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Update of Concepts Underlying
Movement System Syndromes

Presented by: Zinat Ashnagar
An important physiological system of the body
is the movement system and that
dysfunctions of this system can be classifie...
The syndromes for orthopedic conditions causing
musculoskeletal pain are:

(1) based on the movement directions or
alignme...
Key concepts of the movement system that
contribute to the development of pain
syndromes are proposed.
Understanding key c...
1. The majority of musculoskeletal pain
syndromes both acute and chronic are the
result of cumulative microtrauma from str...
• Musculoskeletal pain is the result of a progressive
condition that is related to lifestyle and
degenerative changes in t...
2. The site (joint region) that is moving or stressed
in a specific direction is the site of pain
generation.

3 . The str...
4. Hypermobility, usually accessory motion
hypermobility, is the cause of the pain.
Therefore the offending motions are mo...
5. The body follows the law of physics and takes
the path of least resistance for motion, which
contributes to the hypermo...
6. The path of least resistance is affected by
variation in the stiffness or relative flexibility
of tissues attached to a...
7. The predisposition of a joint to move readily
in a specific direction contributes to the
development of a movement patt...
9. The way everyday activities are performed is
the critical issue.
For efficiency, the body establishes a pattern
of moti...
10. The relative participation of some muscle
groups (disuse or overuse) is the result of
movement patterns and biomechani...
11. Muscle performance is determined by the
pattern of movement.
Correction of faulty patterns is best
achieved by trainin...
12 . The human body is highly capable of motor
equivalency, which is the ability to realize the
same motor outcome with di...
13 . The most important treatment is correcting
the movement pattern that is causing the tissue
to become painful or irrit...
14. The critical issue is how an activity is
performed not just performing the activity.
• Proper movement strategy can op...
15 . An exercise is not effective unless the exercise
limits or corrects the movement at the painful
joint and produces th...
16. If a muscle contributes to the impaired
motion of a painful joint, stretching the muscle
will not stop the motion caus...
If the tibiofemoral rotation is controlled and the
hip joint does not medially rotate or abduct, the
tensor fascia lata il...
18. All neuromuscular adaptations can contribute
to and correct problems. Thus "indiscriminate"
core strengthening exercis...
20. MS syndromes consist of multiple contributing
factors or impairments that combine to produce
the principal movement im...
21. The examination must include tests and
assessments of all regions of the body,
including a determination of how all re...
22 . The movement system needs to be periodically
examined, beginning in childhood and continuing
into old age to:
(1) eva...
THE GENERAL PREMISE: MOVEMENT
SYSTEM IMPAIRMENTS CAUSE
PAIN SYNDROMES
The belief is that correction or modification of
fac...
A major premise of the model is that pain most
often arises from tissues that are stressed by
subtle impairments in moveme...
The activities an individual performs require
movements of multiple joints that are
contiguous, in the same kinematic chai...
Our research supports the premise that the ease
and rapidity with which a joint moves are more
important factors in a move...
These latter factors may have contributed to the
initial development of the flexibility of the
joint causing the pain, but...
The motion contributing to the stress occurs
during the first few degrees of motion or with
initiation of an activity.
The...
Example:
Lumbopelvic motion with lower extremity
motions in patients with low back pain is an
example of abnormal early on...
The predisposition of these joints to move
readily contributes to the frequency of their
movement and furthers the tendenc...
In most joints, the accessory motion impairment is
not clinically observable, thus the physiological
motion associated wit...
As a result, movement in the offending direction
has been associated with pain and is often
impaired
(deviates from the ki...
Correcting the pattern or stopping the movement
in the painful direction is the focus of
treatment because the symptoms ar...
The complete description of all the impairments
evident as signs or causing symptoms that
contribute to the offending or p...
THE HUMAN MOVEMENT SYSTEM

37
The human movement system is a physiological
system of the body that produces motion of the
body or its component parts, o...
Kinesiopathological model
Kinesiopathological refers to how movement
that is excessive, imprecise, or insufficient
contrib...
40
ELEMENTS OF THE MODEL
Base Elements
Modulator Element
Support Elements

41
Base Elements
The components of the base elements are the
muscular and skeletal systems.
These systems are considered the ...
Modulator Element
The component of the modulator element is the
nervous system.
The term modulator is used to emphasize th...
Support Elements
The components of support elements are the
cardiovascular, pulmonary, and metabolic
systems.
These system...
BIOMECHANICS
The model indicates that biomechanics is an
interface between muscular and neurological
activity.
The pattern...
TISSUE ADAPTATIONS
• Inducers
• Modifiers
–Age, Gender, Tissue Mobility,
Anthropometrics, Activity Level

46
47
TISSUE ADAPTATIONS
The dynamic and biological characteristics of the
components of the movement system enable
tissues to a...
TISSUE ADAPTATIONS
For example, alterations in muscle length,
strength, and stiffness can affect the precision
in joint mo...
Inducers
The repeated movements and sustained
alignments associated with everyday activities
are the inducers of the tissu...
Although the physically active person will
improve and increase the size of muscles and
connective tissues, at the same ti...
The repetitive use of specific segments of the
body combined with high and rapid force
development can exceed tissue toler...
Alignments maintained for prolonged periods
can induce changes in muscle length.
Without activity, muscle and connective t...
Modifiers
The modifiers are factors such as age, sex,
height, weight, and genetic characteristics that
include predisposit...
Age
In young individuals, tissues are more extensible
and joints more flexible than in older
individuals.

Thus the offend...
In older individuals or those with a chronic
condition, the movement impairments are
usually more subtle so that the exami...
Gender
Studies of patients with low back pain have
demonstrated a difference in the pain-inducing
movements and alignments...
Tissue Mobility
Of the genetic factors, benign joint hypermobility
syndrome is one of the important problematic
characteri...
Maintaining good alignment and precise motion is
more difficult if the individual is hypermobile
as compared to individual...
Anthropometries
Body proportions are also a contributing factor in
predisposing an individual to musculoskeletal
problems....
Activity Level
The activity level can range from
excessive, which tends to exacerbate the
development of musculoskeletal p...
The therapist needs to also factor into the
examination whether the pain condition is
from excessive activity that can be ...
Activity Level
In the former situation, part of the treatment may
be to decrease the demands on specific muscles
and incre...
Tissue Adaptations of the Skeletal System
Although skeletal structures seem relatively
fixed, bone is a dynamic tissue tha...
Dynamic conditions are correctable and
sometimes easily modifiable, whereas the
static conditions are relatively permanent...
Wolff (1836- 1902) proposed that
"changes in the form and function of bones, or
changes in function alone, are followed by...
In mature bone in which the general shape is
established and no changes are made in the
distribution of forces, the change...
Changes in the shape and alignment of the joint
also affect the characteristics of the ligaments
and the distribution of f...
The initial observations of a patient with pain
problems should be an assessment of the
alignment and the participation of...
Tissue Adaptations of the Nervous
System
Motor control plays a key role in musculoskeletal
pain.
there are two general the...
1. One theory is that pain causes the change in
movement patterns and alters motor control.
2. The other theory is that ch...
But the major question is, "What precipitated the pain
episode? “

As suggested by the model, the repeated
movements and s...
Both concepts require that treatment emphasize
correction of the movement patterns and the
altered motor control.
If alter...
Clinical experience with correcting movement
patterns and alleviating symptoms supports
the belief that the altered moveme...
A prevailing characteristic of the human body is
to reduce the degrees of freedom when
establishing a movement pattern, th...
When considering the factors contributing to
musculoskeletal pain problems, the patterns of
recruitment and derecruitment ...
Tissue Adaptations of the Muscular
System
The adaptations of muscle are changes in:
( 1 ) length, both increased and decre...
78
A, Patient's hip joint angle is almost 90 degrees with
his knees flexed.
B, With passive knee extension to only 45 degrees...
Relative Stiffness/Flexibility
Muscle stiffness is defined as the change in
tension per unit change in length.
Stiffness r...
When a muscle is being elongated and there is
movement at the proximal attachment of the
muscle, the best explanation is t...
82
A, The patient's pelvis is tilted posteriorly, and his
lumbar Spine is flexed when his knee is passively
fully extended.
T...
The concept is that the hamstrings and the
tissues (muscles and ligaments) of the lumbar
spine are springs in series.
When...
85
The earlier the movement at this joint the greater
the indication of the lack of "stiffness or
stability“ of the joint.
A ...
Titin attaches the myosin filament to the Z-line of
the sarcomere and there are 6 titin proteins for
every myosin filament...
88
Realizing that an intrinsic property of the human
body is the minimization of energy expenditure
when inactive or even whe...
The passive tension provided by muscle plays an
important role in joint stability, alignment, and
in some situations contr...
Good alignment is indicative of balanced passive
tension of muscles attaching to a joint or
skeletal segment, such as the ...
The relative stiffness/flexibility properties are
often the contributing factor to:
(1) alignment impairments,
(2) one joi...
Muscle Length Adaptations
Increased length
Small changes in muscle length are changes in
passive resting tension,while gre...
Decreased length
The development of true muscle shortness is
associated with loss of sarcomeres in series in
muscle fibers...
For example:
If the decreased ROM of hip flexion with the
knee extended is only 10 to 15 degrees and
can be regained by st...
In contrast, if the hamstring muscles are limiting
the motion of the joint by 30 to 40 degrees, then
the most likely expla...
Stretching should not be forceful because a
reasonable explanation for this condition is
that the muscle has lost sarcomer...
Although muscles can become shortened by loss
of sarcomeres in series, this is not the most
common problem contributing to...
Muscle Performance
Performance includes timing, length, passive
tension, and the ability to generate active
tension and en...
Manual muscle testing (MMT) can be used to
discern whether the muscle is:
(1) weak because of atrophy and the lack of
sarc...
(2) Strained because of being subjected to forces
that have torn or disrupted the Z-lines of the
sarcomeres and unable to ...
Joint Mobility
As depicted in the model, the problematic
outcome of the tissue adaptations is the
development of a relativ...
Hypothetically, the hypermobility is an accessory
or arthrokinematic motion rather than
physiological or orthrokinematic m...
Thanks for your attention

104
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Update of Concepts Underlying Movement System Syndromes

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Concepts Underlying Movement System Syndromes which was defined by Sahrmann

Update of Concepts Underlying Movement System Syndromes

  1. 1. Update of Concepts Underlying Movement System Syndromes Presented by: Zinat Ashnagar
  2. 2. An important physiological system of the body is the movement system and that dysfunctions of this system can be classified into syndromes. These syndromes provide direction for diagnosis, treatment, and pursuing underlying kinesiopathology. 2
  3. 3. The syndromes for orthopedic conditions causing musculoskeletal pain are: (1) based on the movement directions or alignments that cause pain (2) associated with movement impairments (3) improved by correction of the movement impairment that decreases or eliminates the symptoms. 3
  4. 4. Key concepts of the movement system that contribute to the development of pain syndromes are proposed. Understanding key concepts and their application to patients with musculoskeletal pain will enable the practitioner to develop an appropriate movement system (MS) diagnosis and treatment program. 4
  5. 5. 1. The majority of musculoskeletal pain syndromes both acute and chronic are the result of cumulative microtrauma from stress induced by repeated movements in a specific direction or from sustained alignments, usually in a nonideal position. 5
  6. 6. • Musculoskeletal pain is the result of a progressive condition that is related to lifestyle and degenerative changes in tissues. • The transition from tissue microtrauma to macrotrauma is influenced by a variety of intrinsic (genetics, sex, and age) and extrinsic (amount and type of fitness, work activity) factors. • These repeated movements and sustained alignments occur during the performance of daily activities. 6
  7. 7. 2. The site (joint region) that is moving or stressed in a specific direction is the site of pain generation. 3 . The stress occurs most often during the initiation or earliest phase of the motion rather than at the end of the physiological motion. 7
  8. 8. 4. Hypermobility, usually accessory motion hypermobility, is the cause of the pain. Therefore the offending motions are most often very subtle, and the more chronic the condition or the older the subject, the more subtle the motion. 8
  9. 9. 5. The body follows the law of physics and takes the path of least resistance for motion, which contributes to the hypermobility. 9
  10. 10. 6. The path of least resistance is affected by variation in the stiffness or relative flexibility of tissues attached to adjoining joints. Most activities involve movement across several contiguous joints that are arranged in series and one of these joints moves more readily in a specific direction than the other joints. 10
  11. 11. 7. The predisposition of a joint to move readily in a specific direction contributes to the development of a movement pattern. 8. Insufficient muscle stiffness (because of greater relative flexibility) and increased resting muscle length are more problematic adaptations than specific muscle weakness and shortness. 11
  12. 12. 9. The way everyday activities are performed is the critical issue. For efficiency, the body establishes a pattern of motion that reinforces the relative hypermobility and participation of specific joints, including the joint that moves the most readily in a specific direction. Hypermobility is reinforced and becomes habitual. 12
  13. 13. 10. The relative participation of some muscle groups (disuse or overuse) is the result of movement patterns and biomechanical influences. • In the swayback posture, if the pelvis is tilted posteriorly and the hip is extended, the use of the gluteus maximus muscle is minimized. 13
  14. 14. 11. Muscle performance is determined by the pattern of movement. Correction of faulty patterns is best achieved by training the correct pattern and not by isolated "strengthening" of a muscle. 14
  15. 15. 12 . The human body is highly capable of motor equivalency, which is the ability to realize the same motor outcome with different effectors. Stopping the offending motion at the joint that moves the most readily and redistributing the motion to other adjoining segments expands one's ability to vary patterns of motion. 15
  16. 16. 13 . The most important treatment is correcting the movement pattern that is causing the tissue to become painful or irritated rather than directing treatment to the affected tissue. 16
  17. 17. 14. The critical issue is how an activity is performed not just performing the activity. • Proper movement strategy can optimize performance and minimize tissue injury. Faulty strategy can compromise performance and lead to tissue injury. 17
  18. 18. 15 . An exercise is not effective unless the exercise limits or corrects the movement at the painful joint and produces the desired appropriate movement at adjoining joints. • Redistributing the movement to appropriate joints is the goal. • The same exercise can be used for contrasting problems, depending on the instruction and performance (quadruped rocking to either increase or decrease lumbar flexion). 18
  19. 19. 16. If a muscle contributes to the impaired motion of a painful joint, stretching the muscle will not stop the motion causing pain, but stopping the motion may stretch the muscle. If the tensor fascia lata-iliotibial band contributes to tibiofemoral rotation, stretching the band will not stop the impaired motion during the stretch or functional activities. 19
  20. 20. If the tibiofemoral rotation is controlled and the hip joint does not medially rotate or abduct, the tensor fascia lata iliotibial band can be stretched during walking. 17. Training movement patterns will induce appropriate muscular and biomechanical adaptations that will reinforce the development of optimal neuromuscular action. 20
  21. 21. 18. All neuromuscular adaptations can contribute to and correct problems. Thus "indiscriminate" core strengthening exercises can become a cause of pain as readily as a lack of muscle strength can contribute to pain problems. 19. Every patient with musculoskeletal pain should have a MS diagnosis. 21
  22. 22. 20. MS syndromes consist of multiple contributing factors or impairments that combine to produce the principal movement impairment that is the cause of the symptoms. The syndrome is named for this principal impairment. • The contributing factors are movement and neuromusculoskeletal adaptations. • A systematic examination is required to identify all of the contributing factors. 22
  23. 23. 21. The examination must include tests and assessments of all regions of the body, including a determination of how all regions affect the movement of the painful joint because of the biomechanical interactions of the human body. 23
  24. 24. 22 . The movement system needs to be periodically examined, beginning in childhood and continuing into old age to: (1) evaluate optimal tissue development (2) ascertain the progression of degenerative changes (3) determine and guide exercises to maintain the health of the cardiovascular and metabolic systems. • Guiding exercise for appropriate use can prevent disuse, misuse, or overuse. 24
  25. 25. THE GENERAL PREMISE: MOVEMENT SYSTEM IMPAIRMENTS CAUSE PAIN SYNDROMES The belief is that correction or modification of factors altering the precision of motion (physiological motion but also as much as possible the accessory/arthrokinematic motion) alleviates or reduces the tissue irritation and thus the painful condition. 25
  26. 26. A major premise of the model is that pain most often arises from tissues that are stressed by subtle impairments in movement or alignment and that key factors contribute to these particular impairments. One important factor is that the body, following the laws of physics, takes the path of least resistance for movement. 26
  27. 27. The activities an individual performs require movements of multiple joints that are contiguous, in the same kinematic chain (i.e.,in serial arrangement), and all of which have different flexibility characteristics. The result is that one joint of those that are anatomically arranged in series moves the most easily and most readily when an individual performs an activity. 27
  28. 28. Our research supports the premise that the ease and rapidity with which a joint moves are more important factors in a movement pattern associated with pain than muscle shortness, soft tissue restrictions, or limited range of motion (ROM) of an adjoining joint. 28
  29. 29. These latter factors may have contributed to the initial development of the flexibility of the joint causing the pain, but once established, the offending motion has to be addressed primarily and the tissue adaptations, secondarily. Stretching muscles or soft tissues will not stop the offending motion. But when the offending motion is stopped or controlled, the appropriate tissues will be stretched. 29
  30. 30. The motion contributing to the stress occurs during the first few degrees of motion or with initiation of an activity. The primary impairment is believed to be an accessory rather than a physiological motion, which is consistent with the problem arising during the first few degrees of movement. Accessory motion hypermobility is an underlying characteristic of degenerative joint disease. 30
  31. 31. Example: Lumbopelvic motion with lower extremity motions in patients with low back pain is an example of abnormal early onset joint motion. In the prone position, lumbopelvic rotation occurs earlier and to a greater extent during the first few degrees of knee flexion and hip rotation in patients with low back pain than in control subjects, and the pattern was specific to the MS category. 31
  32. 32. The predisposition of these joints to move readily contributes to the frequency of their movement and furthers the tendency for motion. Thus, a specific joint or joints of the lumbar spine, for example, develop a tendency or susceptibility to move readily in a specific direction (directional susceptibility to movement [DSM]) during all activities. 32
  33. 33. In most joints, the accessory motion impairment is not clinically observable, thus the physiological motion associated with the pain is most often designated as the DSM. when a joint moves more readily than other joints in the same kinetic chain, the repeated movements and prolonged postures associated with everyday activities can be the precipitating, as well as the perpetuating, factors of the joint's DSM. 33
  34. 34. As a result, movement in the offending direction has been associated with pain and is often impaired (deviates from the kinesiological standard). When the movement is corrected, the symptoms decrease or are eliminated. Based on the premise that the diagnosis should direct treatment, the DSM is most often also the diagnosis. 34
  35. 35. Correcting the pattern or stopping the movement in the painful direction is the focus of treatment because the symptoms are decreased or eliminated by this action. The movement direction or alignment that most consistently causes or increases the patient's symptoms and that, when corrected, decreases or alleviates the symptoms is considered the diagnosis. 35
  36. 36. The complete description of all the impairments evident as signs or causing symptoms that contribute to the offending or principal movement impairment is the syndrome. Impairment is defined as any disorder in structure or function resulting from anatomical, physiological, or psychological abnormalities that interfere with normal activities. 36
  37. 37. THE HUMAN MOVEMENT SYSTEM 37
  38. 38. The human movement system is a physiological system of the body that produces motion of the body or its component parts, or the functional interaction of the structures that contribute to the act of moving. The physiological actions of other body systems combine to compose the movement system, with biomechanics playing an important role as the interface among the skeletal, muscular, and nervous systems. 38
  39. 39. Kinesiopathological model Kinesiopathological refers to how movement that is excessive, imprecise, or insufficient contributes to the development of pathology. 39
  40. 40. 40
  41. 41. ELEMENTS OF THE MODEL Base Elements Modulator Element Support Elements 41
  42. 42. Base Elements The components of the base elements are the muscular and skeletal systems. These systems are considered the base elements because they consist of the tissues that provide the foundation and the structure of the system. 42
  43. 43. Modulator Element The component of the modulator element is the nervous system. The term modulator is used to emphasize the regulator activity of the nervous system. 43
  44. 44. Support Elements The components of support elements are the cardiovascular, pulmonary, and metabolic systems. These systems do not contribute directly to movement, but as indicated by the term support, they provide the nutrients and substances required for maintaining the viability and health of those systems that do directly produce movement. 44
  45. 45. BIOMECHANICS The model indicates that biomechanics is an interface between muscular and neurological activity. The pattern of muscular recruitment is highly influenced by relationships to gravity, as well as the force required to move the extremity and react to external forces. The design of the movement system also provides a variety of strategies to develop a moment about a joint. Many of those strategies are determined by biomechanics. 45
  46. 46. TISSUE ADAPTATIONS • Inducers • Modifiers –Age, Gender, Tissue Mobility, Anthropometrics, Activity Level 46
  47. 47. 47
  48. 48. TISSUE ADAPTATIONS The dynamic and biological characteristics of the components of the movement system enable tissues to adapt to the demands placed on them. The specific tissue adaptations are normal biological responses to forms of stress but may contribute to deviations from principles of kinesiology. 48
  49. 49. TISSUE ADAPTATIONS For example, alterations in muscle length, strength, and stiffness can affect the precision in joint motion. In combination, these adaptations can become problematic. 49
  50. 50. Inducers The repeated movements and sustained alignments associated with everyday activities are the inducers of the tissue adaptations. Every aspect of an individual's activities, whether passive or active, also induces changes in tissues. 50
  51. 51. Although the physically active person will improve and increase the size of muscles and connective tissues, at the same time, the risk of injury also increases. Musculoskeletal pain problems and injuries of athletes mostly occur from noncontact stress. Golfers develop back, elbow, wrist, shoulder, and knee problems. 51
  52. 52. The repetitive use of specific segments of the body combined with high and rapid force development can exceed tissue tolerance, resulting in microtrauma. At the other extreme, even individuals who are inactive induce changes by the alignment and movements while sitting and during work activities. 52
  53. 53. Alignments maintained for prolonged periods can induce changes in muscle length. Without activity, muscle and connective tissues are not stressed enough to provide optimal tissue health. 53
  54. 54. Modifiers The modifiers are factors such as age, sex, height, weight, and genetic characteristics that include predisposition to osteoarthritis, benign general joint hypermobility, structural or anthropometric characteristics, and the amount and type of activity. 54
  55. 55. Age In young individuals, tissues are more extensible and joints more flexible than in older individuals. Thus the offending motions are usually of greater ROM than the motions in an older patient. 55
  56. 56. In older individuals or those with a chronic condition, the movement impairments are usually more subtle so that the examination requires careful observation and usually slight corrections. The treatment using movement corrections and stabilizing exercises requires even greater precision in the older individual than in the younger patient. 56
  57. 57. Gender Studies of patients with low back pain have demonstrated a difference in the pain-inducing movements and alignments between men and women. The broader shoulders, higher center of gravity, and larger and stiffer muscles in men as compared to women also contribute to differences in tissue adaptation and movement patterns. 57
  58. 58. Tissue Mobility Of the genetic factors, benign joint hypermobility syndrome is one of the important problematic characteristics. Individuals with hypermobility seem to be more disposed to musculoskeletal pain problems than individuals with tissues that limit joint excursions; this occurs not only with the physiological motion but particularly in the accessory motions. 58
  59. 59. Maintaining good alignment and precise motion is more difficult if the individual is hypermobile as compared to individuals with tissue stiffness. Therefore one of the important assessments during the examination is obtaining information about the general tissue and joint mobility and the effects on alignment and movement patterns. 59
  60. 60. Anthropometries Body proportions are also a contributing factor in predisposing an individual to musculoskeletal problems. For example, a long trunk is usually associated with depressed shoulders and often neck pain. 60
  61. 61. Activity Level The activity level can range from excessive, which tends to exacerbate the development of musculoskeletal pain problems, to insufficient activity. 61
  62. 62. The therapist needs to also factor into the examination whether the pain condition is from excessive activity that can be associated with problems from muscle hypertrophy and associated stiffness, as well as motor pattern incoordination, or from a lack of activity in which a systematic increase in physical activity and exercise to improve the force production deficit is necessary. 62
  63. 63. Activity Level In the former situation, part of the treatment may be to decrease the demands on specific muscles and increase the extensibility of those muscles. 63
  64. 64. Tissue Adaptations of the Skeletal System Although skeletal structures seem relatively fixed, bone is a dynamic tissue that is constantly being modified by the forces acting on it. For purposes of this material, the modifications of skeletal structure and alignment can be considered both dynamic and static. 64
  65. 65. Dynamic conditions are correctable and sometimes easily modifiable, whereas the static conditions are relatively permanent or structural. Another consideration is the effect of prolonged forces on the shape of bones and joints. 65
  66. 66. Wolff (1836- 1902) proposed that "changes in the form and function of bones, or changes in function alone, are followed by changes in the internal structure and shape of the bone in accordance with mathematical laws." During development, the bones will adopt a shape according to the forces imposed on them. 66
  67. 67. In mature bone in which the general shape is established and no changes are made in the distribution of forces, the change is in the mass according to the mechanical demands. 67
  68. 68. Changes in the shape and alignment of the joint also affect the characteristics of the ligaments and the distribution of forces on the articular cartilage, as well as alter the precision of joint motion. A major consideration is how skeletal alignment, both acquired and structural, affects the demands on muscle participation. 68
  69. 69. The initial observations of a patient with pain problems should be an assessment of the alignment and the participation of musculature based on the relationship to the line of gravity. 69
  70. 70. Tissue Adaptations of the Nervous System Motor control plays a key role in musculoskeletal pain. there are two general theories about changes in movement in patients with musculoskeletal pain. 70
  71. 71. 1. One theory is that pain causes the change in movement patterns and alters motor control. 2. The other theory is that changes in movement patterns cause the problems that result in pain. Certainly an acute and intense onset of pain can affect the patient's alignment and movement patterns. 71
  72. 72. But the major question is, "What precipitated the pain episode? “ As suggested by the model, the repeated movements and sustained postures of daily activities induce the changes in tissues and movement patterns that cause the pain problems. Therefore the pathological changes are secondary to the altered movement pattern and motor control and not primary. 72
  73. 73. Both concepts require that treatment emphasize correction of the movement patterns and the altered motor control. If altered movement patterns cause the problem, then guidelines for prevention are possible. If the pain causes the problem, then the precipitating factors may not be easy to identify. 73
  74. 74. Clinical experience with correcting movement patterns and alleviating symptoms supports the belief that the altered movement patterns are the key factor in causing pain and that correcting the movements and the contributing factors is the most effective long-term treatment. 74
  75. 75. A prevailing characteristic of the human body is to reduce the degrees of freedom when establishing a movement pattern, thereby achieving a degree of efficiency and minimizing energy expenditure. Movement patterns become established as they are repeated, and the pattern is reinforced by changes in both the nervous and muscular systems. 75
  76. 76. When considering the factors contributing to musculoskeletal pain problems, the patterns of recruitment and derecruitment are primary. The belief is that the patterns are established by the requirement of the activity, personal characteristics, and intensity of use. 76
  77. 77. Tissue Adaptations of the Muscular System The adaptations of muscle are changes in: ( 1 ) length, both increased and decreased; (2) tension development capacity, hypertrophy, and atrophy; (3) stiffness, the resistance to passive elongation. 77
  78. 78. 78
  79. 79. A, Patient's hip joint angle is almost 90 degrees with his knees flexed. B, With passive knee extension to only 45 degrees, his pelvis tilts posteriorly, and his lumbar spine flexes. The position of the pelvis and lumbar spine indicates that the hamstring muscles are stiffer than the supporting tissues of the lumbar spine. The alignment change occurred before the end of the excursion of the hamstring muscles. C, when the hip joint angle is maintained at 90 degrees, the knee cannot be fully extended. The hamstring muscles are short. 79
  80. 80. Relative Stiffness/Flexibility Muscle stiffness is defined as the change in tension per unit change in length. Stiffness refers to the resistance present during the passive elongation of muscle and connective tissue. The stiffness is a normal property of muscle and is the passive tension of a muscle when stretched. 80
  81. 81. When a muscle is being elongated and there is movement at the proximal attachment of the muscle, the best explanation is that the tissues stabilizing the joint are not stiff enough relative to the stiffness of the muscle being stretched. 81
  82. 82. 82
  83. 83. A, The patient's pelvis is tilted posteriorly, and his lumbar Spine is flexed when his knee is passively fully extended. The position of the pelvis and spine can be the result of relative flexibility,which indicates that the hamstrings are stiffer than the supporting tissues of the lumbar spine but not that the hamstring muscles are short. B, The patient's hip joint angle is 90 degrees, and no motion of the pelvis or lumbar spine occurs when the knee is fully extended passively. The hamstring muscles would not be considered short. 83
  84. 84. The concept is that the hamstrings and the tissues (muscles and ligaments) of the lumbar spine are springs in series. When the passive tension of the spring being stretched (hamstrings) is greater than the passive tension of the spring in series (lumbar spine tissues), there will be motion at the intervening joint. 84
  85. 85. 85
  86. 86. The earlier the movement at this joint the greater the indication of the lack of "stiffness or stability“ of the joint. A major source of the passive tension (stiffness) in muscle fibers is an intracellular contractile protein called titin. Titin is the largest connective tissue protein in the body and provides the passive tension for both striated and cardiac muscle. 86
  87. 87. Titin attaches the myosin filament to the Z-line of the sarcomere and there are 6 titin proteins for every myosin filament. Therefore, muscle hypertrophy that increases the number of sarcomeres in parallel and consequently the amount of myosin will also increase the passive tension or stiffness of the muscle. 87
  88. 88. 88
  89. 89. Realizing that an intrinsic property of the human body is the minimization of energy expenditure when inactive or even when active, the role of passive tension becomes particularly important. Passive tension is a primary contributing factor to alignment, often stability, and even the timing and effectiveness of the mechanical event connected with muscle contraction. 89
  90. 90. The passive tension provided by muscle plays an important role in joint stability, alignment, and in some situations contributes to pain. Muscle stiffness is an extremely valuable property of muscle that enables the body to be supported with minimal energy expenditure. 90
  91. 91. Good alignment is indicative of balanced passive tension of muscles attaching to a joint or skeletal segment, such as the thorax or pelvis. The passive tension, which also has a high correlation to active tension, is the key to the alignment and stabilizing properties of the joint. As in all things, stiffness can become excessive or insufficient. 91
  92. 92. The relative stiffness/flexibility properties are often the contributing factor to: (1) alignment impairments, (2) one joint moving more readily than an adjoining joint, (3) inadequate stabilization or inappropriate movement during the passive elongation of a muscle. 92
  93. 93. Muscle Length Adaptations Increased length Small changes in muscle length are changes in passive resting tension,while greater increases in muscle length are associated with addition of sarcomeres in series in the muscle fibers. 93
  94. 94. Decreased length The development of true muscle shortness is associated with loss of sarcomeres in series in muscle fibers. There is a lack of clarity in clinical practice about the various mechanisms involved in muscle shortness and tissues affected by stretch or the need to stretch. 94
  95. 95. For example: If the decreased ROM of hip flexion with the knee extended is only 10 to 15 degrees and can be regained by stretching for a few minutes, the alteration can best be explained by the creep or viscoelastic properties of muscle. 95
  96. 96. In contrast, if the hamstring muscles are limiting the motion of the joint by 30 to 40 degrees, then the most likely explanation is that the muscle fibers have lost sarcomeres in series and the treatment has to be stretching of long duration (for example, 30 minutes or more, several times a day for many days) and as sustained as possible. 96
  97. 97. Stretching should not be forceful because a reasonable explanation for this condition is that the muscle has lost sarcomeres in series and that requires protein synthesis and not just a change in the conformation of the proteins in the muscle cells. 97
  98. 98. Although muscles can become shortened by loss of sarcomeres in series, this is not the most common problem contributing to musculoskeletal pain. The most common problem is the relative stiffness of muscles attaching to the joint. 98
  99. 99. Muscle Performance Performance includes timing, length, passive tension, and the ability to generate active tension and endurance. Assessment of muscle strength provides information about muscle performance, and the results of the test can provide at least four possible determinations about the muscle. 99
  100. 100. Manual muscle testing (MMT) can be used to discern whether the muscle is: (1) weak because of atrophy and the lack of sarcomeres in parallel and thus unable to develop adequate active tension; 100
  101. 101. (2) Strained because of being subjected to forces that have torn or disrupted the Z-lines of the sarcomeres and unable to develop adequate active tension; (3) Too long, having added sarcomeres in series, and the muscle does not develop the appropriate tension throughout the ROM, (4) Normal. 101
  102. 102. Joint Mobility As depicted in the model, the problematic outcome of the tissue adaptations is the development of a relative stiffness or flexibility condition that becomes exaggerated because the body takes the path of least resistance for movement. The result of this cascade of events is that a joint develops hypermobility. 102
  103. 103. Hypothetically, the hypermobility is an accessory or arthrokinematic motion rather than physiological or orthrokinematic motion. One of the consequences of imprecise movement is the development of points of high contact stress because of inadequate distribution of forces within the joint. 103
  104. 104. Thanks for your attention 104

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