by a variety of intrinsic (genetics, sex, and age) and extrinsic (amount and

type of fitness, work activity) factors.

• These repeated movements and sustained alignments occur during the performance of daily

activities.

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2. The site (joint region) that is moving or stressed in a specific direction is the site of pain

generation.

3 . The stress occurs most often during the initiation or earliest phase of the motion rather

than at the end of the physiological motion.

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4. Hypermobility, usually accessory motion hypermobility, is the cause of the pain.

Therefore the offending motions are most often very subtle, and the more chronic the

condition or the older the subject, the more subtle the motion.

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5. The body follows the law of physics and takes the path of least resistance for motion, which contributes to the hypermobility.

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6. The path of least resistance is affected by variation in the stiffness or relative flexibility

of tissues attached to adjoining joints.

Most activities involve movement across several contiguous joints that are arranged in series

and one of these joints moves more readily in a specific direction than the other joints.

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7. The predisposition of a joint to move readily in a specific direction contributes to the

development of a movement pattern.

8. Insufficient muscle stiffness (because of greater relative flexibility) and increased

resting muscle length are more problematic adaptations than specific muscle weakness and

shortness.

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9. The way everyday activities are performed is the critical issue.

For efficiency, the body establishes a pattern

of motion that reinforces the relative hypermobility and participation of specific

joints, including the joint that moves the most readily in a specific direction.

Hypermobility is reinforced and becomes habitual.

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10. The relative participation of some muscle groups (disuse or overuse) is the result of

movement patterns and biomechanical influences.

• In the swayback posture, if the pelvis is tilted posteriorly and the hip is extended, the use of

the gluteus maximus muscle is minimized.

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11. Muscle performance is determined by the pattern of movement.

Correction of faulty patterns is best

achieved by training the correct pattern and not by isolated "strengthening" of a muscle.

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12 . The human body is highly capable of motor equivalency, which is the ability to realize the same motor outcome with different effectors.

Stopping the offending motion at the joint that moves the most readily and redistributing the motion to other adjoining segments expands

one's ability to vary patterns of motion.

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13 . The most important treatment is correcting the movement pattern that is causing the tissue

to become painful or irritated rather than directing treatment to the affected tissue.

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14. The critical issue is how an activity is performed not just performing the activity.

• Proper movement strategy can optimize performance and minimize tissue injury.

Faulty strategy can compromise performance and lead to tissue injury.

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15 . An exercise is not effective unless the exercise limits or corrects the movement at the painful

joint and produces the desired appropriate movement at adjoining joints.

• Redistributing the movement to appropriate joints is the goal.

• The same exercise can be used for contrasting

problems, depending on the instruction and performance (quadruped rocking to either

increase or decrease lumbar flexion).

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16. If a muscle contributes to the impaired motion of a painful joint, stretching the muscle

will not stop the motion causing pain, but stopping the motion may stretch the muscle.

If the tensor fascia lata-iliotibial band contributes to tibiofemoral rotation, stretching

the band will not stop the impaired motion during the stretch or functional activities.

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If the tibiofemoral rotation is controlled and the hip joint does not medially rotate or abduct, the tensor fascia lata iliotibial band can be stretched

during walking.

17. Training movement patterns will induce appropriate muscular and biomechanical

adaptations that will reinforce the development of optimal neuromuscular action.

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18. All neuromuscular adaptations can contribute to and correct problems. Thus "indiscriminate"

core strengthening exercises can become a cause of pain as readily as a lack of muscle strength can contribute to pain problems.

19. Every patient with musculoskeletal pain should have a MS diagnosis.

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20. MS syndromes consist of multiple contributing factors or impairments that combine to produce the principal movement impairment that is the

cause of the symptoms. The syndrome is named for this principal impairment.

• The contributing factors are movement and neuromusculoskeletal adaptations.

• A systematic examination is required to identify all of the contributing factors.

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21. The examination must include tests and assessments of all regions of the body,

including a determination of how all regions affect the movement of the painful joint

because of the biomechanical interactions of the human body.

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22 . The movement system needs to be periodically examined, beginning in childhood and continuing

into old age to:

(1) evaluate optimal tissue development

(2) ascertain the progression of degenerative changes

(3) determine and guide exercises to maintain the

health of the cardiovascular and metabolic systems.

• Guiding exercise for appropriate use can prevent

disuse, misuse, or overuse.

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THE GENERAL PREMISE: MOVEMENTSYSTEM IMPAIRMENTS CAUSE

PAIN SYNDROMES

The belief is that correction or modification of factors altering the precision of motion

(physiological motion but also as much as possible the accessory/arthrokinematic motion) alleviates or reduces the tissue irritation and thus the painful condition.

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A major premise of the model is that pain most often arises from tissues that are stressed by

subtle impairments in movement or alignment and that key factors contribute to these

particular impairments.

One important factor is that the body, following the laws of physics, takes the path of least

resistance for movement.

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The activities an individual performs require movements of multiple joints that are

contiguous, in the same kinematic chain (i.e.,in serial arrangement), and all of which have

different flexibility characteristics.

The result is that one joint of those that are anatomically arranged in series moves the most

easily and most readily when an individual performs an activity.

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Our research supports the premise that the ease and rapidity with which a joint moves are more

important factors in a movement pattern associated with pain than muscle shortness, soft tissue restrictions, or limited range of

motion (ROM) of an adjoining joint.

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These latter factors may have contributed to the initial development of the flexibility of the joint causing the pain, but once established,

the offending motion has to be addressed primarily and the tissue adaptations,

secondarily.

Stretching muscles or soft tissues will not stop the offending motion. But when the offending

motion is stopped or controlled, the appropriate tissues will be stretched.

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The motion contributing to the stress occurs during the first few degrees of motion or with

initiation of an activity.

The primary impairment is believed to be an

accessory rather than a physiological motion, which is consistent with the problem arising during the first few degrees of movement.

Accessory motion hypermobility is an underlying characteristic of degenerative joint disease.

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Example:Lumbopelvic motion with lower extremity motions in patients with low back pain is an

example of abnormal early onset joint motion.

In the prone position, lumbopelvic rotation occurs earlier and to a greater extent during the first few degrees of knee flexion and hip

rotation in patients with low back pain than in control subjects, and the pattern was specific

to the MS category.

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The predisposition of these joints to move readily contributes to the frequency of their

movement and furthers the tendency for motion.

Thus, a specific joint or joints of the lumbar spine, for example, develop a tendency or susceptibility to move readily in a specific

direction (directional susceptibility to movement [DSM]) during all activities.

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In most joints, the accessory motion impairment is not clinically observable, thus the physiological motion associated with the pain is most often designated as the DSM.

when a joint moves more readily than other joints in the same kinetic chain, the repeated

movements and prolonged postures associated with everyday activities can be the precipitating, as well as the perpetuating, factors of the joint's

DSM.

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As a result, movement in the offending direction has been associated with pain and is often

impaired

(deviates from the kinesiological standard).

When the movement is corrected, the symptoms decrease or are eliminated.

Based on the premise that the diagnosis should direct treatment, the DSM is most often also

the diagnosis.

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Correcting the pattern or stopping the movement in the painful direction is the focus

of treatment because the symptoms are decreased or eliminated by this action.

The movement direction or alignment that most consistently causes or increases the patient's

symptoms and that, when corrected, decreases

or alleviates the symptoms is considered the diagnosis.

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The complete description of all the impairments evident as signs or causing symptoms that

contribute to the offending or principal movement impairment is the syndrome.

Impairment is defined as any disorder in structure or function resulting from anatomical, physiological, or psychological abnormalities

that interfere with normal activities.

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THE HUMAN MOVEMENT SYSTEM

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The human movement system is a physiological system of the body that produces motion of the body or its component parts, or the functional interaction of the structures that contribute to

the act of moving.

The physiological actions of other body systems

combine to compose the movement system, with biomechanics playing an important role as the

interface among the skeletal, muscular, and nervous systems.

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Kinesiopathological model

Kinesiopathological refers to how movement that is excessive, imprecise, or insufficient

contributes to the development of pathology.

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ELEMENTS OF THE MODEL

Base ElementsModulator ElementSupport Elements

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Base Elements

The components of the base elements are the muscular and skeletal systems.

These systems are considered the base elements because they consist of the tissues that provide the foundation and the structure of the system.

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Modulator Element

The component of the modulator element is the nervous system.

The term modulator is used to emphasize the

regulator activity of the nervous system.

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Support ElementsThe components of support elements are the

cardiovascular, pulmonary, and metabolic systems.

These systems do not contribute directly to movement, but as indicated by the term support, they provide the nutrients and substances required for maintaining the

viability and health of those systems that do directly produce movement.

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BIOMECHANICS

The model indicates that biomechanics is an interface between muscular and neurological activity.

The pattern of muscular recruitment is highly influenced by relationships to gravity, as well as

the force required to move the extremity and react to external forces.

The design of the movement system also provides a variety of strategies to develop a moment about a joint. Many of those strategies are determined by

biomechanics.

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TISSUE ADAPTATIONS

• Inducers• Modifiers–Age, Gender, Tissue Mobility,

Anthropometrics, Activity Level

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TISSUE ADAPTATIONS

The dynamic and biological characteristics of the components of the movement system enable

tissues to adapt to the demands placed on them.

The specific tissue adaptations are normal biological responses to forms of stress but may

contribute to deviations from principles of kinesiology.

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TISSUE ADAPTATIONS

For example, alterations in muscle length, strength, and stiffness can affect the precision

in joint motion.

In combination, these adaptations can become

problematic.

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InducersThe repeated movements and sustained

alignments associated with everyday activities are the inducers of the tissue adaptations.

Every aspect of an individual's activities, whether passive or active, also induces

changes in tissues.

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Although the physically active person will improve and increase the size of muscles and

connective tissues, at the same time, the risk of injury also increases.

Musculoskeletal pain problems and injuries of athletes mostly occur from noncontact stress.

Golfers develop back, elbow, wrist, shoulder, and knee problems.

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The repetitive use of specific segments of the body combined with high and rapid force development can exceed tissue tolerance,

resulting in microtrauma.

At the other extreme, even individuals who are inactive induce changes by the alignment and

movements while sitting and during work activities.

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Alignments maintained for prolonged periods can induce changes in muscle length.

Without activity, muscle and connective tissues are not stressed enough to provide optimal

tissue health.

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Modifiers

The modifiers are factors such as age, sex, height, weight, and genetic characteristics that include predisposition to osteoarthritis, benign

general joint hypermobility, structural or anthropometric characteristics, and the amount

and type of activity.

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AgeIn young individuals, tissues are more extensible

and joints more flexible than in older individuals.

Thus the offending motions are usually of greater ROM than the motions in an older

patient.

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In older individuals or those with a chronic condition, the movement impairments are

usually more subtle so that the examination requires careful observation and usually slight

corrections.

The treatment using movement corrections and stabilizing exercises requires even greater

precision in the older individual than in the younger patient.

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Gender

Studies of patients with low back pain have demonstrated a difference in the pain-inducing movements and alignments between men and

women.

The broader shoulders, higher center of gravity, and larger and stiffer muscles in men as compared to women also contribute to

differences in tissue adaptation and movement patterns.

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Tissue Mobility

Of the genetic factors, benign joint hypermobility syndrome is one of the important problematic

characteristics.

Individuals with hypermobility seem to be more disposed to musculoskeletal pain problems than

individuals with tissues that limit joint excursions; this occurs not only with the

physiological motion but particularly in the accessory motions.

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Maintaining good alignment and precise motion is more difficult if the individual is

hypermobile as compared to individuals with tissue stiffness.

Therefore one of the important assessments during the examination is obtaining information about the general tissue and joint mobility and

the effects on alignment and movement patterns.

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Anthropometries

Body proportions are also a contributing factor in predisposing an individual to musculoskeletal

problems.

For example, a long trunk is usually associated with depressed shoulders and often neck pain.

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Activity Level

The activity level can range from excessive, which tends to exacerbate the development of musculoskeletal pain problems, to insufficient

activity.

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The therapist needs to also factor into the examination whether the pain condition is

from excessive activity that can be associated with problems from muscle hypertrophy and associated stiffness, as well as motor pattern incoordination, or from a lack of activity in

which a systematic increase in physical activity and exercise to improve the force

production deficit is necessary.

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Activity Level

In the former situation, part of the treatment may be to decrease the demands on specific muscles and increase the extensibility of those muscles.

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Tissue Adaptations of the Skeletal System

Although skeletal structures seem relatively fixed, bone is a dynamic tissue that is

constantly being modified by the forces acting on it.

For purposes of this material, the modifications of skeletal structure and alignment can be

considered both dynamic and static.

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Dynamic conditions are correctable and sometimes easily modifiable, whereas the

static conditions are relatively permanent or structural.

Another consideration is the effect of prolonged

forces on the shape of bones and joints.

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Wolff (1836- 1902) proposed that

"changes in the form and function of bones, or changes in function alone, are followed by changes in the internal structure and shape of the bone in accordance with mathematical laws."

During development, the bones will adopt a shape according to the forces imposed on

them.

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In mature bone in which the general shape is established and no changes are made in the distribution of forces, the change is in the

mass according to the mechanical demands.

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Changes in the shape and alignment of the joint also affect the characteristics of the ligaments and the distribution of forces on the articular

cartilage, as well as alter the precision of joint motion.

A major consideration is how skeletal alignment, both acquired and structural, affects the

demands on muscle participation.

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The initial observations of a patient with pain problems should be an assessment of the

alignment and the participation of musculature based on the relationship to the line of gravity.

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Tissue Adaptations of the Nervous System

Motor control plays a key role in musculoskeletal pain.

there are two general theories about changes in movement in patients with musculoskeletal

pain.

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1. One theory is that pain causes the change in movement patterns and alters motor control.

2. The other theory is that changes in movement patterns cause the problems that result in

pain.

Certainly an acute and intense onset of pain can affect the patient's alignment and movement

patterns.

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But the major question is, "What precipitated the pain episode? “

As suggested by the model, the repeated movements and sustained postures of daily activities induce the changes in tissues and

movement patterns that cause the pain problems.

Therefore the pathological changes are secondary to the altered movement pattern and motor

control and not primary.

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Both concepts require that treatment emphasize correction of the movement patterns and the

altered motor control.

If altered movement patterns cause the problem, then guidelines for prevention are possible.

If the pain causes the problem, then the precipitating factors may not be easy to

identify.

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Clinical experience with correcting movement patterns and alleviating symptoms supports

the belief that the altered movement patterns are the key factor in causing pain and that

correcting the movements and the contributing factors is the most effective long-term

treatment.

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A prevailing characteristic of the human body is to reduce the degrees of freedom when

establishing a movement pattern, thereby achieving a degree of efficiency and

minimizing energy expenditure.

Movement patterns become established as they are repeated, and the pattern is reinforced by

changes in both the nervous and muscular systems.

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When considering the factors contributing to musculoskeletal pain problems, the patterns of

recruitment and derecruitment are primary.

The belief is that the patterns are established by the requirement of the activity, personal

characteristics, and intensity of use.

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Tissue Adaptations of the Muscular System

The adaptations of muscle are changes in:

( 1 ) length, both increased and decreased;

(2) tension development capacity, hypertrophy, and atrophy;

(3) stiffness, the resistance to passive elongation.

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A, Patient's hip joint angle is almost 90 degrees with his knees flexed.

B, With passive knee extension to only 45 degrees, his pelvis tilts posteriorly, and his lumbar spine flexes. The position of the pelvis and lumbar spine indicates that the hamstring muscles are stiffer than the supporting tissues of the lumbar spine. The alignment change occurred before the end of the excursion of the hamstring muscles.

C, when the hip joint angle is maintained at 90 degrees, �the knee cannot be fully extended. The hamstring muscles are short.

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Relative Stiffness/Flexibility

Muscle stiffness is defined as the change in

tension per unit change in length.

Stiffness refers to the resistance present during the passive elongation of muscle and

connective tissue.

The stiffness is a normal property of muscle and is the passive tension of a muscle when

stretched.

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When a muscle is being elongated and there is movement at the proximal attachment of the

muscle, the best explanation is that the tissues stabilizing the joint are not stiff enough

relative to the stiffness of the muscle being stretched.

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A, The patient's pelvis is tilted posteriorly, and his lumbar Spine is flexed when his knee is passively fully extended.

The position of the pelvis and spine can be the result of relative flexibility,which indicates that the hamstrings are stiffer than the supporting tissues of the lumbar spine but not that the hamstring muscles are short.

B, The patient's hip joint angle is 90 degrees, and no motion of the pelvis or lumbar spine occurs when the knee is fully extended passively. The hamstring muscles would not be considered short.

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The concept is that the hamstrings and the

tissues (muscles and ligaments) of the lumbar spine are springs in series.

When the passive tension of the spring being stretched (hamstrings) is greater than the

passive tension of the spring in series (lumbar spine tissues), there will be motion at the

intervening joint.

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The earlier the movement at this joint the greater the indication of the lack of "stiffness or

stability“ of the joint.

A major source of the passive tension (stiffness) in muscle fibers is an intracellular contractile

protein called titin.

Titin is the largest connective tissue protein in the body and provides the passive tension for

both striated and cardiac muscle.

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Titin attaches the myosin filament to the Z-line of the sarcomere and there are 6 titin proteins for

every myosin filament.

Therefore, muscle hypertrophy that increases the

number of sarcomeres in parallel and consequently the amount of myosin will also increase the passive tension or stiffness of the muscle.

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Realizing that an intrinsic property of the human

body is the minimization of energy expenditure when inactive or even when active, the role of

passive tension becomes particularly important.

Passive tension is a primary contributing factor to alignment, often stability, and even the timing

and effectiveness of the mechanical event connected with muscle contraction.

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The passive tension provided by muscle plays an important role in joint stability, alignment, and

in some situations contributes to pain.

Muscle stiffness is an extremely valuable property of muscle that enables the body to be supported with minimal energy expenditure.

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Good alignment is indicative of balanced passive tension of muscles attaching to a joint or

skeletal segment, such as the thorax or pelvis.

The passive tension, which also has a high correlation to active tension, is the key to the

alignment and stabilizing properties of the joint.

As in all things, stiffness can become excessive or insufficient.

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The relative stiffness/flexibility properties are often the contributing factor to:

(1) alignment impairments,

(2) one joint moving more readily than an adjoining joint,

(3) inadequate stabilization or inappropriate movement during the passive elongation of a muscle.

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Muscle Length Adaptations

Increased length

Small changes in muscle length are changes in passive resting tension,while greater increases in muscle length are associated with addition of sarcomeres in series in the muscle fibers.

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Decreased length

The development of true muscle shortness is associated with loss of sarcomeres in series in

muscle fibers.

There is a lack of clarity in clinical practice about the various mechanisms involved in muscle shortness and tissues affected by

stretch or the need to stretch.

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For example:

If the decreased ROM of hip flexion with the knee extended is only 10 to 15 degrees and

can be regained by stretching for a few minutes, the alteration can best be explained

by the creep or viscoelastic properties of muscle.

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In contrast, if the hamstring muscles are limiting

the motion of the joint by 30 to 40 degrees, then the most likely explanation is that the muscle fibers have lost sarcomeres in series and the

treatment has to be stretching of long duration (for example, 30 minutes or more, several

times a day for many days) and as sustained as

possible.

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Stretching should not be forceful because a reasonable explanation for this condition is that the muscle has lost sarcomeres in series

and that requires protein synthesis and not just a change in the conformation of the proteins in

the muscle cells.

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Although muscles can become shortened by loss of sarcomeres in series, this is not the most

common problem contributing to musculoskeletal pain.

The most common problem is the relative stiffness of muscles attaching to the joint.

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Muscle Performance

Performance includes timing, length, passive tension, and the ability to generate active

tension and endurance.

Assessment of muscle strength provides

information about muscle performance, and the results of the test can provide at least four possible determinations about the muscle.

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Manual muscle testing (MMT) can be used to discern whether the muscle is:

(1) weak because of atrophy and the lack of sarcomeres in parallel and thus unable to develop adequate active tension;

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(2) Strained because of being subjected to forces that have torn or disrupted the Z-lines of the sarcomeres and unable to develop adequate

active tension;

(3) Too long, having added sarcomeres in series,

and the muscle does not develop the appropriate tension throughout the ROM,

(4) Normal.

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Joint Mobility

As depicted in the model, the problematic outcome of the tissue adaptations is the

development of a relative stiffness or flexibility condition that becomes exaggerated because the

body takes the path of least resistance for movement.

The result of this cascade of events is that a joint develops hypermobility.

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Hypothetically, the hypermobility is an accessory or arthrokinematic motion rather

than physiological or orthrokinematic motion.

One of the consequences of imprecise movement is the development of points of high contact stress because of inadequate distribution of

forces within the joint.

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Thanks for your attention