Too often, manual therapists label a patient’s condition in a way that does not provide adequate information about the nature of their dysfunction.
Terms like shoulder impingement, tennis/golfer’s elbow, osteoarthritic knee pain, and even more general terms like low-back pain, neck pain, and sciatica do little to define the nature of the injury. Therefore, consider using a functional musculoskeletal assessment system to better assess, classify, and treat muscle and joint related injuries.
The key to this system””and to clinical success””is locating muscle motor or neuromuscular inhibition. Muscles will “shut-off” or become inhibited for three reasons triggered by different forms of noxious stimuli:
- Trauma or repetitive strain injury (RSI)
- Pain
- Changes in the joint (e.g., arthritis)
In a 2012 peer-reviewed study, researchers determined that nociception is often processed without conscious thought. Consequently, in many cases, neither patients nor clinicians are aware of the interaction or of the motor inhibition taking place.1
Chronic nociceptive stimuli, therefore, could result in inhibition that might prevent effective motor retraining in patients.
The study’s results indirectly tell us that proper patient rehabilitation will not occur unless the motor inhibition is revealed and corrected before actively re-training the impaired muscle. By determining where the dysfunctions are, you can then make the appropriate treatment decisions that will restore function and adaptability in your patients’ musculoskeletal systems.
The basics of assessment
What if you were to apply an assessment system where, as a doctor of chiropractic, you could locate motor inhibition in patients who experience a musculoskeletal problem? An assessment approach focuses on the skeletal foundations of the musculoskeletal system, which include:
- Vertebral column
- Scapular girdle
- Pelvic girdle
Your goal is to assess the stability, strength and range of motion of the skull and extremities in relation to those foundations. A 2006 study described the girdles as the founda- tions of human movement.2
That is because the shoulder and pelvic girdles protect and serve as adaptable attachment sites for muscles of the upper and lower extremities.
The skull is supported by muscles and soft tissue that anchor to the vertebral column (cervical spine) while the scapular girdle anchors itself to the skull, vertebral column, humerus of the upper extremity, and the vertebral column (t-spine/l-spine), which has soft-tissue attachments to the pelvic girdle that anchor to structures in the lower extremities, beginning with the femur.
Focus on the foundations
A 2005 study concluded that muscle groups in the proximal girdle of the kinetic chain of movement were associated with strength deficits in distal joint injuries.3
This finding aligns with that of an earlier study in 1994, which noted the influence of distal joint injury on muscle activation of proximal muscles of the pelvic girdle.
This research, combined with contemporary ideas, outlines an assessment system that encompasses the tissues involved around the girdles, which constitute the centers of kinetic movement.
Upper- and lower-body scans
A patient’s chief complaint deter- mines which body scan(s) to perform to assess their range of motion, stability, and location of motor inhibition along the skeletal foundations.
For example, if the patient presents with anterior shoulder pain, you’d perform an upper-body scan. If the patient presents with left-sided low-back pain, you’d want to scan the lower body. Typically, upper-body musculoskeletal complaints will prompt you to perform upper body scans and lower body scans will be performed for lower body injuries.
The ultimate goal is to be comfort- able performing scans that can be completed in clinical practice within two to three minutes.
Case study
A 32-year-old female presents with R lateral elbow pain of four months’ duration. She is a competitive racquetball player and has had to modify her stroke to compensate for the elbow pain. NSAIDs and ice give her temporary relief. A musculoskeletal assessment reveals:
- On gait analysis, her right arm swings much less than her left.
- The right trapezius is elevated during gait.
- An upper-body scan reveals her cervical rotation (45 degrees on visual inspection) and lateral flexion is limited to the right (10 degrees). Marked weakness occurs upon testing the supraspinatus in both full and empty can positions, and her serratus anterior is inhibited.
Traditional Dx: R tennis elbow or lateral epicondylitis.
Traditional Rx: Treat the local area with any number of different modalities.
Functional Dx: R lateral elbow pain associated with limited cervical spine movement and R scapulo-thoracic joint dysfunction.
Functional Rx: Restore motor inhibition in the scapular girdle and supraspinatus using a manual soft- tissue technique like acupuncture or muscle release and then focus on restoring dysfunction in the cervical spine. Do not address the area that is causing pain until this has been completed.
The fundamental point is that musculoskeletal assessment involves more than just performing orthopedic testing””it is an assessment of the adaptability of the mechanics of the body. To be successful you must be willing to think locally but assess globally.
Anthony J. Lombardi, DC, is the creator of the eXStore assessment system. He is a consultant and treatment provider to professional athletes in the NFL, NHL, and CFL. He can be contacted at info@hamiltonbackclinic.com or through hamiltonbackclinic.com.
References
1 Nijs J, et al. Nociception affects motor output: a review on sensory-motor interaction with focus on clinical implications. Clin J Pain.
2012;28(2):175-181.
2 Hamill J, Knutzen KM. (2006). Biomechanical Basis of Human Movement. Baltimore: Lippincott Williams & Wilkins.
3 Aminaka N, Gribble PA. A systematic review of the effects of therapeutic taping on patellofemoral pain syndrome. J Athl Train. 2005;40(4):341.
4 Bullock-Saxton JE, Janda V, Bullock MI. The influence of ankle sprain injury on muscle activation during hip extension. Int J Sports Med. 1994;(6):330-4.
