L11: Motor control examination Flashcards
When are 3 situations where functional motor control tests are appropriate?
- To further confirm motor control impairment
- To assess level of ability (or inability) to control movement
- Significance (someone who has very mild symptoms and only have it when they are under high loads/fatigue OR no load)
When are 2 situations where assessment of specific muscle groups are appropriate?
- Where there is an improvement in symptoms with isolating a specific muscle group
- Where a patient cannot achieve motor control exercises at a more functional level
- Only look at specific muscle groups if they can’t achieve specific functional tasks
How do I know which test to choose for the functional motor control tests?
If we identify motor control impairment direction in subjective, we can assess this in the physical with specific tests
OR
We can look at a task that challenges the patient in a function that they have difficulty with (example: sitting or standing)
BUT… If you’re not sure, its ok to just start with a challenging test and see what the patient can do.
With functional motor control tests, can they appropriately control a movement?
- What movement/moment do they tend to go into
- Does this match with their symptoms?
- Extension? Flexion?
What are 3 things that include “appropriate” in controlling a movement?
- Being aware of their position
- “I can see that you are starting to bend your back. Can you tell me when you start to do that?”
- Being able to control the movement
- Not having to excessively brace, and still move freely and comfortably Don’t have good motor control
What are the 5 movement control tests for the assessment of motor control and local muscle systems?
- Lumbopelvic dissociation in sitting
- Forward lean test in sitting and standing
- 4 point kneel- neutral spine with upper/lower limbs
- Lumbopelvic dissociation in 4 point kneel
- Hip Extension in Prone
What are the 2 static tests for the assessment of motor control and local muscle systems?
- Transversus Abdominis
- Multifidus
What are 3 things tha lumbo-pelvic dissociation in sitting assess?
- This assesses patient’s ability to move the lumbar spine separate to the hips
- Assess ability to move to end range of anterior/posterior rotation without moving the hips.
- Assess if they can do this independently (tests ability to move without hips and also awareness of finding neutral)
- Can they keep their lumbar spine still while moving out of pelvis?
What does the lumbo-pelvic dissociation in sitting show?
Show the patient how to find neutral spine in sitting (cues and/or handling).
What is the finding if patients struggle with the lumbo-pelvic dissociation in sitting?
- Have problems with sitting
- Persistent pain
When is repositioning in sitting and forward lean testing in sitting appropriate?
- Flexion or extension control impairment
- Especially where sitting is an issue
What does the positioning in sitting and forward lean testing in sitting show?
Show the patient how to find neutral spine in sitting (cues and/or handling).
What is the procedure for the forward lean testing in sitting?
- Fully slump and ask the patient to return to the neutral position
- Can they maintain this corrected position?
- If so, can they maintain it into a forward lean from the Hips? (forward lean test in sitting).
- Ask them to lean forward from hips.
- Stop as soon as they feel they have lost position. do they have the awareness of their back movement
- Try not to tell them to ‘keep their back straight’
- Monitor spine position and breathing/bracing
What is it important not to do in the forward lean testing in sitting?
- Keep back straight is not important
- Want them to “maintain” posture
When is the forward lean test in standing (Waiter’s Bow) appropriate?
- flexion or extension control impairment
- Especially where standing relating tasks are an issue
What does the forward lean test in standing (Waiter’s Bow) assess?
- Ability to keep neutral spine under load
- More loading during standing compared to sitting
What is the procedure for the forward lean test in standing (Waiter’s Bow) assess?
- Ask the patient to maintain normal breathing and lean forward at the hips.
- Maintain your back and lean forward with your hips
- Try not to tell them to ‘keep their back straight’ unless they really cant do it. R
- epeat to assess over time and consider under higher load.
- Where relevant, progress to dead lift with load.
What is the progression of the forward lean test in standing (Waiter’s Bow) assess?
- Go into a deadlift position
- Add load or knee flexion
What are 2 reasons to assess the 4 point kneeling tests?
- Find a neutral spine
- Keep a neutral spine through movement
What do you ask the patient to do in the 4 point kneeling tests?
- Ask the patient to move the pelvis in/out of ant/post rotation.
- Ask them to reposition back to original position.
What are the 2 tests in 4 point kneeling?
- Flexion control
- Extension control
What do you ask the patient to do in the 4 point kneeling tests for flexion control?
instruct to keep back still when sitting to heels and awareness of when back starts to bend (lumbo-pelvic dissociation in 4 point kneeling)
What do you ask the patient to do in the 4 point kneeling tests for extension control?
- ability to keep neutral spine with arm or leg lift If they cant, reassess ability with instructions and more feedback (a mirror) If they still cant, try with local TA contraction
- Can tell them to stop when they feel there back start to move Can go into back extension (to early sometimes)
Why do 4 point kneel compared to sitting or standing?
- If have significant motor control impairment = less variables to control
- If find nothing on the sitting or standing positions (to challenge them)
What is the procedure for the prone hip extension (extension control test)?
- Assess their hip extension range passively
- Need to understand their range first
- Ask them to lift leg up and see how much they move from back vs hip
- As them to lift leg while keeping back still, maintaining breathing
- If they cant, reassess ability with instructions to recruit TA
- This is a good TDT = quite high level test/ difficult to do
What is the procedure for the knee flexion in prone (extension control test)?
- Assess their knee flexion range passively to check they have range
- Ask patient to maintain neutral spine (with breathing control)
- Ask patient to bend knee
- If they cant keep lumbar area stable with breathing control, reassess ability with instructions to recruit TA
When is the knee flexion in prone (extension control test) used?
if hip extension test too difficult = regression
Pain at the gym doing squats or other similar loading tasks. What tests should be used?
assess ability to keep relaxed neutral spine on squat, deadlift, forward lean test in standing or sitting
Pain on prolonged standing or running or extension based activity. What tests should be used?
consider ability to keep neutral spine using tests that are in neutral or challenge extension – hip extension in prone, 4 point kneeling Look at something similar to their problem
What happens when a patient has an extension control impairment?
they go into increased lumbopelvic extension on movements – may have pain with extension based activities, or flexion based if under load.
We might want to assess whether they can control a movement without going into increased extension
What happens when a patient has a flexion control impairment?
they may go into flexion early and easily on movements – may have pain with flexion based activities –assess whether they can control a movement without going into lumbar flexion
What are 4 examples to consider when assessing if they have an awareness of not keeping neutral on movements in flexion control movements?
tests that challenge them going into flexion
- repositioning in sitting
- forward lean in sit or stand
- squat – keeping neutral spine
- keeping neutral spine in 4 point kneeling sit to heels
Clinical example: Young patient with pain in upper Lumbar region. Especially on sitting prolonged periods and after the gym – especially deadlifts. Finds that back goes into ‘spasm’ when it is aggravated and patient cannot move for a few minutes.
Observation: Increased Lumbar Lordosis, hypertrophy lumbar paraspinals.
Observation of functional task deadlift: increased lordosis throughout movement – hyperextends at bottom of deadlift.
AROM – holds lordosis until near end.
PPAIVMs – pain on central and unilateral L2-4
What is the motor control assessment like? List 3
Issues with functional tasks –> observe those tasks
- Ability to keep neutral spine on squat or deadlift without weight, or if too difficult, a forward lean test in sitting or standing.
- Consider ability to keep neutral spine/not hyperextend on 4 point kneel tests or hip extension in prone.
- Back probably doesn’t need ‘strengthening’ but may have motor control impairment (extension)
Clinical example: Pain with gardening and prolonged sitting. Noticing pain after these activities – especially with going from sit to stand or on small movements once back is aggravated. Worse with prolonged sitting. Becoming a recurrent problem.
Observation: posterior pelvic tilt slightly in standing. Lumbar flexed in sitting posture.
AROM: reduced flexion in standing with pain throughout the movement. Reduced hamstring length.
What is the motor control assessment like? List 3
- Ability to hold neutral spine in sitting – then on forward lean test.
- Standing forward lean test – can they keep neutral spine?
- Keeping neutral spine in 4 point kneeling sit to heels
Where can you palpate for transverse abdominus?
Where can you place the transducer for US when testing transverse abdominus?
- Transducer halfway between ASIS and the ribcage along mid-axillary line
- One advantage of RTUS is the ability to assess these muscles in many postures and during functional tasks (quadruped, sitting or standing).
- A higher frequency curvilinear transducer, with its diverging field of view, is ideal, as it allows for greater visualization of the muscle throughout its length.
What are we looking for when testing transverse abdominus during US?
- Change in the thickness of a muscle or a lateral displacement (slide) of the anterior medial edge.
- As the TrA muscle thickens and shortens, a lateral slide of the anterior aspect of the TrA muscle and its fascia can be observed, particularly in supine.
- Dimensions of EO and IO relatively unchanged
TA contracts = becomes thicker
EI and EO = maintain relaxed
What you look for when patient contracts transverse abdominus?
Increase thickness of TA and maintainence of thickness of others
TA is usually they darkest line on US
Where is multifidus?
What are the 5 steps in the contraction when testing multifidus?
- Index finger (middle phalanx) and thumb either side of spinous process (or use two thumbs) and apply gentle pressure (to compare sides)
- Breathe in and out and cease breathing
- Instruct to swell muscle slowly and gently under fingers – make sure ease off finger pressure as contraction occurs
- Resume breathing while hold contraction
- Aim for 10 seconds
Can co-ordinate with breathing
Can do 10 X 10 sec holds
Can achieve with Transverse Abdominis contraction
MONITOR and avoid:
- Trunk flexion should not flex
- Pelvic tilt should be no movement
What does the multifidus look like on an US?
- Lumbar Multifidus in Parasagittal Section View Probe located alongside spine
- Prone or side-lye Increased depth of multifidus – looks like spine moves down on image as MF contracts
- Can measure CSA or compare side to side
- Measuring CSA on contraction has poor reliability
What are 2 ways to reassess pain and/or observe movement in motor control?
- Asking the patient to repeat it in a different way (demonstrate or use cues)
- Ask the patient to repeat it using local muscle recruitment strategy (for example, improved hip extension in prone control with TA recruitment)
If the correction of the pattern results in a reduction of the pain, then this supports that the movement disorder is contributing to the symptoms.
