Retraining strategies for uncontrolled movement

Rehabilitation management and retraining

The retraining of efficient control of uncontrolled movement (UCM) will depend on the pattern of the dysfunction and the site and direction of the UCM. From the assessment (as outlined in Chapter 3) the translation and range of UCM and restriction will have been identified. Correcting aberrant motor control and recruitment patterns is the priority in the rehabilitation of the local stability system. Correcting length and recruitment dysfunction is the priority of the global system. Addressing the UCM and restriction is the key to rehabilitation and this principle is covered throughout this text.

As well as dealing with mechanical components of movement dysfunction the pathology must be addressed and non-mechanical issues identified and managed. Dependent upon reported signs and symptoms, local tissues should be assessed to identify the pain-producing or most damaged structure(s). Intervention may include treatment of the pain mechanisms, inflammation and pathology with techniques such as large amplitude manual mobilisations, cryotherapy, heat, active exercise, electrophysiological modalities, neurodynamic techniques, acupuncture, trigger point release, positional release and appropriate medication. These interventions should be supplemented with fitness and exercise programs which are effective approaches for the management of chronic low back pain (Frost et al 1998; Torstensen et al 1998). Consideration and management of psychosocial factors is also essential in the management of chronic low back pain and other chronic musculoskeletal conditions. Cognitive behavioural approaches have a significant role to play for optimal outcomes in chronic low back pain (Waddell 2004). The more multifactorial the patient’s pain presentation is, the more likely a multidisciplinary approach will be required. The clinical reasoning framework to encompass these factors has previously been described in Chapter 1.

Management overview

In the integrated management of musculoskeletal pain there are several factors that require consideration (Figure 4.1).

Figure 4.1 Overview of the ‘pyramid’ of mechanical movement dysfunction

Firstly, the mechanical components of the dysfunction need to be addressed. These include identifying and understanding the relationships between articular and myofascial restrictions and the compensations that develop to maintain good function. The compensations require more detailed assessment and UCM needs to be identified in terms of the site and direction of UCM. The UCM can present as uncontrolled translation which is best controlled by local muscle retraining or uncontrolled range which is best controlled by global muscle retraining. These restrictions and uncontrolled compensations make up the base of the ‘pyramid’ of mechanical movement dysfunction. The top of the pyramid involves treating the pain-sensitive tissues to optimise the resolution of inflammatory pathology and to promote an optimal healing environment. Finally, if the dysfunction is longstanding (chronic or recurrent), then ‘yellow flag’ issues also need consideration. Yellow flag issues may include peripheral and central neurogenic sensitisation and contextual factors such as behavioural or psychosocial factors that can affect both the perception of pain and the prognosis for symptom change.

It is important to relate the site and direction of UCM to symptoms and pathology and to the mechanisms of provocation of symptoms. Management of the dysfunction that relates to the symptoms and pathology becomes the clinical priority. UCM that may be evident, but does not relate to symptoms, is not a priority of pathology management. However, it may indicate a potential risk for the future (Mottram & Comerford 2008; Roussel et al 2009). The movement control dysfunction can be labelled and classified by the site and direction of UCM and is described in following chapters.

Therapeutic exercise

Therapeutic exercise within clinical practice is beneficial (Taylor et al 2007). There is evidence that different types of therapeutic exercise are beneficial to many different groups of patients, including those with osteoarthritis of the knee (Brosseau et al 2003; Pelland et al 2004), chronic low back pain (Hayden et al 2005), shoulder pain (Green et al 2003) and chronic neck pain (Kay et al 2005). Different patients appear to need different therapeutic exercises to manage different therapeutic goals. There are indications that specifically targeted and individualised exercise programs are more beneficial than standardised programs (Stuge et al 2004; Taylor et al 2007). The development of rehabilitation strategies directed at correcting the movement faults, identified by evidence-based assessment, rather than developing rehabilitation strategies based on diagnosis of pathology alone, is gaining recognition and acceptance because patients may present with a similar diagnosis of pathology but differing kinematic mechanisms. However, there remain many examples of exercise programs being developed with the ‘one size fits all’ ideology. Most of these programs become ‘protocols’ for ‘core stability’ training or a particular injury such as patellar malalignment, shoulder instability or a post-surgical protocol.

Protocol-based training regimens can be designed with clear goals, performance targets and structured timeframes and the ‘protocol’ can be readily disseminated to a large number of people. The developers of these protocols have the unenviable task of producing a program that must be simple yet at the same time comprehensive enough to deal with a wide range of variability in patient presentation and complications. However, it is difficult for one protocol to cover the timeframe from injury to return to high level function (e.g. elite sport).

An inherent weakness with protocol-based training programs is an assumption that all people who use the protocol have, to a large extent, the same problem. Most protocols are designed along a linear framework. That is, there are a series of linear progressions from one skill or stage to the next. Consequently, in the attempt to account for individual differences in presentation (especially if injury and pathology are involved) many protocols are modified or adapted, often many times over. The primary problem then with protocol-based training programs is that they are forced to become ‘recipes’. The recipe works well for one particular goal or a ‘textbook’ presentation of a problem. However, therapists and trainers who regularly work with injured athletes know that they rarely present as the ‘textbook case’. Each patient has his or her own variations, complications and differing expectations.

Thus, a paradigm shift is needed towards a process of systematic assessment and analysis that can be used to guide the rehabilitation of dysfunction and retraining of performance deficits. Based on a comprehensive assessment of an individual’s deficits, the development of individualised and specific retraining programs to better manage real priorities in injury rehabilitation and performance training can be developed. The subsequent retraining program is designed along a multidimensional and parallel framework, rather than a linear recipe.

When a clinical reasoning process is used in the application of exercise for a therapeutic purpose, several distinct goals can be identified.

Therapeutic exercise can be used to:

1. maintain mobility/flexibility and mobilise restrictions (especially after manual therapy mobilisation or myofascial stretching)

2. manage pain and symptoms (unload or support pain sensitive tissues)

3. control segmental translatatory motion (local muscle system motor control)

4. control aberrant motion – uncontrolled direction or range (global muscle system motor control)

5. recondition and recover from atrophy and tolerate load (increase strength and endurance)

6. cope with speed (produce acceleration and control momentum)

7. train and re-enforce sport-specific skills (skill and coordination)

8. influence mood and sense of wellbeing to assist in the management of behavioural/affective issues.

Figure 4.2 incorporates these goals into a non-linear therapeutic exercise paradigm.

Figure 4.2 A paradigm of therapeutic exercise goals

In a clinical situation, a patient may be prescribed an exercise program to achieve one or several goals at the same time. As the condition changes the exercise prescription should progress to match the changing nature of the condition and the goals themselves will change as the condition improves and resolves. Some of the exercise goals may also be incorporated into either a short-term or a long-term maintenance program. These goals should not be prescribed in rigid linear progressions; that is, start with one, then as its aims are achieved, progress to the next one. There seems to be an assumption that the skills acquired with one goal are a necessary prerequisite before starting the next one. This assumption does not have any real evidence base.

It is more appropriate and more functional to prescribe therapeutic exercise in parallel combinations based on a clinical assessment and then decide what rehabilitative changes are required and how and when those changes can be implemented. Therapeutic exercise uses movement as a tool to decrease pain, increase joint range and muscle extensibility, to enhance movement performance and to improve wellbeing. The best way to approach therapeutic exercise is to use a clinical reasoning approach. The steps involved in this approach are outlined in Box 4.1. Box 4.2 highlights some key questions that the therapist should be able to answer and justify. These factors should be understood by the therapist prescribing therapeutic exercise and can be explained and supported with the therapeutic exercise plan.

Box 4.1 Clinical reasoning steps in therapeutic exercise prescription

• Identify general aim of an exercise process – look at the process (i.e. what the exercise can make a difference to).

• Identify key therapeutic goals that may be helped by exercise (these goals will continually change and evolve as the patient’s condition changes).

• Match an exercise process to the immediate therapeutic goals.

• Keep it simple – do not over-complicate the application.

• Where appropriate, work on more than one goal at the same time – integrate and progress along parallel paths.

• Do not use recipes – ensure a clear reason for giving any particular exercise and make sure there is a clear understanding of when the exercise can be stopped or progressed.

Box 4.2 Key factors to be explained with the therapeutic exercise plan

• What is the reason for giving this exercise?

• Is this exercise appropriate for this patient, having considered their presenting symptoms and dysfunction?

• Should the exercise be started now or later?

• What is the exercise dosage? (e.g. For how long? How many repetitions? How often?)

• When can it be progressed?

• When can it be stopped?

• How do I know it is working? What changes should I look for?

• Over what timeframe should I expect to see some change?

• Are there any risks? Can the exercise be provocative or increase symptoms? If so, what is acceptable and what is not?

Therapeutic exercise can use movement as a tool to decrease pain, to increase joint range and muscle extensibility, to enhance muscle performance and to promote wellbeing. This and other chapters in this text detail the concept and strategy to ‘look at movement’; to be able to make mechanical subclassifications according to site and direction of UCM; relate UCM to symptoms, disability, dysfunction, recurrence, risk and performance; make a clinical diagnosis in terms of site and direction of uncontrolled motion, complaining tissue and presenting pain mechanisms. Rehabilitation will focus on re-establishing control of the site and direction of UCM including functional integration. The key to delivering effective treatment is to understand the principles behind assessment and sound clinical reasoning.

The therapist’s clinical decision-making should consider the patient’s perspective and interventions should be primarily aimed at those aspects of impairments that have a direct bearing on disability and/or functional limitations. In the subjective examination, patients define their perspective in terms of pain, disability and dysfunction. These factors will be further influenced by contextual factors such as fear of pain/provocation, their coping ability, their work and social requirements, their belief systems, etc.

Therapeutic exercise needs to address real everyday functional limitations; for example, the inability to bend over when tying shoelaces (due to low back pain or the fear of provoking low back pain), or the inability (due to shoulder pain) to reach up to a cupboard. If a patient with low back pain is unable to actively control movements of the low back, especially flexion control while performing a ‘waiter’s bow’ (Luomajoki 2008), then clinicians should aim an intervention at the neuromuscular impairment underpinning this. Likewise, if a patient with shoulder pain is unable to actively control the scapula during functional movements of reaching with the arm (von Eisenhart-Rothe et al 2005; Tate et al 2008), then clinicians should aim an intervention strategy at regaining this control. There is evidence to support the use of movement retraining to gain an improvement in function (Jull et al 2009; Roussel et al 2009b).

Altering movement patterns via exercise can influence clinical signs (Tate et al 2008). However, it is important to establish a clear diagnosis of the movement faults and from this diagnosis develop an appropriate rehabilitation strategy. The therapist requires a sound knowledge of exercise concepts so a patient-specific retraining program can be developed. This is dependent on expertise in the assessment of movement disorders as described in Chapters 1 and 3, and effective clinical reasoning.

The site and direction of UCM

Chapter 3 has detailed the assessment of the site and direction of UCM. The next stage is regaining control of the UCM and integrating this new movement pattern into normal movement and function.

The key goal to effective retraining is to re-establish control of the UCM and regain normal mobility of motion restrictions. The dissociation tests, as described in Chapter 3, are tests of motor control and these establish the site and direction of UCM. If this UCM is related to symptoms, disability, recurrence, risk of injury and performance, a key focus of rehabilitation is regaining the control of movement and changing motor control patterns. The aim is to change the recruitment pattern and actively control movement at the site and in the direction of stability dysfunction. This is a process of sensory-motor reprogramming.

Retraining in control of the site and direction of UCM

• Firstly, position the site of UCM within its neutral training region (as described in Chapter 3) and teach the person how to recruit the appropriate muscles to control a specific direction of movement at this site, while concurrently moving an adjacent joint (above or below) in the same direction (or moving the same segment in a different direction). For example, if the site of the UCM is the lumbar spine, position it in a long shallow mid-range lordosis. If the direction of the UCM is uncontrolled flexion, the therapist instructs the person to control or prevent lumbar flexion while the person flexes forwards independently at the hips, or flexes the thoracic spine independently of any lumbar movement. The person is taught to use whatever feedback helps to monitor and ensure that the lumbar spine does not increase flexion during the retraining exercise.