Case review: the management of uncontrolled movement in practice 2

13th October 2011

Case review: Shoulder

Let's set the scene.

A bricklayer presents with right shoulder pain. He complains of localised superficial pain at the acromion and near the anterior coracoid. His pain is aggravated by lowering the arm from overhead positions. The pain is worst as he lowers his arm from 110° to 80°. The pain is most provoked by resisting arm lifting in flexion and in abduction.

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 supraspinatus and the long head of biceps tendons as the sources pain pathology.

Question 2: How do movement faults or uncontrolled movement (UCM) contribute to this pain and injury?

· the serratus anterior and trapezius muscles lack appropriate co-ordination or are functionally inefficient, then, a lack of ability to maintain some upward rotation of the glenoid results in increased subacromial compression and impingement of the supraspinatus and biceps tendons. This person demonstrates uncontrolled downward rotation or forward tilt of the scapular during arm movements.

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 orientate the scapular in a neutral mid-range position and then to cognitively control downward rotation or forward tilt of the scapular during lifting and lowering the arm from 0° to 90° of flexion and abduction. The inability to control or prevent scapular movement, especially during the eccentric lowering of the arm, demonstrates a movement control dysfunction that is related to the patient’s pain mechanism and pain behaviour.

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. Movement control training:  to train the patient to position and orientate their scapular in a neutral mid-position and then learn to control scapular downward rotation or forward tilt during small range arm lifting, lowering and rotation activities.

2. Perform recruitment efficiency training of the specific scapular stabiliser muscles that can protect against subacromial compression. In this case, retraining inner range holding efficiency of the serratus anterior and trapezius muscles would be effective.

3. Improve the pattern of recruitment synergy between the scapular stabiliser muscles that eccentrically control downward rotation and forward tilt and the mobiliser muscles that produce downward rotation and forward tilt.

The 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