Journal of Bodywork & Movement Therapies (2015) 19, 150e159

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PREVENTION & REHABILITATION: EDITORIAL

Movement Health

The Movement theme not refined enough to explain all the observations made
about pain affected differences in movement. In the
Journal, Pain, Hodges and Tucker (2011) suggests that pain
‘Movement’ has been the key theme of two recent Pre-
creates changes at multiple levels of the nervous system
vention and Rehabilitation editorials and companion pieces
leading to a variability in response to pain within muscles
in this Journal. The first looked at two types of exercises
and between them. These changes may have short term
that can be used in exercise prescription to fix an uncon-
benefits as adaptation to pain aims to reduce pain and
trolled movement (UCM), which is a movement, usually in a
protect the painful part, but long term consequences such
specific direction such as flexion or a rotation, that an in-
as that altered movement patterns created by pain don’t
dividual cannot knowingly control. The exercises described
necessarily return to a pre-pain state.
were: direction control exercises, that help teach the
When a pathology alters movement these conditions are
control of the neutral joint position, and, range control
referred to by Sahrmann (2014) as being ‘pathokinesio-
exercises, which help develop the muscular control of a
logic’. Sahrmann identifies a second group of conditions as
movement through a joints ideal range (McNeill, 2014a,
PREVENTION & REHABILITATION: EDITORIAL

being ‘kinesiopathologic’ where movement, in this case

2014b), the second editorial looked at the development
faulty movement, creates the pathology itself.
of Movement screens as an analysis tool (McNeill, 2014c,
Sahrmann suggests that the physical therapy profession
2014d). The final part in this informal series on Movement
should be ‘focussing attention on kinesiopathologic and not
looks beyond assessment or types of specific exercise on to
just pathokinesiologic conditions.’ Sahrmann is advising
a bigger picture e Movement Health. What is it? And what is
physical therapists that the focus on the pathoanatomical
its role in prevention and rehabilitation?
issue, though not unimportant, can perhaps misdirect ther-
apists to try, with good intent, to positively affect an injured
We all move differently part. Treatments such as gentle joint mobilisations that open
an intervertebral foramen and off load a nerve root that a
Professor Shirley Sahrmann of the Washington University, disc bulge may be encroaching on, may, provide temporary
says, in an audio interview published on Physiopedia relief, but does it change much for the client in the long
(websource 1), that her career focus changed from looking term? More importantly it is the understanding of the
at neurological patients, primarily stroke patients with movement system that the disc injury is part of and altering
spasticity, to those with musculoskeletal pain. Sahrmann the behaviours of the client that may have caused the injury
reports that the common link between the two groups of in the first place is perhaps more likely to be effective.
patients was altered movement. Sahrmann says, ‘I have Isobel Warnock, a British Physiotherapist, describes a
always been intrigued by movement; how you can recognise case study where changing the movement system was the
a person from a distance by how they move long before you only effective form of treatment available. She describes
are close enough to see their face,’ and ‘how, if there is an ‘Ollie’, who early in life sustained an injury to his left
ideal or normal gait pattern why there are so many ‘man- anterior cruciate ligament, but with no apparent further
ifestations of different.’ Her interest in the differences in problems once it resolved, however, 8 years later Ollie
the movement of patients is responsible for transforming started to develop a significant limp in the same leg. The
the vision of the American Physical Therapy Association, hip was clearly painful and Ollie would walk with his hip
and, by extension the profession itself (Sahrmann, 2014). moving significantly into adduction in stance to the point
Paul Hodges from the Queensland University also says where he would lose balance. It was decided that the most
‘People move differently in pain.’ He comments that this appropriate therapy was going to be hydro-therapy. Ollie
view is unquestioned but that two current theories, ‘the was placed on a treadmill in a pool in chest high water. He
vicious cycle theory,’ and ‘the pain adaptation theory’ are walked into a flow of water which actually pushed his leg

http://dx.doi.org/10.1016/j.jbmt.2014.12.001
1360-8592/ª 2014 Elsevier Ltd. All rights reserved.
Prevention & rehabilitation: Editorial 151

out of adduction into a more aligned posture and slowly independent activation while overactive superficial mus-
over repeated visits Ollie reduced his limp to the point he cles need to be inhibited in an individualised manner.’
was walking normally. His pain also clearly reduced, but by
how much on a VAS (visual analogue pain scale) e difficult A definition
to say e as Ollie is Isobel Warnock’s dog.
Yes, there will have been pathoanatomic factors in
‘A definition of Movement Health (Blandford, 2014a, 2014b)
Ollie’s injury but the inability to ask Ollie how he was
is that it is, ‘a desired state that is not only injury free and
feeling meant that pain was not the key focus of the
absent of the presence of uncontrolled movement but also
treatment, his movement system was. The Canine Hydro-
a state that allows the exerciser to choose how to move.’
therapist didn’t use electrotherapy or manual therapy on
This suggests that Movement Health goes beyond a
the painful hip, the Canine Hydro-therapist just off-loaded
medical model and into a wellness or fitness model. Pre-
the hip using buoyancy and encouraged, with a flow of
vention of injury (or recurrence of injury) may mean that an
water, a better gait pattern that, over time, better
individual might need to perform exercises from the reha-
recruited and then strengthened the musculature of Ollie’s
bilitative sphere, while they are otherwise well to help
rear left leg (He is now enjoying his walks again and is
maintain a state of Movement Health.
running without falling over).
Having a choice on how to move suggests that there are
Sarah Mottram, co-author of ‘Kinetic Control: The
different options available so if someone with Movement
management of uncontrolled movement’ (Comerford and
Health has a full library shelf of possible movement solu-
Mottram, 2012) said at a recent lecture, ‘as the focus of
tions to respond to any single movement challenge, the CNS
musculo-skeletal research is on the management of pain
(Central Nervous System) can just reach a hand back and
there is a dearth of solid evidence about how people, who
grab the first solution that comes to hand to successfully
are not in pain, move. Normal movement is variable,
accomplish that movement task. When someone is not in
especially in the trunk where there is such redundancy of
Movement Health their CNS reaches back and finds their
muscles that can perform the same or similar tasks. Good
library shelf empty save just one or two tired and overused
movement control is about finding optimal ways to move
solutions that don’t quite fit the required movement
and it seeks to create movement efficiency.’
challenge.
Sahrmann in her 2014 paper suggests that Physical
To remain in or re-attain Movement Health an individual
Therapists should be aiming to become “Lifespan practi-
needs:
tioners.” What she means by this is that physical therapy
should be about optimising good movement behaviour
1 Awareness: of the body, movement and movement

PREVENTION & REHABILITATION: EDITORIAL

within their clients lives appropriate to the stage in life that
quality
they have reached. This reduces the problems created by
2 Control: of the software (CNS) and hardware (muscula-
poor movement strategies, as well as rehabilitating those
ture and structure) of the neuromusculoskeletal system
whose movement have been altered by pain. This is what
3 Varied Intensity: A postural task needs to be achieved at
Mottram refers to as ‘Movement Health.’
a low intensity of physical work and a strength based
‘Movement matters!’ says Mottram.
task needs to be met with an appropriate high intensity
‘Poor movement control is regularly shown in the liter-
of muscular effort
ature to be related to the onset of symptoms, recurrence of
4 Variability: a wide choice of movement strategies
symptoms, altered movement function & decreased per-
should be available for use for a single movement task
formance (Comerford and Mottram, 2012).’
(Blandford, 2014b).
Nijs et al. (2014) points out that brain grey matter
density and volume decrease in patients with chronic low
When recently interviewed for this editorial, Mottram
back pain (specifically in the dorsolateral prefrontal cortex,
said, ‘The reason that it is important to understand the
thalamus, brain stem, and somatosensory cortex), and this
concepts around varied intensity is that an individual can
was strongly correlated with pain duration and pain in-
have movement faults in low threshold movements e the
tensity. Nijs suggests that ‘longitudinal studies should un-
movements associated with postural loads that require light
ravel whether brain changes are the cause or the
effort to control, or in high threshold movements e that
consequence of pain.’ Apparently, ‘many of the grey mat-
require strength to control, or both. This means that the
ter changes observed in patients with pain subsided with
strategies needed to gain these controls are different and
cessation of pain . It is suggested, therefore, that the grey
require different “doses” of exercise to correct.’
matter abnormalities found in people with chronic spinal
The approach to the exercises to ‘fix’ the weakened
pain do not reflect brain damage but rather a reversible
musculature found in a high threshold UCM is the traditional
consequence of chronic pain, which normalises when the
strength and conditioning strategies. This involves the
pain is adequately treated.’ In another study Nijs quotes in
increasing application of load to exercises over time using,
his paper, ‘it was shown that motor control training, and
say, 3 sets of a 6RM e (repetitive maximum). A repetitive
not unskilled general exercise, can reverse reorganization
maximum is discovered by testing at what weight could an
of the motor cortex in patients with low back pain.’ (Tsao
individual shift it only 6 times (in this case) before fatigue
et al., 2010) So perhaps mindful movement matters too!
stops the activity. This can be described as as ‘Time under
‘The aim of motor control training,’ Nijs explains using a
tension.’ The load providing the muscular tension required
Richardson and Jull paper (1995) ‘is to restore an optimal
for strength and/or hypertrophy (Blandford, 2014b;
balance among the different muscles, which often means
Comerford et al., 2014).
that the deeper muscles need to be facilitated by
 152 Prevention & rehabilitation: Editorial

On the other hand the ‘fix’ for low threshold uncon- requires the individual to concentrate while performing the
trolled movements involves the individual concentrating exercise.
hard on how to recruit the right muscles at a light tension to The term repetitive maximum can be seen in practice in
control the movement. This can be described as ‘Time any weights gymnasium around the world, it often can
under attention’ (Blandford, 2014b; Comerford et al., include the last final repetitions of an exercise that are
2014). poorly executed and may involve muscle substitutions, to
Two gluteal exercises are described in the following differentiate a Movement Health definition of a repetitive
Practical Exercise. One clearly ‘Time under tension’ and maximum practiced under control, Movement Performance
the other ‘Time under attention.’ Making sure a strength- Solutions use the term ‘control repetitive maximum’ (often
ening exercise is actually fatiguing is important, as is abbreviated to ‘Con Rep Max’) (Comerford et al., 2014).
making sure the postural load is a correct load that actually

Practical Exercise: time under tension, time under attention

This practical worksheet aims to differentiate a high threshold ‘time under tension’ exercise from a low threshold
‘time under attention’ exercise using the gluteal musculature. It is based on the work of Mottram and Comerford’s
strategies for rehabilitation of movement control impairments (2008).
Movement Health has a number of components of which awareness, control, and variability comprise three. Awareness
relates to proprioception including a sensitivity of position, movement and recruitment from not only the desired
musculature but that of the body as a whole. This awareness feeds into enhanced control as movement outcomes are
achieved with desired strategies. A further enhancement of this state of control is the quality of variability the
exerciser can display to achieve the same movement result. This allows different synergists to be called upon to
initiate movements, the ability to show an ‘altered’ movement and then compare this to a desired sequence. The
movement system in question can be seen to possess an even more comprehensive array of qualities if these first three
components are evident at differing intensities of challenge. The exercises presented below focus on targeting the
portion of the deep gluteus maximus that inserts directly onto the femur as opposed to those that attach to the ilio-
tibial band.
PREVENTION & REHABILITATION: EDITORIAL

Both exercises require the hip to be initially flexed then extended, eliciting recruitment of the femoral part of the
gluteals while at the same displaying the ability to maintain a low back neutral, an equally important movement
control outcome. Possession of control and variability during an exercise will supply the CNS a greater choice in this
movement outcome is achieved.
Clearly delineating exercise 1 from exercise 2 is the nature of the intensity involved. Exercise 1 supplies a traditional
time under tension challenge in which a peripheral fatigue is sought in the musculature targeted while the ability to
control the trunk is challenged. To further qualify this intensity and to ensure quality and not just volume are attained
a control repetition maximum can be introduced. This states the intensity must sufficient to produce a fatigue that
compromises control qualities at a given point in time a 60 s control repetition maximum identifies control can only be
maintained for the duration stated. A control repetition maximum sets the limit of failure at the point at which control
is lost as opposed to the point at which the load can no longer be moved, therefore stating a ‘how’ to the intensity as
opposed to just a ‘what’. To induce fatigue the addition of a 5 Kg dumbbell was provided. This loading strategy needs
to be manipulated to ensure the exercise remains bespoke to the client in question and the duration of effort desired.
The second exercise requires a cognitive challenge of recruitment and alignment to be elicited within its 2 min time
frame. Rather than time under tension, this intensity can be described as one of a time under attention, in which the
suitably challenged subject will display a ‘thousand yard stare’ as they intently focus on the desired movement
outcome. Central components are challenged and, following a principle overload, these systems adapt. Worsley et al.
(2013) reported desirable adaptations to scapulo-thoracic synergists’ contribution and temporal qualities following a
2 min ‘time under attention’ challenge.
Exercise 1
Single leg deadlift (Fig.1)
Start position: Single leg stance with a small knee bend and knee and second toe alignment maintained throughout.
Non-weight bearing leg is flexed to 90 at hip and knee.
Maintain the desired trunk alignment as the weight bearing hip flexes and the trunk travels forward as the non weight
leg travels behind the body, extending at hip and knee in the process.
Return to start position e
Prevention & rehabilitation: Editorial 153

If performed next to a wall balance concerns can be countered with a finger tip placed on a fixed surface until balance
improves. Palpation of the femoral gluteal region may assist in enhanced contributions from this mono-articular
synergist of low back extension control. The asymmetrical exercise set up will also demand further contribution
from the diagonally orientated musculature of the trunk and pelvis. The small base of support and the single leg loading
supply sufficient challenge to ensure the exercise remains in the high threshold realm. The ultimate test of confidence
in the achievement of a high threshold environment is fatigue within the time frame specified (Fig. 1).

Figure 1 Single leg dead lift start, middle and end positions.

Exercise 2
Wall Squat with lean (Fig.2)

PREVENTION & REHABILITATION: EDITORIAL

Start position: Stand with parallel feet, hip width apart and their back against a wall and the heels approx. 5e10 cm
away from wall dependent upon ankle dorsi-flexion range. The hips are flexed so that there is a small bend at the knee
of about 5e10 . Typically, a mid-position of the trunk is found at the start of the exercise.
The subject places their hands on the deep gluteals, avoiding the superficial region inserting into the ilio-tibial band.
They voluntarily contract the deep femoral gluteals sufficiently enough to feel a change in tone of this region but
without employing excessive effort and co-contraction rigidity.
The subject slowly slides down the wall, maintaining the gluteal recruitment and the trunk mid-position alignment
before returning to start. For some individuals this recruitment and alignment challenge may prove difficult, especially
on the return, therefore an option is supplied. To assist performance, consider increasing proprioceptive flow to the
system, by using load facilitation, asking the subject to initially flex at the hips and allow the trunk to come forwards
until a sufficient gluteal recruitment is felt. This longer lever and change in the length and, therefore tension/force
producing capabilities of the gluteals, may facilitate a sustainable recruitment. Once recruitment is established the
subject is guided to return, bringing the shoulders back in contact with the wall without losing either gluteal
recruitment or control of spinal alignment. The subject can be seen to working at the correct level to bring about the
desired changes to their movement quality if they possess a thousand yard stare, a strong indicator of experiencing and
benefitting from a ‘time under attention’ challenge (Fig. 2).

Figure 2 Wall Squat with Lean: a. Start position, b. Knee bend, c. Lean, d: Return from lean, e. End position.
 154 Prevention & rehabilitation: Editorial

Movement Health is about developing movement The review of his current state found that his previous
choices, and possession of a greater range of strategies to Physiotherapy and been hands on soft tissue release and
achieve movement outcomes. If movement is considered as joint mobilisation, with gentle mobility exercises and
a language a greater vocabulary allows for an enhanced stretches as a homework program. On examination Mr. H.
exactitude of expression; this expression is analogous to was found to have mild neural tension signs on the right
Movement Health. In movement terms a greater vocabulary upper limb, joint restrictions in the cervical spine and
is the greater choice of strategies available to the CNS. cervico-thoracic junction, particularly in rotation and side
bend. The right side lumbar spine was also very tender on
Movement prioritised case description joint palpation. Mr. H. had positive impingement signs
affecting his right shoulder. He had muscle spasm particu-
The following case description is a typical treatment where larly in the right side neck and upper shoulder musculature,
movement has been prioritised over other forms of treat- and in the right lumbar paravertebrals and quadratus
ment modalities. Reasons for this include previous hands on lumborum.
treatment to discharge that failed to rehabilitate the The relevant findings of a movement analysis discovered
client, and a limit of 3 sessions as the clients employer was a significant right sided shoulder elevation on full shoulder
funding the treatment. flexion and abduction not present on the left. On standing
In April 2014, Mr. H., a Theatre Lighting Technician was and being asked to flex his right hip to above 45 Mr. H. side
in a vehicle travelling on a motorway when it came into bent his spine to the right and he hitched his right side
contact with a lorry. This caused Mr. H.’s vehicle to spin and pelvis up. On repeating the test on the left, his lumbar
impact the drivers side of the vehicle on to the barriers at spine stayed straight and his pelvis remained level. As only
the side of the road. Mr. H.’s airbags deployed, fortunately three sessions of Physiotherapy were authorised, hands on
preventing more serious injury so overall injuries were therapy was regarded as low priority whereas patient ed-
relatively mild e soft tissue disruption with no fractures. ucation and appropriate movement and exercise prescrip-
Areas of his body that were left in pain after the incident tion were prioritised (Fig. 3).
included right side neck and shoulder as well as the right In the shoulder region Mr. H. was found to be over-
side lumbar area. Through his motor insurance company Mr. recruiting his shoulder elevators including the rhomboids
H. was seen by an Orthopaedic Consultant who diagnosed a and levator scapulae on the right. The clinical reasoning for
whiplash and referred him for a course of Physiotherapy this suggested that he was avoiding pain at the gleno-
which he attended 8 times before eventually being dis- humeral joint by elevating the shoulder to reduce the
charged by both the Consultant and the Physiotherapist. compressive forces around the sub-acromial space. This
PREVENTION & REHABILITATION: EDITORIAL

Six months after his accident his Theatre’s Medical may have been caused by either an impact related injury to
Department referred him for a Physiotherapy review at a the distal end of the acromion or a later development of
different practice. Mr. H. had found his ability to work in his pain as the whiplash injury to the neck may have altered
quite physical profession significantly hampered by his right Mr. H’s previously pain free neck and arm movement pat-
side shoulder and neck pain and he was reporting a right terns, provoking an inflammatory reaction under the acro-
side low back pain related to moving about the theatre and mion when Mr. H. returned to work. Simple tasks involving
climbing stairs. Being placed on lighter duties took into lifting his arm now altering the movement of the shoulder,
account that overhead work such as lifting lights to hang provoking the impingement at the gleno-humeral joint.
them on lighting bars and climbing ladders was not only Likewise at the low back the post injury inflammatory
painful but a concern from a safety point of view to him and response led to over activity in the Quadratus lumborum,
his work colleagues. Mr. H. felt he was no longer improving. causing the right side of the pelvis to be lifted at every step

Figure 3 Mr. H. basic movement testing a. Back view standing in a natural posture. b. Bilateral gleno-humeral abduction to pain
limit. c. Right hip flexion.
Prevention & rehabilitation: Editorial 155

of the right foot, the pattern becoming entrenched over this single leg stance suggested that gluteal recruitment
time. His weight bearing femur rotated in during single leg exercises were also required.
stance meaning his Tensor fascia lata (TFL) took most of his A correct pattern of abdominal stability was regarded as
weight helping to elevate the opposite pelvis. His hip fundamental for Mr. H’s eventual recovery so how he
flexors, primarily TFL tested short. His gluteus medius on established his stability was assessed. It was found that Mr.
the stance leg appeared unengaged. He stood with a mildly H. was unable to co-ordinate a corset like recruitment of
anteriorly tilted pelvis. his lower abdominals without breath holding it was decided
With limited client contact time available an exercise to focus on gaining this motor skill first. Any abdominal
regime was to be instigated as the clients self practice exercise that reinforced the breath hold pattern was to be
would multiply and prolong the effectiveness of the treat- avoided, until this skill was gained. The decision as to what
ment choice, whereas a hands on approach, which the start position to use was made by testing his ability to
client may have been expecting, is more likely to only actively draw in the lower abdominal wall in a vertical
provide a temporary change. As there was a need to ach- position versus a supine position. Mr. H. proved he could
ieve compliance to the exercises it was deemed necessary more reliably draw the lower abdominal wall in a few mil-
to keep the total number of exercises to a minimum. The limetres while continuing to breathe laterally costally,
aims of the exercises had to be clarified to aid in the cor- while standing than he could when lying supine. This was
rect choice of exercises. As pain was still present care had thought to be related to the increased feed back of the
to be taken so that the exercises were not provocative. more stretched abdominal wall in vertical postures as
Six months post injury the healing processes Mr. H. was compared to a ‘baggy’ anterior abdominal wall in supine as
going through should have been well under-way and the the abdominal contents settle more posteriorly in supine
current issues were more likely to be related to chronicity postures whereas in vertical positions gravity affects the
factors that involved adaptations within the CNS due to abdominal contents and provides a stretch to the lower
the ongoing effects of the injury. This suggested that the anterior abdominal wall.
initial exercises needed to be aimed at altering the brain
and its recruitment of the musculature more than exer- Exercise: lower abdominal pull in and breathe
cises aimed just strengthening or hypertrophying the (Fig. 4)
muscles themselves. A further reason was that strength-
ening exercises tend to target regional groups of muscles
and a pattern of movement in current use within that Mr. H. was set as his recruitment focussed breathing and
region is maintained, Mr. H.’s movement patterns were abdominal exercise a vertical (sitting or standing) low

PREVENTION & REHABILITATION: EDITORIAL

faulty and his daily activities appeared to be maintaining abdominal ‘pull in’ while breathing. He was requested to
them. use one hand to feel the anterior abdominal wall below the
Stretches were considered for the shortened muscula- umbilicus and his other hand on the anterior abdominal wall
ture, the right sided; levator scapulae, rhomboids and the above the umbilicus. He was asked to keep the breathing
quadratus lumborum, but in terms of efficiency for the regular using a lateral costal pattern while pulling in the
greatest result from the least effort, stretches on their own lower abdominal wall. Mr. H. was advised that the abdom-
would not lengthen the shortened musculature if the under inal wall had to be completely relaxed before he began and
recruited muscles were not first recruited, as, on balance, he was told to pull in smoothly and slowly as far as he could
the shortened musculature would remain in a shortened (up to about 3 cm) but to stop pulling in as soon as he
position or be actively recruited during movement for detected any drawing in above the umbilicus. He was asked
significantly greater periods of time, cancelling out the to hold this position for 10 s before relaxing and then to
effectiveness of any stretch. Mr. H was told he could repeat it 10 times. He was asked to perform this exercise,
continue with the previous stretches he was taught, but to formally, at least twice a day, preferably in front of a mirror,
follow the stretches with his new recruitment exercises. but he was encouraged to repeat it frequently informally. If
The greater priority was considered to be low threshold his performance degraded he was to stop, and come back to
exercises focussing on the musculature that had not been the exercise again later in the day. Mr. H. was able to
working efficiently due to the dominance of his over active perform this exercise reliably at the end of the first session
musculature. A choice had to be made as to whether the but only if he drew in his abdominals just a few millimetres,
shoulder or low back had the greater treatment priority. It if he tried to draw in further he tended to stop breathing
was decided to look at his centre first. (Fig. 4).
Centrally Mr. H. was found not to be actively recruiting It was decided that further abdominal or even gluteal
his obliques, and, when he thought he was engaging his exercises at this point could negatively affect the attain-
obliques he substituted a diaphragm dominant breath hold ment of this desired recruitment pattern. So addressing the
raising his intra-abdominal pressure which did effectively shoulder region became the next focus in the first session.
stiffen his spine though did not allow him to breathe during As Mr. H. had developed a significant shoulder hitch
light loads in postural and low level functional activities. So during shoulder abduction and flexion movements, muscles
recruitment exercises for the obliques to improve their that contain these directions of travel were assessed for
ability to control anterior tilt of the pelvis and assist side- recruitment efficiency. These are primarily the lower
bend control of the low back and pelvis on single leg trapezius and the serratus anterior muscles that work
stance were thought to be a high priority. together as a force couple to place the scapula on the
His lack of gluteal control during single leg standing chest wall in an ideal position before movement. This po-
allowed a pattern of the anterior hip abductors to dominate sition keeps the scapula flat on the chest wall (no winging
 156 Prevention & rehabilitation: Editorial

Exercise: incline lean half push ups (Fig.5)

Mr. H. was instructed to lean at an angle facing into a wall

with his hands at shoulder level. He was told to bring his
chest onto his scapulae and broaden them. Once this po-
sition was attained he was to slowly perform half press ups
into the wall and back out again while maintaining the
scapulae in the same position without moving them. He was
encouraged not to allow his shoulder elevators to recruit,
and if he noticed the shoulders hunching to stop and reset,
or to stop and resume later in the day. The half press up as
opposed to full meant that Mr. H could be prevent all
scapula movement e keeping the breadth of the shoulder
girdle as a full press up requires the medial borders of the
scapulae to move towards each other. If the recruitment
pattern remained ideal he was to perform the exercise
slowly for over 2 min, however at this initial session he
could not keep the recruitment ideal for very long at all.
This exercise is a good example of a direction control
exercise with the incline lean half push up dissociating a
stable scapulo-thoracic joint from gleno-humeral move-
ment (Fig. 5).

Figure 4 Lower abdominal pull in and breathe demonstra-

tion of hand positioning to differentiate between upper area of
the abdominal corset versus the lower area of the abdominal
PREVENTION & REHABILITATION: EDITORIAL

corset.

or pseudo winging) and keeps the glenoid elevated so as to

keep the distal end of the acromion off the structures that
lie between it and the top surface of the humeral head.
During movement the force couple works to dynamically
stabilise the scapula. Mr. H. was found to have the scapula
relatively protracted and tilted, glenoid down, and during
movement into shoulder flexion or abduction he main-
tained this orientation but hitched the scapula upwards
which allowed him to lift his hand. In the first session Mr. H.
showed some difficulty in recruiting the lower trapezius
without also recruiting the rhomboids. This meant that as
he tried to place the scapula into a more ideal start posi-
tion with the glenoid elevated, the scapula hitched. A
lower trapezius approach was discounted for this session. A
different strategy more focussed on the serratus anterior
was therefore tried. This involved using bodyweight in a
four point kneeling (quadruped) start position. He was
instructed to first hang his chest off his shoulder blades
allowing a separation between the posterior chest wall and
the scapulae. He was then asked to bring his chest up onto
the shoulder blades while broadening them. As this exer-
cise is relatively loaded (bodyweight) though still a
recruitment focused, low threshold exercise, Mr. H. was
able to achieve this manoeuvre, while not substituting with
the shoulder elevators, as the load provided greater
feedback. This was also taught to Mr. H. in an incline lean
standing position.
Mr. H. was given two exercises to practice this recruit- Figure 5 Demonstration of an incline lean half push up at its
ment skill. maximum elbow flexion point.
Prevention & rehabilitation: Editorial 157

Exercise: Salutes (Fig. 6) Exercise: pain free gleno-humeral abduction in

scaption (Fig. 7)
Mr. H. was asked to get into a quadruped start position and
holding the scapulae appropriately, as described above, he Mr H. was given a corrected scapula start position and
was asked to slowly salute first one hand to his forehead, shown how to move into it using a mirror for feedback. He
return the hand to the floor and then repeat the moment on was advised that the lower trapezius and serratus anterior
the other side. His attention was focussed on to the weight worked together to achieve this position, he was shown a
bearing side scapula positioning and serratus anterior model of the scapula and humerus, shown images of the
recruitment and isometric hold. Mr H. needed to have his muscle, a 1 min video of a subject with a poor scapula
attention drawn to his abdominal musculature to prevent placement and the technique as to how they needed to
(initially reduce) pelvic rotation as the hand just leaves the correct their scapula position and abduction movement. His
floor, thus linking his pelvic girdle to his shoulder girdle. lower trapezius was manually facilitated and his scapula
Again he was to build this exercise up to being able to was physically pulled into a correct start position. He was
perform it easily for over 2 min (Fig. 6). encouraged to feel his upper shoulder musculature to
Mr. H. was given an aide memoire for his exercises, given ensure he was not over-activating his shoulder elevators,
further advice about time scales of recovery and how to and he was instructed to abduct his arm with his hands
approach his occupational requirements and asked to re- approximately 15 in front of him e the plane of scaption.
turn twice more, a week between sessions. He was to stop at the point his impingement was about to
At his repeat visits Mr. H. was quizzed about his become evident, or if his shoulder elevated unduly. He was
compliance with the exercises, he had the execution of his also instructed to concentrate harder during the return
exercises checked and modified, and he was taught two from abduction to prevent the scapula from losing its ideal
new exercises. Focus was placed on his functional abilities positioning. This exercise focuses Mr. H.’s attention on his
and potential improvements and little focus was placed on control of his scapulo-thoracic joint while dissociating
his still present, though moderate pain. gleno-humeral movement. By limiting the movement to the
At the second session the focus for the quadruped Sa- pain free range re-aggravation of potentially inflamed tis-
lutes was changed as he had improved the ease at which he sues is minimised (Fig. 7).
could recruit the serratus anterior and was also beginning
to feel the contribution of the lower trapezius in scapula
placement. He was given a more difficult recruitment
challenge to now focus more on the saluting arms scapula

PREVENTION & REHABILITATION: EDITORIAL

positioning while maintaining the skill in holding the weight
bearing scapula’s position. The difficulty in the challenge
was to maintain the serratus recruitment with a lighter load
e the free moving, non weight bearing limb with its
reduced proprioceptive feed back coming in from the
muscular system into the CNS. Adding slightly to the chal-
lenge is the need to control the scapula’s small movement
to allow the salute and to consciously damp the automatic
desire, especially on the right, to allow the elevators to
dominate.
As the lower trapezius could now begin to be consciously
recruited another direction control exercise was instigated.

Figure 7 Demonstration of the mid position of a gleno-

Figure 6 Demonstration of a Salute exercise in quadruped. humeral abduction in scaption.
 158 Prevention & rehabilitation: Editorial

At the final session it was found that Mr. H. was

improving his ability to recruit the lower oblique corset
without breath holding. His ability to draw the abdominals
in gently and smoothly significantly more than at the first
session suggested that further abdominal work could now
be attained. As Mr. H. was at work and his tasks required
him to move around the theatre and climb stairs it was
decided not to give him a supine abdominal exercise but
rather one that reflected the activities he had to do on a
regular basis. As his standing hip flexion on the right showed
a right sided hip hitch and a right side bend, a standing hip
flexion exercise was chosen.

Exercise: standing hip flexion, weight transfer

to single leg stance (Fig. 8)

Mr. H. was asked to stand with his feet in parallel in front of

a mirror, pre-engage his oblique abdominals as he had with
Exercise 1. Lower abdominal pull in and breathe. He was
also encouraged to pre-engage his gluteus medius and turn
his femur out so his patellae pointed the same direction as
his feet. Then as he starts to lift his foot off the floor while
flexing both his hip and knee, he was to increase the use of
his abdominals and gluteals to keep his pelvis level. As he
moves to be fully standing on one leg he was to aim to
prevent excessive pelvic side shift/stance leg hip adduction
by keeping his umbilicus vertically above his stance legs
great toe. After holding this position for a few seconds he
was to repeat the movement onto the other leg while
PREVENTION & REHABILITATION: EDITORIAL

smoothly changing the sidedness of the abdominal and

gluteal contractions (Fig. 8).
At the end of the three sessions Mr. H. was beginning to
utilise musculature that could, over time, go on to be
dominant over his current movement pattern strategies and
give Mr. H. a chance to move to a more ideal pattern of Figure 8 Demonstration of Standing hip flexion, weight
movement. As he was a client presenting with pain it was transfer to single leg stance.
more appropriate to give him low threshold exercises
focussing on recruitment, though as he improves and his should be a model in which a ‘Physical Therapist will see a
needs change there are very likely to be true muscular lot of people, infrequently e like a yearly visit, or a check
weaknesses evident, especially as his occupation requires
up every six months.’ This will in effect mean that Physical
the lifting and carrying of loads. At that point another
Therapists will need to promote links with other disciplines
movement analysis could identify areas that may require and refer to personal trainers or Pilates teachers with a
further low threshold recruitment work, ‘time under
Movement Health plan and a ‘watch-out-for’ list to assist
attention’ but also specific strengthening ‘time under
the client in the exercise supervision and motivation. They
tension.’ should also refer to other specialists within or without their
own profession.
Adopting the movement system To go from the previous physical therapy model to the
suggested future one requires significant changes in how a
Professor Sahrmann is respected throughout the world but Physical Therapist views what they do. Sahrmann suggests
especially by the American Physical Therapy Association. that Physical Therapists need to, ‘adopt a system.’ She
Sahrmann has been critically looking at the profession and points out that a Cardiologist looks at the cardio-vascular
its future direction, in the Physiopedia interview system, that a Neurologist looks at the Neurological system,
(websource 1) she says that ‘physical therapy has tradi- so a Physical Therapist, she suggests, should be a specialist
tionally used a model where a Physical Therapist sees only a of the ‘Movement System’. Sahrmann clearly outlines an
few people, intensively, but for a short time,’ but, due to argument that the movement system can be defined as a
what is currently happening in American health care, with physiological system (Sahrmann 2014).
increasing costs to the client or the increasing difficulty in To be known as specialists of a system of the human
getting reimbursement for what a Physical Therapist may body means that the physiotherapy profession can look at
do with them, Sahrmann suggests that, ‘this business and the system in their own way and develop the tools best
practice model will have to change,’ she considers that this suited for managing that system. She suggests that within a
Prevention & rehabilitation: Editorial 159

current standard physical therapy session the Physical McNeill, W., 2014a. Pilates: ranging beyond neutral. J. Bodywor.
Therapist cannot diagnose a disc prolapse as being the Mov. Ther. 18, 119e123. Editorial.
cause of a sciatica, as that requires imaging to confirm, at McNeill, W., 2014b. Pilates: ranging beyond neutral e a practical
best, the Physical Therapist can perhaps identify a, ‘flexion discussion. J. Bodywor. Mov. Ther. 18, 124e129.
McNeill, W., 2014c. Are movement screens relevant for Pilates,
based lumbar spine problem with an associated peripheral
circus or dance? J. Bodywor. Mov. Ther. 18, 469e476. Editorial.
neuropathy.’ McNeill, W., 2014d. The double knee swing test e a practical
Sahrmann is inclusive and encouraging, she does not example of the performance matrix movement screen. J.
suggest that her diagnostic categories are all that those Bodywor. Mov. Ther. 18, 477e481.
interested in Movement Health need to use. She just sug- Mottram, S., Comerford, M., 2008. A new perspective on risk
gests that diagnostic categories looking at movement are assessment. Phys. Ther. Sport 9, 40e51.
used by those interested in physical therapies. Nijs, J., Meeus, M., Cagnie, B., Roussel, N.A., Dolphens, M., Van
To that end the papers included in this section of the Oosterwijck, J., Danneels, L., 2014. A modern neuroscience
JBMT also are about Movement and exercise. Validation of approach to chronic spinal pain: combining pain neuroscience
interater reliability in tests using a Pilates Classification education with cognition-targeted motor control training. Phys.
Ther. 94, 730e738.
system is the subject of Kwan et al.’s paper, and shows part
Richardson, C.A., Jull, G.A., 1995. Muscle control- pain control:
of the scientific process required to develop a system. Hügli what exercises would you prescribe? Man. Ther. 1, 2e10.
et al.’s paper is a pilot study looking at adherence to home Sahrmann, S.A., 2014. The human movement system: our profes-
exercises in non-specific low back pain. Prescribing specific sional identity. Phys. Ther. 94, 1034e1042.
exercise is all well and good e but only if the prescription is Tsao, H., Galea, M.P., Hodges, P.W., 2010. Driving plasticity in the
adhered to. motor cortex in recurrent low back pain. Eur. J. Pain. 14, 832e839.
Websource 1. http://www.physiospot.com/physiopedia/the-
movement-system-an-interview-with-shirley-sahrmann/.
Acknowledgements Worsley, P., Warner, M., Mottram, S., Gadola, S., Veeger, H.,
Hermens, H., Morrissey, D., Little, P., Cooper, C., Carr, A.,
Thanks to Sarah Mottram of Movement Performance Solu- Stokes, M., 2013. Motor control retraining exercises for shoulder
tions, whose vision of Movement Health is the basis of the impingement: effects on function, muscle activation, and
content of this Editorial and for the permission to quote her biomechanics in young adults. J. Shoulder Elb. Surg. 22 (4),
lectures and course notes. 11e19.

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