Case review: the management of uncontrolled movement in practice - 1

9th August 2011

Lumbar Spine
Let's set the scene:
A female waitress presents with back pain in the low lumbar spine. She stands in a sway back posture. She complains of a deep central ache in the L5-S1 region with an intermittent sharp stabbing pain on the right side of the L5 region. Her pain is aggravated by prolonged standing, walking, leaning backwards and lifting trays above shoulder height. She gets some relief of her symptoms if she sits and stretches forward to hang her body between her knees and if she “curls up in ball”. She has had radiographic diagnosis of a L5-S1 spondylolisthesis.

In managing this person’s pain and dysfunction we need to be able to answer some important questions.

Question 1: Where does the pain come from? What structures are injured?
•    Manual therapy assessment involving assessment of provocative movements, palpation of pain sensitive tissues and structural testing implicates that the L4-5-S1 facets joints (right > left) and the L5-S1 disc are a significant sources of pain and pathology.

Question 2: How do movement faults or uncontrolled movement (UCM) contribute to this pain and injury?
•    This lady demonstrates an aberrant movement pattern when she performs functional movements into spinal extension. She has pattern of initiating trunk extension by swaying the pelvis forward and hinging into extension off the lumbosacral junction. The thoraco-lumbar junction has reduced extension and there is reduced anterior pelvic tilt. If the oblique abdominals and the gluteal muscles lack appropriate co-ordination or are functionally inefficient, then, there is a lack of ability to maintain control of the pelvis swaying forward and hip extension initiating the functional movement of trunk extension.
•    The observation of the spine sentimentally hinging into extension is usually associated with inhibition of the deep single segment fibres (local muscle compartment) of lumbar multifidus.
•    This person demonstrates uncontrolled L5-S1 segmental hinging into extension.

Question 3: How do we test for and identify uncontrolled movement that is related to pain and dysfunction?
•    The evaluation of uncontrolled movement involves a process of assessing cognitive motor control abilities. In this case, the test involves instructing the patient to initiate trunk extension with thoraco lumbar extension and the anterior tilt of the pelvis while at the same time preventing the pelvis from swaying forward at all. The inability to control prevent forward sway of the pelvis during initiation of thoraco lumbar extension demonstrates a movement control dysfunction that is related to the patient’s pain mechanism and pain behaviour.
•    The ability to cognitively activate lumbar multifidus at the segmental level of pain and pathology, without pelvic or spinal movement (global mobiliser substitution) demonstrates efficiency of recruitment of the local muscle compartment of lumbar multifidus. This patient's inability to cognitively activate the local fibres multifidus at the right L5-S1 level demonstrates a recruitment efficiency of one of the muscles that can potentially control segmental translation and therefore control and mechanism of spondylolisthesis.

Question 4: What movement control strategies can be used to recover this dysfunction?
•    There are a variety of movement control options to deal with this dysfunction.
1.    Use movement control dissociation to train the patient to prevent forward sway the pelvis during small range thoracic extension activities
2.    Perform recruitment efficiency training of the specific lumbo-pelvic stabiliser muscles that can protect against forward sway the pelvis and segmental hinging at the lumbar pelvic junction. In this case, retraining inner range holding efficiency of the oblique abdominal and gluteus maximus muscles would be effective.
3.    Improve the recruitment efficiency with cognitive retraining of the local (segmental) fibres of multifidus at the right side L5-S1 segment.

Our Movement Solution course provides these answers and solutions to enhance and integrate your manual therapy skills into contemporary movement control theory and practice. Our aim is to develop a diagnostic framework of movement function so that for each patient you make a diagnosis of: 1) the injured or pain generating tissues (e.g. supraspinatis tendon); 2) the site and direction of uncontrolled movements that causes the tissue stress and strain (e.g. uncontrolled scapula downward rotation); 3) the pain mechanisms involved in the pain experience (e.g. peripheral inflammatory). Contextual factors, such as environment and ergonomics are also considered (e.g. picking up bricks with the palm down and the shoulder in medial rotation). The Movement Solution provides multiple retraining solutions and options to manage each of these diagnoses.

Keywords: Case Study, Movement Control Impairments