Chapter 1 

Uncontrolled movement

The key to managing movement dysfunction is The movement system comprises the coordi­
thorough assessment. This includes the deter­ nated interaction of the articular, the myofascial,
mination of any uncontrolled movement (UCM) the neural and the connective tissue systems of
and a comprehensive clinical reasoning process the body along with a variety of central nervous
by the clinician to evaluate contributing factors system, physiological and psycho-social influ­
which influence the development of UCM. This ences (Figure 1.1). It is essential to assess and
first chapter details the concept of UCM and the correct specific dysfunction in all components of
clinical reasoning process which is the framework the movement system and to assess the mechani­
for assessment and rehabilitation. cal inter-relationships between the articular, myo­
fascial, neural and connective tissue systems. This
chapter will describe a systematic approach to
evaluation of the movement system and identifi­
UNDERSTANDING MOVEMENT   cation of the relative contributions of individual
AND FUNCTION components to movement dysfunction.

Normal or ideal movement is difficult to define. Movement faults

There is no one correct way to move. It is normal
to be able to perform any functional task in Identifying and classifying movement faults is
a variety of different ways, with a variety of dif­ fast becoming the cornerstone of contemporary
ferent recruitment strategies. Optimal movement rehabilitative neuromusculoskeletal practice
ensures that functional tasks and postural control (Comerford & Mottram 2011; Fersum et╯al 2010;
activities are able to be performed in an efficient Sahrmann 2002). In recent years clinicians and
way and in a way that minimises and controls researchers have described movement faults and
physiological stresses. This requires the integra­ used many terms to describe these aberrant pat­
tion of many elements of neuromuscular control terns. These terms include substitution strategies
including sensory feedback, central nervous (Richardson et╯al 2004; Jull et╯al 2008), compen­
system processing and motor coordination. If this satory movements (Comerford & Mottram
can be achieved, efficient and pain-free postural 2001a), muscle imbalance (Comerford & Mottram
control and movement function can be main­ 2001a; Sahrmann 2002), faulty movement
tained during normal activities of daily living (Sahrmann 2002), abnormal dominance of the
(ADL), occupational and leisure activities and in mobiliser synergists (Richardson et╯al 2004;
sporting performance throughout many years of Jull et╯al 2008), co-contraction rigidity (Comer­
a person’s life. ford & Mottram 2001a), movement impairments

© 2012 Elsevier Australia

DOI: 10.1016/B978-0-7295-3907-4.00001-3 3
 Kinetic Control: The management of uncontrolled movement

Movement system

Articular system
Myofascial system
• physiological/functional
• accessory/translational Active force transmission
• afferent feedback • static controllers of posture
isometric co-contraction
Psycho-social
• dynamic movement
influences
concentric – production and acceleration of movement
Connective eccentric – control and deceleration of momentum
Behavioural and affective tissue system • afferent feedback
‘yellow flags’
proprioception
• movement anxiety Links all systems
• fear-avoidance • structure and support Neurogenic
• poor coping skills • energy storage sensitisation
• depression • passive force transmission
• blame transference • proprioception and feedback Neurogenic sensitisation and associated 2°
• abnormal pain beliefs allodynia and hyperalgesia
• exaggerated pain • altered thresholds of Wide Dynamic Range
behaviour receptors in lamina V dorsal horn
Neural system
• abnormal ion channels within CNS
neurons
• motor control via • abnormal sensitivity of peripheral
sensory-motor integration neurodynamic mobility
• neurodynamics

Figure 1.1╇ Inter-related components of the movement system

(Sahrmann 2002; O’Sullivan et╯al 2005) and syndromes are seldom caused by isolated events;
control impairments (O’Sullivan et╯al 2005; and that habitual movements and sustained
Dankaerts et╯al 2009). All of these terms describe postures play a major role in the development of
aspects of movement dysfunction, many of which movement dysfunction. These statements have
are linked to UCM. been fundamental in the development of the
The focus of this text is to describe UCM and movement dysfunction model. Clinical situations
explore the relationship of UCM to dysfunction which have a major component of movement
in the movement system (Comerford & Mottram dysfunction contributing to pain include: pos­
2011). Movement dysfunction represents multi­ tural pain; pain of insidious onset; static loading
faceted problems in the movement system and or holding pain; overuse pathology (low force
the therapist needs the tools to relate UCM and repetitive strain or high force and/or impact
faults in the movement system to symptoms, repetitive strain); recurrent pain patterns; and
recurrence of symptoms and disability. Skills are chronic pain.
required to analyse movement, make a clinical It is important to identify UCM in the func­
diagnosis of movement faults and apply a patient- tional movement system. It is our hypothesis that
specific retraining program and management the uncontrolled segment is the most likely source
plan to deal with pain, disability, recurrence of of pathology and symptoms of mechanical origin.
pain and dysfunction. There is a growing body of evidence to support
Sahrmann (2002) has promoted the concept the relationship between UCM and symptoms
that faulty movement can induce pathology, not (Dankaerts 2006a, 2006b; Luomajoki et╯al 2008;
just be the result of it; that musculoskeletal pain van Dillen et╯al 2009). The direction of UCM

4
 Uncontrolled movement Chapter |1|

relates to the direction of tissue stress or strain

and pain producing movements. Therefore it is Symptoms Dysfunction
important in the assessment to identify the site
and the direction of UCM and relate it to the
symptoms and pathology. The UCM identifies the
Disability Recurrence
site and the direction of dynamic stability dysfunc­
tion and is related to the direction of symptom-
producing movement. For example, UCM into
lumbar flexion under a flexion load may place Risk Performance
abnormal stress or strain on various tissues and
result in lumbar flexion-related symptoms. Like­
wise, uncontrolled lumbar extension under exten­ Figure 1.3╇ Factors relating to the site and direction of
sion load produces extension-related symptoms, uncontrolled movement
while uncontrolled lumbar rotation or side-bend
and/or side-shift under unilateral load produces
unilateral symptoms.
Symptoms
Symptoms are what the patient feels and com­
plains of and include pain, paraesthesia, numb­
IDENTIFICATION AND CLASSIFICATION ness, heaviness, weakness, stiffness, instability,
giving way, locking, tension, hot, cold, clammy,
OF UCM nausea and noise. The treatment of symptoms is
often the patient’s highest priority and is a primary
Figure 1.2 illustrates the link between UCM and short-term goal of treatment.
pain. Abnormal stress or strain that exceeds tissue Pain is frequently one of the main symptoms
tolerance can contribute to pain and pathology. that the patient presents with to the therapist and
The relationship between UCM and pain/ is inherently linked to movement dysfunction.
pathology will be explored further in Chapter 3. Contemporary research clearly demonstrates that
In this text the identification and classification individuals with pain present with aberrant
of movement faults are described in terms of site movement patterns (Dankaerts et╯al 2006a, 2009;
and direction of UCM. These movement faults Falla et╯al 2004; Ludewig & Cook 2000; Luoma­
will be discussed in Chapter 2 in relation to joki et╯al 2008; O’Sullivan et╯al 1997b, 1998).
changes in motor recruitment and strength (Com­ Research has demonstrated a consistent finding:
erford & Mottram 2001b, 2011). Scientific litera­ in the presence of pain, a change occurs in recruit­
ture and current clinical practice are linking the ment patterns and the coordination of synergistic
site and direction of UCM in relation to symp­ muscles. Individuals with pain demonstrate pat­
toms, disability, dysfunction, recurrence, risk and terns of movements that would normally be used
performance (Figure 1.3). only in the performance of high load or fatiguing
tasks (e.g. pushing, pulling, lifting weights) to
perform low load non-fatiguing functional tasks
(e.g. postural control and non-fatiguing normal
movements). Clearly UCM is a feature of many
Uncontrolled
musculoskeletal pain presentations and identify­
movement
ing and classifying these movement faults is
essential if therapists are to effectively manage
Abnormal symptoms by controlling movement faults.
stress or strain

Disability
Disability is the experienced difficulty doing
Pain Pathology activities in any domain of life (typical for one’s
age and sex group, e.g. job, household manage­
Figure 1.2╇ Uncontrolled movement: the link to pain and ment, personal care, hobbies, active recreation)
pathology due to a health or physical problem (Verbrugge &

5
 Kinetic Control: The management of uncontrolled movement

Jette 1994). Movement faults are related to disa­ treatment or therapy over a variable timeframe
bility. For example, Lin et╯al (2006) demonstrated and subsequent reassessment of dysfunction pro­
that changes in scapular movement patterns (in vides the basis of evidence-based practice. Reduc­
particular a loss of posterior tilt and upward rota­ tion of dysfunction is a primary short-term goal
tion) correlated significantly with self-report and of therapeutic intervention, although the patient
performance-based functional measures indicat­ is frequently symptom free before dysfunction
ing disability. The relationship between disability is corrected. Treatment should not cease just
and movement faults has been identified in many because the symptoms have disappeared, but may
other fields of physical therapy (e.g. neurological need to continue until no more dysfunctions are
and amputee rehabilitation). Indeed, in relation measurable.
to gait dysfunction, management and retraining The process of identifying and measuring UCM,
of UCM is a key factor in rehabilitation of people and linking UCM to musculoskeletal pain, and
with lower limb amputations using a prosthesis to changes in muscle function, is a developing
(Hirons et╯al 2007). area of active research in the field of pain and
Reduction of disability is the primary long-term movement dysfunction (Gombatto et╯al 2007;
goal of therapy or rehabilitation. Disability is Luomajoki et╯al 2007, 2008; Mottram et╯al 2009;
individual and what one person considers disa­ Morrissey et╯al 2008; Scholtes et╯al 2009; Roussel
bility another person might consider exceptional et╯al 2009a; van Dillen et╯al 2009). Muscle dys­
function. For example, an elite athlete’s disability function is most clearly apparent in people with
may be a function that most people do not have pain (Falla & Farina 2008; Hodges & Richardson
the ability to do, do not want to do or need to 1996; Hungerford et╯al 2003; Lin et╯al 2005). The
do. Movement dysfunction, however, can affect a changes in muscle function underlying pain can
person’s ability to function independently and present in two ways: 1) as altered control strat­
therefore decrease quality of life. The disablement egies (van Dillen et╯al 2009; O’Sullivan 2000);
process model in disease as well as in rehabilita­ and 2) as physiological peripheral muscle changes
tion is gaining recognition (Escalante & del (Falla & Farina 2008). Physiological changes
Rincon 2002; Verbrugge & Jette 1994) and retrain­ associated with muscle dysfunction are discussed
ing movement faults has been shown to improve further in Chapter 2, and altered control strategies
function (O’Sullivan et╯al 1997a; Stuge et╯al are discussed further in Chapter 3.
2004).
Recurrence
Dysfunction
The correction or rehabilitation of dysfunction
Dysfunction can imply disturbance, impairment has been shown to decrease the incidence of pain
or abnormality in the movement system. It can recurrence (Hides et╯al 1996; Jull et╯al 2002;
be objectively measured and quantified and/or O’Sullivan et╯al 1997a). This reinforces the need
compared against a normal or ideal standard for therapy to be aimed at correcting dysfunction
or some validated or calculated benchmark. in the management of musculoskeletal disorders
These impairments may present as weakness, and not just relieving symptoms.
stiffness, wasting, sensory–motor changes (includ­
ing proprioception changes, altered coordination
Risk of injury
and aberrant patterns or sequencing of muscle
recruitment) or combinations of several impair­ Evidence suggests history of injury is a predictive
ments. Dysfunction measurements include: joint factor for re-injury and therefore outcome meas­
range of motion (physiological or accessory); ures that are defined in terms of normal range of
muscle strength (isometric, concentric, eccentric, joint motion and muscle strength are inadequate
isokinetic, power and endurance); muscle length; to prevent recurrence (Mottram & Comerford
flexibility; stiffness; speed; motor control (recruit­ 2008). Making the link between UCM and pain
ment, inhibition, coordination and skill per­ is not new, but the concept of linking it to injury
formance); bulk (girth, volume, cross-sectional prevention is.
area); and alignment. Some recent research has highlighted the
A baseline measurement of dysfunction, fol­ potential for linking UCM to risk of injury. A
lowed by an intervention with some form of recent study on dancers identified two movement

6
 Uncontrolled movement Chapter |1|

control tests that may be useful for the identifica­ risk of injury and performance. This model has
tion of dancers at risk of developing musculo­ been developed through the analysis and synthe­
skeletal injuries in the lower extremities (Roussel sis of historical and contemporary research from
et╯al 2009a). Athletes with decreased neuromus­ many sources; however, it is not intended to be a
culoskeletal control of the body’s core (core sta­ comprehensive summary of the current level of
bility) are at an increased risk of knee injury knowledge surrounding movement analysis.
(Zazulak et╯al 2007). Indeed, there is now growing Kendall and colleagues (2005) described muscle
evidence that motor control and physical fitness function in detail. Their now classic text has been
training prevent musculoskeletal injuries (Roussel the foundation for assessment of muscle func­
et╯al 2009b), highlighting the importance for tion, especially with reference to the graded
therapists to be more knowledgeable about move­ testing of muscle strength and analysing the inter­
ment control and function. relationship of strength and function. Janda
(1986) had previously developed the concept of
muscle imbalance and patterns of dysfunction by
Performance
analysing the pattern of movement sequencing.
At present there is little published literature to His primary intervention was to increase extensi­
relate UCM to performance. However, anecdotal bility of short muscles. Sahrmann (2002) and
empirical evidence has shown that retraining co-workers further developed the concept of
movement faults can improve performance in muscle imbalance, again analysing patterns of
athletes. movement, and have developed a diagnostic
The movement dysfunctions associated with framework for movement impairments (direction
pain and disability have been shown to be revers­ susceptible to motion).
ible so there is a developing need to identify UCM The 1990s saw a huge advancement in the iden­
in relation to injury risk and performance and to tification of motor control dysfunction (Jull et╯al
objectively evaluate the outcome of retraining. 2008; Richardson et╯al 2004). Hodges (Hodges &
Cholewicki 2007) has developed a large body of
evidence linking motor control of deep muscles
A MODEL FOR THE   to spinal stability. O’Sullivan and co-workers have
provided objective measurements to support the
ASSESSMENT AND RETRAINING   links between altered muscle recruitment and
OF MOVEMENT FAULTS direction-related musculoskeletal pain (Dankaerts
et╯al 2006a). From this research a classification
Many clinicians and researchers have made a system based on diagnostic subgroups has been
significant contribution to the body of evidence proposed (Vibe Fersum et╯al 2009).
relating to movement, movement impairments Vleeming et╯al (2007) and Lee (2004) have
and corrective retraining. Some have described a developed the model of form and force closure
particular approach to assessment and retraining and have linked this to anatomical fascial slings.
and most support each other’s philosophies or McGill’s (2002) research has emphasised the
provide different pieces of the puzzle to enable importance of training more superficial muscles
an understanding of the ‘whole picture’. No single to stabilise the core during loaded and sporting
approach has all the answers but the therapist function and is often referred to as core streng­
who wants to provide ‘best practice’ for clients thening. All these clinicians and researchers
can benefit enormously from a synthesis of the have contributed important aspects to a com­
different approaches and concepts proposed to prehensive and integrated model of movement
date, along with the ongoing development analysis.
and integration of original ideas and applied
principles.
Alternative therapies
Figure 1.4 illustrates the development of the
movement analysis model. The movement analysis In the search to identify the defining characteris­
model identifies UCM in terms of the site (joint), tics of therapeutic exercise, a brief review and
direction (plane of motion) and recruitment analysis of many different approaches and con­
threshold (low or high) and further establishes cepts including alternative therapies is appropri­
links to pain, disability, dysfunction, recurrence, ate. Some of these approaches are supported by

7
 Kinetic Control: The management of uncontrolled movement

Assessment of muscle function

Kendall & McCreary
‘Traditional’ strengthening

Sahrmann Janda
Motor control research
and training model
(Hodges, Jull, Richardson) Flexibility

Muscle balance

Force closure model Analysis and development of

The Performance Matrix
(Mooney, Stoeckart, Movement analysis model
(Comerford & Mottram)
Vleeming, Lee) (Comerford & Mottram)

Model of clinical ‘Alternative’ therapies

movement analysis and ‘Core’ strengthening
movement dysfunction diagnosis (McGill)
• Sahrmann (Direction susceptible to motion)
• Comerford & Mottram — Kinetic Control
(Site and direction of uncontrolled movement) Task-specific training
• O’Sullivan and Dankaerts and functional integration
(Control impairment)

Figure 1.4╇ The development of the movement analysis model

clinical evidence (Emery et╯al 2010; Rydeard et╯al

Box 1.1╇ Useful alternative therapies in the
2006). Box 1.1 lists some useful approaches to
management of movement dysfunction
pain management and/or movement dysfunction
to explore. Many exercise approaches have either Tai chi
stood the test of time or their popularity suggests The Alexander technique
that people who practise them feel or function Yoga
better. Pilates
Whilst the various exercise concepts feature dis­ Physio ball (Swiss ball)
tinctive elements that characterise their approach,
Feldenkrais
there are features that are common to all
Martial arts
approaches (Box 1.2). These common features
GYROTONIC®
may contribute to good function and warrant
closer inspection and further investigation.
Breathing control is a key feature in many of these
therapies. The link between respiratory disorders

8
 Uncontrolled movement Chapter |1|

Box 1.2╇ Common features in and increased risk of development of back pain
alternative therapies has recently been established (Smith et╯al 2009)
and altered breathing patterns have been noted
• Multi-joint movements during lumbopelvic motor control tests (Roussel
• Slow movements et╯al 2009c).
• Low force movements
• Large range movements
• Coordination and control of rotation THE ASSESSMENT AND MANAGEMENT
• Smooth transition of concentric–eccentric movement OF UCM
• Awareness of gravity
• Concept of a ‘core’
Effective intervention requires the therapist to
• Coordinated breathing have a thorough understanding of the mech­
• Awareness of posture anisms of aberrant movement patterns, an ability
• Intermittent static hold of position to confidently diagnose and classify the move­
• Control of the centre of mass of one body segment ment faults and to manage these dysfunctions.
with respect to adjacent segments Guidelines for a comprehensive analysis of move-
• Proximal control for distal movement ment dysfunction have been described with factors
• Positive mental attitude the therapist needs to consider in Box 1.3

Box 1.3╇ Procedure for analysis of movement dysfunction

Uncontrolled movement: assessment and ii. personal factors (intra-individual) (e.g. lifestyle
retraining guidelines and behavioural changes, psychosocial
╇ 1. Assess, diagnose and classify movement in terms of attributes, coping skills).
pain and dysfunction from a motor control and a ╇ 5. Make links between uncontrolled movement and pain
biomechanical perspective. and other symptoms, dysfunction, recurrence, risk of
╇ 2. Develop a large range of movement retraining injury and performance.
strategies to establish optimal functional control. ╇ 6. Make a link between uncontrolled movement and
╇ 3. Use a clinical reasoning framework to prioritise the disability through the disablement process model.
clinical decision-making challenges experienced in ╇ 7. Make links between uncontrolled movement and
contemporary clinical practice. changes in motor control, strength, joint range of
╇ 4. Develop an assessment framework that addresses the motion, myofascial extensibility and functional
four key criteria relevant to dysfunctional movement: activities.
a. diagnosis of movement dysfunction ╇ 8. Identify the clinical priorities in terms of retraining
uncontrolled movement and mobilising restrictions of
i. site and direction of uncontrolled movement
normal motion.
ii. uncontrolled translation
╇ 9. Use a clinical assessment tool to identify deficiencies
iii. uncontrolled range of motion
and reassess improvements in motor control efficiency.
iv. myofascial and articular restriction
10. Integrate non-functional motor control retraining skills
v. aberrant guarding responses with functionally relevant movement.
b. diagnosis of pain-sensitive tissue(s) 11. Use other techniques and strategies (e.g. taping to
i. patho-anatomical structure support uncontrolled movement or facilitate motor
c. diagnosis of pain mechanisms relearning and strengthening).
i. peripheral nociceptive (inflammatory or 12. Use a clinical reasoning framework to identify priorities
mechanical) for rehabilitation, where to start retraining and how to
ii. neurogenic sensitisation be specific and effective in exercise prescription to
d. identification of relevant contextual factors develop individual retaining programs.
(Verbrugge & Jette 1994) 13. Know which way and how fast to progress, and know
i. environmental factors (extra-individual) (e.g. how to tell when retraining has achieved an effective
physical and social context) end-point independently of symptoms.

(Comerford & Mottram 2011)

9
 Kinetic Control: The management of uncontrolled movement

(Comerford & Mottram 2011). An understanding

Box 1.4╇ Ten key steps to understanding
of the inter-relationship of the elements of the
movement and pain
movement is needed alongside an understanding
of factors relating to normal movement, function ╇ 1. Classify the site and direction of uncontrolled
and dysfunction (Chapter 2). A sound clinical movement.
reasoning process underpins this process to ╇ 2. Relate the site and direction of uncontrolled
optimise the assessment and retraining strategy. movement to symptoms.
This process is described in the following ╇ 3. Relate assessment findings to disability.
section. ╇ 4. Identify the uncontrolled movement in terms of
‘uncontrolled translation’ and ‘uncontrolled range’,
and restrictions in terms of articular restriction and
myofascial restrictions.
THE CLINICAL REASONING PROCESS ╇ 5. Management plan for uncontrolled movement and
restrictions.
The efficient and effective management of UCM ╇ 6. Relate pain mechanisms to presentation.
in relation to symptoms, disability, dysfunction, ╇ 7. Consider tissues or structures that could be
contributing to the patient’s signs and symptoms.
recurrence, risk of injury and performance is
dependent on a comprehensive assessment. This ╇ 8. Assess for environmental factors and personal factors
(e.g. lifestyle and behavioural changes, psychosocial
should lead to a specific action plan for the
attributes and coping skills).
individual patient. Exercise protocols do have
╇ 9. Integrate other approaches or modalities as
a place in the management of musculoskeletal appropriate.
disorders. However, because of differences in
10. Consider prognosis.
presentation and diagnostic subgroups, effective
management is dependent on assessment analy­
sis and management planning. Exercise protocols
can be effective when dysfunction can be clearly
defined into diagnostic subgroups rather than 1╇ Classify the site and direction of UCM
based on pathology. The key to identifying these As indicated above, UCM is labelled in terms of
diagnostic subgroups lies in making the link its site and direction. These can be assessed using
between movement dysfunction and symptoms specific tests and evaluated with a clinical rating
(Comerford & Mottram 2001b; Sahrmann 2002; system (Chapter 3). Indeed, the assessment may
Vibe Fersum 2009). well identify more than one direction of UCM in
The following section presents a series of points the same site, or different regions. Some examples
to direct clinical reasoning for the integration of of the site and direction of UCM, as well as the
movement dysfunction assessment and planning appropriate test, are given in Table 1.1. The kinetic
of a targeted rehabilitation strategy for movement medial rotation test has been shown to be valid
dysfunction. (Morrissey et╯al 2008) and the standing bow test
is considered reliable (Luomajoki et╯al 2007;
Roussel et╯al 2009a). These tests are described in
The 10 point analysis and clinical detail in following chapters in this text.
reasoning framework for UCM
A clinical reasoning framework can be used to Table 1.1╇ Examples of the site and direction of
develop an understanding of the relationships uncontrolled movement
between movement, symptoms, dysfunction, and
other factors that influence the clinical reasoning SITE DIRECTION TEST
process (Comerford & Mottram 2011). Box 1.4 Scapula Downward Kinetic medial
presents 10 key steps to understanding movement rotation rotation test (KMRT)
and pain. The first five steps relate specifically to (T60 page 372)
the site and direction of UCM. The last five steps Forward tilt
relate to other factors necessary to develop a full
Lumbar Flexion Standing trunk lean
understanding of the dysfunction, as well as a spine test (T1 page 93)
management plan.

10
 Uncontrolled movement Chapter |1|

Chapter 3 of this text will explain the process

Box 1.5╇ Commonly used evaluation measures
used to identify the site and direction of UCM
for disability
using specific tests and evaluation with a system­
atic clinical rating system. Disability questionnaires
• For the cervical spine:
2╇ Relate UCMs to symptoms – Neck Disability Index (Vernon & Mior 1991)
The link between the site and direction of UCM – Bournemouth Neck Questionnaire (Bolton &
and the presenting symptoms needs to be estab­ Humphreys 2002).
lished to direct rehabilitation. For example, in the • For the lumbar spine:
shoulder, less upward rotation and backward tilt – Roland-Morris Disability Questionnaire (Roland &
(which relates to uncontrolled downward rota­ Morris 1983)
tion and forward tilt) of the scapula has been – Oswestry Disability Questionnaire (Fairbank et╯al
1980; Fairbank & Pynsent 2000).
identified in people with symptoms related to
shoulder impingement (Ludewig & Cook 2000). • For the shoulder:
Uncontrolled lumbar flexion has been identified – Shoulder Pain and Disability Index (Heald et╯al 1997;
Roach 1991)
in people with back pain (Luomajoki et╯al 2008;
– Disabilities of the Arm, Shoulder and Hand
Roussel et╯al 2009a).
Questionnaire (Hudak et╯al 1996).
Outcome measures commonly used to evaluate
• For the hip:
pain symptoms include the visual analogue scale
– Western Ontario and McMaster Universities
(VAS), the numerical rating scale (NRS), the
Osteoarthritis Index (WOMAC) (Bellamy 1988)
verbal numerical rating scale (VNRS) and the
– Hip Outcome Score (Martin & Philippon 2007).
quadruple VAS (Von Korff et╯al 1993).

3╇ Relate assessment findings to disability

The link between functional disabilities and Table 1.2╇ Uncontrolled movements and restrictions
movement faults needs to be identified. Func­ (Comerford & Mottram 2001b)
tional disabilities as a result of pain or movement Uncontrolled Intersegmental Range
dysfunction may relate to reduced ability to par­ movement translation
ticipate in work, leisure or relationships. For
Translation Physiological or
example, Long et╯al (2004) showed that subjects movement at a functional range
with back pain and a direction preference to pain- single motion of movement at
relieving postures (e.g. flexion provoked lumbar segment one or more
pain relieved by extension movements or pos­ motion segments
tures) who were treated with exercises matched
Restriction Articular Myofascial
to their direction preference had significant
improvements in outcomes of rapidly decreased +/− neurodynamic
pain, decreased medication use, reduced dis­ influence
ability, reduced depression and decreased work
interference.
A standard procedure to record disability is to
Mottram 2001a). This is shown in Table 1.2.
interview individuals about difficulties by means
Restriction can be described as articular restric­
of self-reports or proxy reports, with simple
tion and/or myofascial restriction (Comerford &
ordinal or interval scoring of degree of difficulty
Mottram 2001a). Neural sensitivity is linked with
(Verbrugge & Jette 1994). Examples of commonly
a neurophysiological response in the myofascial
used outcome measures are listed in Box 1.5.
system presenting as a myofascial restriction
(Coppieters et╯al 2001, 2002, 2006; Edgar et╯al
4╇ Identify the UCM and restrictions 1994; Elvey 1995).
UCM can be described in terms of uncontrolled Table 1.3 gives examples of UCM in terms of
translation (e.g. uncontrolled intersegmental translation and range at the shoulder girdle, and
translation) and uncontrolled physiological or joint and myofascial restrictions. Uncontrolled
functional range of movement (Comerford & anterior translation can be measured in people

11
 Kinetic Control: The management of uncontrolled movement

Table 1.3╇ Example of uncontrolled movement and 5╇ Management plan for UCM and
restrictions at the shoulder girdle restrictions
Uncontrolled Intersegmental Range Following the assessment of the UCM and restric­
movement translation tions, a management plan can be established. In
this text, we describe the retraining of the site and
Uncontrolled anterior Uncontrolled
translation at the scapula
direction of UCM but specific retraining strategies
glenohumeral joint forward tilt can also target the local stability muscle systems
(to control intersegmental translation) (Comer­
Restriction Articular Myofascial ford & Mottram 2001a) and the global muscle
Posterior translation Restriction of systems (to control range) (Comerford & Mottram
at glenohumeral joint medial rotation 2001a). Restrictions need to be mobilised with
(infraspinatus/ appropriate (manual) therapy, to regain extensi­
teres minor) bility of the myofascial systems (Comerford &
Mottram 2001a).
To cover all aspects of motor control assessment
and retraining, four principles of assessment and
Table 1.4╇ Example of uncontrolled movement and retraining are proposed (Comerford & Mottram
restrictions at the lumbar spine 2001a):
1. Control of direction: the assessment and
Uncontrolled Intersegmental Range
movement translation
retraining of the site and direction of
uncontrolled movement (see Chapters 3
Uncontrolled Uncontrolled and 4).
intersegmental lumbar flexion 2. Control of translation: specific assessment
translation (e.g.
and retraining strategies to target the local
at L4 or L5)
stability muscle system to control translation.
Restriction Articular Myofascial 3. Control through range: specific assessment
Restriction of Restriction in hip and retraining strategies to target the global
intersegmental flexion (hamstrings, stability muscle system to control range of
translation superficial gluteus movement.
maximus) 4. Control of extensibility: specific assessment
and retraining strategies to target the global
mobility muscle system to regain
extensibility and control the active
with shoulder pain (Morrissey 2005), as can lengthening of these muscles.
uncontrolled range, illustrated with uncontrolled In addition, manual therapy can address any
forward tilt (Lin et╯al 2005, 2006). Interestingly, articular restrictions and neural issues that may
this uncontrolled forward tilt (and loss of back­ cause muscle overactivity and restrictions. Elvey
ward tilt) corresponds to a decrease in serratus (1995) has described how ‘muscles protect nerves’
anterior activity, which confirms the role of ser­ so these issues need to be explored in relation to
ratus in producing backward tilting of the scapula any restrictions (for more detail see Butler 2000;
(and controlling forward tilting). Shacklock 2005).
Table 1.4 provides examples of UCM in terms Figure 1.5 illustrates the management plan
of translation and range at the lumbar spine. outline indicating the targeted interventions
UCM in the lumbar spine has been described in applied where uncontrolled translation, uncon­
terms of uncontrolled lumbar flexion (Dankaerts trolled range, UCM site or direction, articular or
et╯al 2006a; Luomajoki et╯al 2008; Sahrmann myofascial restriction are identified. An example
2002; Vibe Fersum et╯al 2009). Uncontrolled of a management plan developed for a person
lumbar flexion has been associated with either presenting with shoulder pain and dysfunction is
uncontrolled range of lumbar flexion relative to illustrated in Figure 1.6; and an example of a
hip flexion, or abnormal segmental initiation of management plan developed for a person pre­
lumbar motion during forward bending and senting with back pain and lumbar dysfunction
other flexion-related activities. is given in Figure 1.7.

12
 Uncontrolled movement Chapter |1|

Uncontrolled translation Uncontrolled range

Target local muscle system Target global muscle system

Site and direction of

uncontrolled movement

Retrain site and direction of

uncontrolled movement

Articular restriction Myofascial restriction

Manual therapy Regain extensibility of global mobility

muscle system and address any neural
sensitivity

Figure 1.5╇ The management planning outline

Uncontrolled translation Uncontrolled range

Target local muscle system Target global muscle system

Retraining of the glenohumeral Retraining of the scapula
local stability muscles to global stability muscles to
retrain control of translation at Site and direction of retrain control of range at the
the glenohumeral joint (e.g. uncontrolled movement scapulothoracic joint (e.g.
the rotator cuff) retrain efficiency of serratus
Retrain site and direction of anterior to control anterior tilt
uncontrolled movement and produce posterior tilt)

(e.g. site: scapulothoracic, direction:

forward tilt)

Articular restriction Myofascial restriction

Manual therapy Regain extensibility of global mobility muscle

system and address any neural sensitivity
Articular mobilisation of joint restrictions
(e.g. anterior posterior glide at the Regain extensibility of infraspinatus
glenohumeral joint)

Figure 1.6╇ The management plan developed for a person with shoulder pain and uncontrolled scapula forward tilt

6╇ Relate pain mechanisms to presentation movement control (e.g. the influence on proprio­
Pain mechanisms can have a significant influence ception, allodynia and motor control). Useful
on movement control and consideration of screening tools for neuropathic pain could include
changes within the nervous system is a key com­ the S-LANSS (Bennett et╯al 2005) or the pain
ponent of the clinical reasoning process (for more DETECT questionnaire (Freynhagen et╯al 2006),
detail see Breivik & Shipley 2007; Butler & Moseley while the McGill Pain Questionnaire (Melzack
2003). It is essential to consider the influence of 1975; Melzack & Katz 1992) also evaluates the
mechanical nociceptive or inflammatory pain in affective aspects of pain for a patient.

13
 Kinetic Control: The management of uncontrolled movement

Uncontrolled translation Uncontrolled range

Target local muscle system Target global muscle system

Retraining of the lumbar Retraining of the lumbar
spine local stability muscles global stability muscles to
to retrain control of Site and direction of retrain control of range (e.g.
translation (e.g. the uncontrolled movement retrain efficiency of
integrated inner cylinder, superficial multifidus and
transversus abdominis, Retrain site and direction of spinalis to control flexion and
segmental lumbar multifidus, uncontrolled movement produce extension)
posterior fasciculi of psoas,
diaphragm, pelvic floor) (e.g. site: lumbar, direction: flexion)

Articular restriction Myofascial restriction

Manual therapy Regain extensibility of global mobility muscle

system and address any neural sensitivity
Articular mobilisation of joint restrictions
Regain extensibility of hamstrings and
superficial gluteus maximus

Figure 1.7╇ The management plan developed for a person with back pain and uncontrolled lumbar flexion

7╇ Consideration of tissues or structures objectively assessed (and reassessed) with valid
contributing to symptoms and reliable questionnaires such as the Pain
Coping Inventory (PCI; Kraaimaat & Evers 2003),
The site and direction of UCM may match the
Tampa Scale of Kinesiophobia (TSK; Swinkels-
pathology identified. For example, people with a
Meewisse et╯al 2003; Vlaeyen et╯al 1995), Fear
shoulder impingement demonstrate UCM at the
Avoidance Beliefs Questionnaire (FABQ; Waddell
scapula (Morrissey 2005). Abnormal quality of
1998) and the Pain Self-Efficacy Questionnaire
motion in spinal lumbar segments has been dem­
(PSEQ; Nicholas 2007; Nicholas et╯al 2008).
onstrated to be associated with spondylolisthesis
Once the site and direction of UCM have been
pathology (Schneider et╯al 2005). The link
established, effective rehabilitation should ensure
between tissue stress resulting in pathology and
that movement dysfunction is addressed through­
abnormal range or quality of movement is becom­
out functional tasks. Control of movement during
ing more evident. The therapist needs to find a
functional activities, and awareness of the UCM
link between the UCM and any presenting
during posture, daily activities, sport and training
pathology.
programs should be promoted. For example, a
person with uncontrolled scapula downward
8╇ Assess for environmental and rotation needs to be aware of this movement
personal factors fault during daily activities such as reaching for a
cup in a cupboard. A person with uncontrolled
Personal factors (e.g. lifestyle and behavioural lumbar flexion needs to be aware of this move­
changes, psychosocial attributes, coping and ment fault when bending forwards to tie up their
activity accommodations) and environmental shoelaces.
factors (e.g. medical care and rehabilitation, med­
ications and other therapeutic regimens, external
supports, physical and social environment) 9╇ Integrate other approaches or modalities
should also be assessed. Personal factors com­ There are many other therapeutic modalities that
monly assessed within the context of physical can influence the correction of movement faults.
therapy include items such as depression, anxiety, Table 1.5 details some examples. This is not
coping skills and cognition. These can be intended to be an exhaustive list but illustrates

14
 Uncontrolled movement Chapter |1|

Table 1.5╇ Examples of therapeutic modalities that can influence the correction of movement faults

OTHER THERAPEUTIC EXAMPLES

APPROACHES
Pathophysiological approaches Ice, heat, electrotherapy, medication
Articular approaches Joint mobilisation and manipulation (Maitland et╯al 2005; Cyriax 1980;
Kaltenborn et╯al 2003)
Ergonomic and environmental factors Work place assessment, postural advice
Neurodynamic approaches Neurodynamic mobilisation (Butler 2000; Shacklock 2005)
Sensory-motor approaches Neuromuscular facilitation (Rood in Goff 1972), Bobath ‘normal movement’
(Bobath 1990), neurofunctional training (Carr & Shepherd 1998),
neurosensory approach (Homstøl 2009)
Soft tissue approaches Massage therapy (Chaitow 2003)
Psychosocial approaches Behavioural evaluation and therapy (Waddell 1998; Woby et╯al 2008)
Biomechanical approaches Taping, orthotics, bracing

useful adjuvant modalities in retraining UCM, and work disability proved to be the most
managing pain, mobilising restrictions or treating consistent predictors for poor recovery in these
pathology. studies.
The relative influence of factors beyond physi­
10╇ Consider prognosis ological processes is a contemporary research
subject and there is a growing body of evidence
Although the management of symptoms has been indicating that socio-demographic, physical and
the primary aim in the treatment of musculoskel­ psychological factors strongly affect short- and
etal disorders, research has also demonstrated long-term outcomes. These factors must be taken
links between UCM and dysfunction, disability into consideration when establishing a realistic
and the recurrence of symptoms. It is therefore timeframe for when dysfunction, symptoms and
appropriate that dysfunction and disability are disability could be expected to improve and by
also considered, along with symptoms, when pro­ how much.
viding a prognosis for recovery in the manage­
ment of musculoskeletal disorders. The timeframe
for expected improvement in symptoms should
be considered independently of the timeframes CLINICAL REASONING IN A DIAGNOSTIC
for recovery of dysfunction and disability when
FRAMEWORK
making prognostic judgments for recovery.
Physiological tissue repair timelines have been
well researched and are reasonably well defined. As noted in Box 1.3, when a patient presents with
In more acute (less than 6 weeks) conditions, neuromusculoskeletal pain and dysfunction, it is
these provide a useful guideline. In more chronic good clinical practice to assess and identify four
(more than 12 weeks) conditions, other prognos­ key criteria:
tic factors become more important. A systematic 1. diagnosis of movement dysfunction
review on prognostic factors in whiplash- 2. diagnosis of pain-sensitive or pain-generating
associated disorders established that factors structures
related to poor recovery included: female gender; 3. diagnosis of presenting pain mechanisms
a low level of education; high initial neck pain; – peripheral nociceptive and neurogenic
more severe disability; higher levels of somatisa­ sensitisation
tion and sleep difficulties (Hendriks et╯al 2005; 4. evaluation and consideration of contextual
Scholten-Peeters et╯al 2003). Neck pain intensity factors.

15
 Kinetic Control: The management of uncontrolled movement

1╇ Diagnosis of movement with chronic pain suggests it is more appropriate

dysfunction (site and direction of to explore factors affecting impairment of func­
tion and participation than to attempt to diag­
uncontrolled motion)
nose specific structures or tissues as a source of
The initial priority is to identify the site and direc­ nociception.
tion of UCM that best correlates with the patient’s
presenting mechanical symptoms. In complex
3╇ Clinical diagnosis of presenting
presentations, there is frequently more than one
site of UCM. When this is the case, it is useful to pain mechanisms
identify whether one site is the site of primary It is essential to have an understanding of the
dysfunction and whether the other site is com­ relevant pain mechanisms contributing to any
pensating for the primary one. individual’s pain presentation. In a person with
If there are obvious restrictions that are causing chronic or recurrent pain it is common to find
compensatory UCM, it is very effective for the different mechanisms contributing to their symp­
therapist to work to achieve normal mobility of toms. Melzack’s (1999) neuromatrix theory of
these restrictions early in the management plan pain proposes that pain is a multidimensional
(see Chapter 4). experience produced by characteristic ‘neurosig­
The therapist should also identify if there is a nature’ patterns of nerve impulses generated by
priority to retrain local stability muscle function a widely distributed neural network in the brain.
early or if this can be retrained later in the reha­ It proposes that the output patterns of the neu­
bilitation process. Similarly, the therapist should romatrix activate perceptual, homeostatic, and
identify any contributing muscle imbalance issues behavioural responses after injury, pathology
related to the dysfunction, such as altered length or chronic stress. The resultant pain experience
and recruitment relationships between mono- is produced by the output of a widely distributed
articular stabiliser muscles and multi-articular neural network in the brain rather than solely by
mobiliser muscles. If these imbalances are identi­ sensory input evoked by injury, inflammation or
fied, the global stabiliser muscle recruitment effi­ other pathology (Moseley 2003). Therefore, pain
ciency should be retrained to recover active is a multi-system output that is produced when
control through the full available range of motion, a cortical pain neuromatrix is activated.
and the global mobility muscle extensibility Ideally, an attempt should be made to deter­
should be restored. mine the relevant proportions of these mech­
anisms; that is, the degree to which peripheral
nociceptive (mechanical/inflammatory) elements
2╇ Clinical diagnosis of pain-sensitive contribute to the pain experience and the degree
or pain-generating structure(s) to which neurogenic sensitisation is present.
Behavioural, social and psychosomatic influences
The therapist should identify the structure or further contribute to the multidimensional
tissue that is the source of the symptoms or pain nature of chronic and recurrent pain. The
that the patient complains of. Patients who dominant mechanisms need to be addressed
present with a chronic or recurrent condition fre­ as a priority. A multidisciplinary and multidi­
quently report more than one tissue contributing mensional approach can be more effective in
to the pain experience. The clinical reasoning managing symptoms, both in the short and long
process that identifies a variety of pain-sensitive term.
tissues requires a thorough understanding of
tissue anatomy and physiology, a knowledge of
the mechanism of injury (if there is one) and an 4╇ Evaluation and consideration of
understanding of the typical responses of differ­
contextual factors
ent tissues to stress and strain and injury. All avail­
able therapeutic skills, tools or modalities can be The therapist should assess for the influence of
utilised to best provide an optimal environment contextual factors – both personal and environ­
to allow and promote tissue healing and to mental – on the patient’s signs and symptoms
control or manage the presenting signs and symp­ and explore how these might relate to UCM
toms. Contemporary clinical reasoning in patients (Figure 1.8).

16
 Uncontrolled movement Chapter |1|

Health condition
Four key criteria within clinical reasoning framework
(disorder or disease)
1. Diagnosis of movement dysfunction
– site and direction of uncontrolled motion.
2. Diagnosis of pain-sensitive tissue(s) (linked to pathology).
3. Diagnosis of pain mechanisms
– peripheral nociceptive
– neurogenic sensitisation.
4. Evaluation and consideration of contextual factors. Body functions
Activities Participation
and structures
Figure 1.8╇ Four key criteria within a clinical reasoning
framework

THE DISABLEMENT  
ASSESSMENT MODEL
Environmental Personal
factors factors
Researchers and clinicians have become increas­
ingly aware that there is frequently little corre­ Figure 1.10╇ Model of functioning and disability,
lation between pathology and (functional) International Classification of Functioning Disability and
limitations in activities and participation. This is Health, ICF. World Health Organization, Geneva, 2001
even more evident for chronic complaints. Con­
temporary clinical reasoning has seen a paradigm
shift from a biomedical to a bio-psychosocial functions and ADL are limited. These are defined
model. For instance, in the analysis of movement as ‘disabilities’ and can be evaluated by valid and
dysfunction model presented in Box 1.3, a modi­ reliable questionnaires and performance tests.
fied version of a disablement process model This provides the opportunity to reassess the
(Verbrugge & Jette 1994) is included. Such a disa­ patient in an objective way and evaluate efficacy
blement assessment model uses the same theo­ of interventions. Within the clinical reasoning
retical construct as a starting point for assessment process the therapist evaluates the four factors in
and treatment (Figure 1.9). the diagnostic framework criteria (see Figure 1.8),
In a disablement process model, the therapist, and relates these to the functional limitations.
together with the patient, determines which In this partially reversible system, the functional
limitations are continuously influenced by extra-
and intra-individual factors. These existing and
potential risk factors are the reason why path­
ology presents as or evolves into impairments.
Using a clinical decision-making process, the
therapist is able to assess and determine if a
Disability Pathology
normal or aberrant course is present.
Different terminology is used in the Interna­
Risk tional Classification of Functioning, Disability,
Intra-individual and Health (ICF 2001) model of functioning and
factors
factors
disability (Figure 1.10). However, essentially the
intra-individual factors in the disablement process
Functional model are comparable with the ICF’s personal
Impairments
limitations factors and the extra-individual factors are com­
parable with the environmental factors.
The rehabilitation problem solving (RPS) form
Extra-individual (Figure 1.11) was developed to address patients’
factors perspectives and to enhance their participation
in the decision-making process during their
Figure 1.9╇ Disablement assessment model: modified from assessment. The RPS form is based on the
Disablement Process Model (Verbrugge & Jette 1994) ICF model of functioning and disability and

17
 Kinetic Control: The management of uncontrolled movement

In the ICF model the horizontal dimension of

Disorder a health status or profile is illustrated as being
influenced by elements in the vertical dimension.
The ICF model could be considered a method of
classification, describing a health condition at a
particular moment, such as a picture or ‘freeze
Patient

frame’. In contrast, the disablement process rep­

resents constructs within the ICF model under the
constant influence of risk factors and hence could
Body structures/ be described as more like a ‘film’.
Activities Participation
functions To summarise, ‘health’ can be described in
terms of:
• health condition (using ICF terminology)
Therapist

• course (normal or aberrant)

• prognostic profile
• patient’s perspective.
Clinical decision-making should start from the
Personal Environmental patient’s perspective and interventions should be
factors factors primarily aimed at those aspects of impairment
that have a direct bearing on disability and/or
functional limitations. In the subjective examina­
tion, the patients will define their perspective in
terms of disability and functional limitations; for
Figure 1.11╇ The rehabilitation problem solving form,
example, the inability (due to low back pain) to
adapted from Steiner et╯al 2002
bend over from standing to tie shoelaces or the
inability (due to shoulder pain) to reach into a
cupboard above the shoulders. These self-reported
facilitates the analysis of patient problems, focus­ symptoms are explored further within the phy­
ing on specific targets, and relating salient disa­ sical examination to inform the clinical decision-
bilities to relevant and modifiable variables. making process. For example, if patients with
This form can include the diagnostic criteria low back pain are unable to actively control
within the clinical reasoning framework described movements of the low back, especially flexion
in Figure 1.8 in order to assess the key criteria control while performing a waiters’ bow (Luoma­
that relate to the functional limitations. This joki 2008), then clinicians should direct their
process identifies links between factors in the intervention towards correcting the neuromus­
diagnostic framework and subsequent functional cular impairment underpinning this. Similarly, if
limitations so that the mechanism behind the patients with shoulder pain are unable to actively
dysfunction can be addressed to optimise efficacy control the (re-) positioning of the scapula during
of intervention. The form in Figure 1.11 can functional movements (Tate et╯al 2008; von
include the diagnostic framework as described in Eisenhart-Rothe 2005), then clinicians should
Figure 1.8. aim their intervention strategy at regaining this
The essence of both the ICF model of function­ control. Therapists should not solely focus on
ing and disability and the RPS form is that an addressing an isolated pathology, but use frame­
individual’s (dys-)functioning or disability repre­ works such as the disablement assessment
sents an interaction between the health condition model to facilitate effective intervention. The
(e.g. diseases, disorders, injuries, traumas and all link between specific movement retraining and
factors in the diagnostic framework) and the con­ improvement in functional tasks is now well
textual factors (i.e. ‘environmental factors’ and supported by evidence (Jull et╯al 2009; Roussel
‘personal factors’). The interactions of the com­ et╯al 2009b).
ponents in the model are two-way, and interven­ Practitioners need to have the skills to identify
tions in one component can potentially modify and retrain movement faults. These skills should
one or more other components. be integrated into current practice and the patient

18
 Uncontrolled movement Chapter |1|

managed in a holistic way with consideration of neuromusculoskeletal disorders. To assist in this

all aspects of the human motion system, and the reasoning process the anatomical and physiologi­
influence of both intra- and extra-individual cal principles are reviewed in Chapter 2 and how
factors. An understanding of how UCM can influ­ pain, dysfunction and pathology can effect UCM
ence pain is essential in the management of is explored in Chapter 3.

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