Movement System Diagnoses. Movement System Impairment Syndromes of the Lumbar Spine. MSI Syndrome - Assumptions. Return From Forward Bending

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Movement System Diagnoses Kinesiopathologic Pathokinesiologic Movement System Impairment Syndromes of the Lumbar Spine Shirley Sahrmann, PT, PhD, FAPTA Washington University St.

(Neuromuscular) Movement System Impairment (MSI) Syndromes Impairment level of the organism Any abnormality of anatomical, physiological or psychological function.

1 Movement System Diagnoses Kinesiopathologic Pathokinesiologic Movement System Impairment Syndromes of the Lumbar Spine Shirley Sahrmann, PT, PhD, FAPTA Washington University St. Louis School of Medicine MDT Musculoskeletal Neurological Cardiopulmonary MSI syndromes (Neuromusculoskeletal) Tissue Impairments (Pathoanatomic) Treatment Diagnoses O Sullivan Class MSI syndromes (Neuromuscular) Movement System Impairment (MSI) Syndromes Impairment level of the organism Any abnormality of anatomical, physiological or psychological function. Syndromes Collection of impairments based on observable abnormalities, primarily kinesiologic, and their relationship to symptoms Correction decreases or eliminates the symptoms Named for principal impairment the movement direction most consistently affecting the symptoms Other impairments are contributing factors MSI Syndrome - Assumptions LBP is associated with movement in a specific direction Subgroups can be identified Repeated movements & sustained alignments cause development of a joint s accessory motion to occur too readily usually in a specific direction. Relative flexibility induce muscle and connective tissue changes contributing to relative stiffness behavior. Relative stiffness Result in neuromuscular activation patterns. Motor learning Relative flexibility, relative stiffness, and motor learning combine to contribute to the development of a path of least resistance for movement Low Back Pain: Case Presentation Return From Forward Bending Observe pattern of bending and returning to standing Hip extension Back extension Ankle sway 1

Extension Hip flexors Structural Lumbar Rotation Femoral anteversion / retroversion L Flexion Cam impingement

parallel Passive stretch of stiff & < stiff muscle in series elongation of least stiff muscle The Lumbar MSI

Low Back Pain: Case Presentation Low Back Pain: Case Presentation Age 23 Weight 175 lbs (80 kg) Height 6 ft

2 How Much Does the Hip Contribute? Muscular Factors Affect Low Back Muscular Lumbar Rotation hip rotators, abductors L Flexion Hip extensors L Extension Hip flexors Structural Lumbar Rotation Femoral anteversion / retroversion L Flexion Cam impingement Pincer impingement L Extension Hip flex/abd flexor Hip Extensors short Muscles = Springs in series & in parallel Passive stretch of stiff & < stiff muscle in series elongation of least stiff muscle The Lumbar MSI Syndromes Flexion Flexion - rotation Extension Extension rotation Rotation Primary Secondary < stiff m Stiff m Low Back Pain: Case Presentation Low Back Pain: Case Presentation Age 23 Weight 175 lbs (80 kg) Height 6 ft (183 cm) Student Competitive cyclist Flat lumbar spine Tentative MSI diagnosis? Excessive lumbar flexion Decreased hip flexion Low back pain is increased Lumbar spine flexed Hips not flexed to 90 deg 2

Spinal Pathology and Movement Disc herniation offending motions Flexion and rotation Spondylosis - degenerative osteoarthritis of the joints between the centra of the spinal vertebrae and/or

More specifically it is defined as a defect in the pars interarticularis of the vertebral arch LUMBAR FLEXION SYNDROMES Young Tall - Acute Spondylolisthesis -anterior or posterior

All extension induced Spinal stenosis extension induced Case Presentation: Low Back Pain - Flexion Long psoas Long back extensors Demographics: 40 year old male 6 feet tall Lumbar Flexion

3 Spinal Pathology and Movement Disc herniation offending motions Flexion and rotation Spondylosis - degenerative osteoarthritis of the joints between the centra of the spinal vertebrae and/or neural foraminae. Spondylolysis is a defect of a vertebra. More specifically it is defined as a defect in the pars interarticularis of the vertebral arch LUMBAR FLEXION SYNDROMES Young Tall - Acute Spondylolisthesis -anterior or posterior displacement of a vertebra or the vertebral column in relation to the vertebrae below. All extension induced Spinal stenosis extension induced Case Presentation: Low Back Pain - Flexion Long psoas Long back extensors Demographics: 40 year old male 6 feet tall Lumbar Flexion Syndrome Prolonged posture: Sitting short hamstrings Tx: Shorten Hip flex Back ext Kendall: Muscles Testing & Function 1983 Complaint: LBP sitting>standing Occupation: Executive Leisure-time activity: ultramarathonist Repeated movement: Running effect on abdominal muscles hamstrings and lumbar spine Patient Preferred Motion Patient Preferred Position and Effect of Knee Extension Limited hip flexion Thoracic flexion Symptoms increase 3

4 Patient Preferred Alignment Trunk flexed Hip are flexed less than 90 deg Case Presentation: Low Back Pain flexion Young tall flexible: student/diver sit-up exercises Hip extensors not short Relative flexibility: abdominals > hip extensors > back ext Lordotic? Excessive flexion Flexion Moment Abdominals strong Back extensors more flexible than the hip extensors Case Presentation Lumbar Flexion 64 yo Spinal Flexion and Rotation DDD of entire lumbar spine: Having chronic pain and acute episodes Quadruped Alignment Immediate Change Post Quadruped Rocking Backward Doing all the wrong exercises Pre Immediate Post 4

Kinesiopathological Model Of Human Movement System Base Modulator Support Muscular Nervous Cardio/pulmon Skeletal Metabolic Biomechanics: Static/Dynamics Age,

(excessive/insufficient) Tissue adaptations Hypertrophy, atrophy, Muscular, neuro, skeletal long, short, stiff, stabilize, Motor Performance recruit,

curve Return with lumbar extension > hip extension Extension - increased pain Sitting Posture when Teaching & Playing the Piano MSI Syndrome: Extension Pt s

5 Kinesiopathological Model Of Human Movement System Base Modulator Support Muscular Nervous Cardio/pulmon Skeletal Metabolic Biomechanics: Static/Dynamics Age, anthopometrics, sex Inducers Repeated movements Personal Modifiers general tissue mobility, genetics, Sustained alignments characteristics Activity level (excessive/insufficient) Tissue adaptations Hypertrophy, atrophy, Muscular, neuro, skeletal long, short, stiff, stabilize, Motor Performance recruit, derecruit, cocontract coordination, boney/joint shape Low Back Pain: Case Presentation Pain with standing worse than sitting Age 45 Height 5 3 (160.5 cm) Weight 140 lbs (63.5 kg) Lordosis with anterior pelvic tilt Piano teacher Low Back Pain: Case Presentation Physical Exam: Forward bending decreased pain barely reverses lumbar curve Return with lumbar extension > hip extension Extension - increased pain Sitting Posture when Teaching & Playing the Piano MSI Syndrome: Extension Pt s height, weight, age Alignment Pattern of bending & returning to standing Occupation/recreational activity All influence mechanical factors leading to pain with extension What are the adaptive tissue changes contributing to this condition? LUMBAR EXTENSION SYNDROMES Old short chronic Variation in contributing factors 5

6 Extension Case Presentation: Low Back Pain What was her sport Why does she stand in this alignment? Why is she standing with her trunk swayed back? Are her hip flexors short? Relative Stiffness of Abdominal Muscles vs Hip Flexor Muscles Case Presentation: Lumbar Extension General Joint hypermobility Lumbar Extension Case Presentation: Lumbar Extension Very Stiff & inflexible Case Presentation:Lumbar Extension Initial Visit Two Weeks Later Abdominals too short contributing to kyphosis and swayed back posture rectus abdominis anti-gravity muscle 6

The MS Examination Purpose: assess symptoms and relationship to Alignment and movement; movement pattern Of the trunk and of the extremities and how they affect the spine Preferred (natural movement)

7 The MS Examination Purpose: assess symptoms and relationship to Alignment and movement; movement pattern Of the trunk and of the extremities and how they affect the spine Preferred (natural movement) & corrected movement Biomechanically linked system, therefore movement at one segment affects other segments, particularly adjoining segments Format: standing; supine, sidelying, prone, quadruped, sitting, walking The Examination Standing: Sx, position; alignment; forward bending; return; sidebending; rotation; single-leg standing Supine: position; Hip flexor length; pass&act hip/knee flexion; hip abd/lat rot; Sidelying: position; hip lat rot; hip abd Prone; position, knee flex; hip rot Quadruped: position; rocking back; shoulder flex Sitting: knee ext Standing: back to wall Gait: Pts with LBP Clustering of Potential Findings Flexion Extension Characteristics Young/tall Old/short Abdominals Strong/stiff Weak/long Back Weak/long Strong/stiff extensors Hip flex length Long Short/stiff Hip ext length Short/stiff Long Activities Sit flexed Sit extended LUMBAR ROTATION SYNDROMES Pain side bending, rotating, flex & ext Signs and not symptoms Types: primary & secondary Patient with Low Back Pain Alignment Observe her pelvis while walking; note structural characteristic of hips 7

8 Rotation Side lying Hip Lateral Rotation (L) Side lying Hip Abduction (L) Prone Knee Flexion Prone Hip Rotation Walking Corrected 8

9 Lumbar Rotation flexion & extension LUMBAR ROTATION Extension and Flexion Quadruped Rocking correct the flexion and posterior shift by allowing the back to flatten correct the rotation by allowing the spine extend and using the overlap of the facet joints to decrease the rotation. Rotation - Primary Herniated disc scheduled for surgery Rotated Spine Increases when Rocking Backward Hip flexion limited most likely structural Has pain when rotated Treatment Effect Before After quadruped rocking Case Presentation: Low backpain with left radiculopathy 6 months post-partum - twins 8/23 8/29 Initial visit 5 days later 9

Successive Visits 8/23 9/5 Rotation to Left When Rocking Back 8/29 Right iliopsoas pulling > Left iliopsoas Natural standing: Right foot on

patients Modification of trunk & limb movements decrease or eliminate symptoms Relative Stiffness / Flexibility Knee flexion, hip lateral

subcategories of LBP NOT the length of muscles IS the relative stiffness of the spine Takes stretch off of the iliopsoas Summary Consistent

and prolonged postures Multifactorial Classification according to painful movement direction is consistent with A joint s directional

should be Based on a movement system diagnosis; Directed toward pre-disposing and contributing factors; Address contributing factors to slow

accessory motion underlying cause of degeneration Treatment Strategy Current recommendation During an activity Train to decrease lumbar

10 Successive Visits 8/23 9/5 Rotation to Left When Rocking Back 8/29 Right iliopsoas pulling > Left iliopsoas Natural standing: Right foot on footstool Summary of Evidence Clinical Exam: reliability tests of trunk and limb movements Valid for classifying subgroups of low back patients Modification of trunk & limb movements decrease or eliminate symptoms Relative Stiffness / Flexibility Knee flexion, hip lateral rotation & trunk lateral bending, passive elastic stiffness of trunk Cause earlier lumbopelvic motion in LBP vs No LBP Have a relationship to subcategories of LBP NOT the length of muscles IS the relative stiffness of the spine Takes stretch off of the iliopsoas Summary Consistent With Evidence Low back pain (musculoskeletal pain syndromes) are from cumulative trauma Progressive changes in tissue from repeated movements and prolonged postures Multifactorial Classification according to painful movement direction is consistent with A joint s directional susceptibility to movement (DSM) moves more readily in a specific direction than other joints that move in that same direction Treatment: should be Based on a movement system diagnosis; Directed toward pre-disposing and contributing factors; Address contributing factors to slow or prevent recurrences (progressive degeneration) Movement patterns associated with all activities Specific exercises Hypermobility of accessory motion underlying cause of degeneration Treatment Strategy Current recommendation During an activity Train to decrease lumbar region motion while increasing movement in other regions Validation Did the symptoms improve? Training which segments are contributing, how much and when they are contributing 10

11 How? Dependent on contributing factors Neural control Motor Pattern Incoordination Musculoskeletal Neural control Consideration - are musculoskeletal factors modifiable or not, i.e., increasing risk? Force Production Deficit Priority Decrease lumbar region motion (accessory motion hypermobility) Increase motion of relatively stiffer segments Incorporate training into specific everyday movements 11

Movement System Impairment Syndromes Concepts Lumbar Spine Syndromes

Movement System Impairment Syndromes Concepts Lumbar Spine Syndromes Developed by Shirley Sahrmann, PT, PhD, FAPTA Professor Emerita Washington University School of Medicine STL Program in Physical Therapy