Multi-joint testing - it is all about the individual
Literature appears to be supporting what the experienced clinician instinctively knows; we need to assess and manage each patient/client very much as an individual.
Everyone finds their own way
A research group out of the University of Nantes wanted to explore whether they could identify a consistent task sharing strategy within the human quadriceps (i.e. is there a consistent pattern of compensation within the quads when you fatigue one of them, electrically). In the presence of selective fatigue of one of the quadriceps, the other knee extensors were seen to accommodate for this struggling synergist by increasing their contribution. However, there was not one consistent strategy seen as sometimes the vastus medialis, the rectus femoris or both muscles produced more force to compensate for a fatigued vastus lateralis (Bouillard et al, 2013). The take home message; each person solves movement problems in their own way.
Many ways to solve the same problem
In a related study, it emerged there is not only a lack consistency in the synergists used to accommodate fatigue or pain around a region but there is also a large degree of variance in the differing regions of the body employed, both above and below this site to help individuals get through a task (Hug et al., 2013). Take home 2; people use whatever they can to get the job done and it’s hard to correctly guess how they do this before you assess. Therefore, to increase not only quality of service but also effectiveness of retraining interventions, we need to assess each person’s unique approach to problem solving the movement demands of function, including pain, fatigue or any other factor likely to alter movement (previous injury, restriction). Therefore, there is need to consider multi-joint testing to identify how clients solve these issues.
Multi-joint testing – a clinic/field example
The ‘Double Knee Swing’ (DKS) is just one test from the multiple-test battery forming The Performance Matrix (TPM) (McNeill, 2014). See Mischiaiti (2015) for relaibility. Here we present it as a clinical example of multi-joint movement assessment, revealing client’s highly personalised approach to test’s demands.
The Back Story
First, we present a little background on the testing protocol. The testing procedure looks at three factors within movement control, the site, direction threshold® of movement control (Comerford & Mottram, 2012). A failure to control a movement is referred to as an uncontrolled movement (UCM). Within the test procedure, the client needs to know that they are being tested on their ability to control a specific movement, be given a chance to learn the test movement, be able to practice the control of the movement for a few repetitions, plus be corrected as necessary and then finally, perform the test - without feedback.
Double Knee Swing (DKS)
The DKS is a non-fatiguing (low threshold) test, so the load is body weight only. It is imperative the test movement gets to the benchmark position as this test identifies not ‘if’ but ‘how’ clients get through the demands of function. Any observed and questioned compensation may not be able to be prevented which would then be identified as a failure to pass this aspect of the test - thus defining the failure as an UCM.
The start position of the test moves from a parallel standing position to a small knee bend.
The test movement involves the knees swinging in tandem from side to side, rotating at the hip. The benchmark dictates that the knees have to reach 20° to each side.
Observing and questioning movement multi-joint movement
The tester is required to answer a number of questions about the client’s movement control.
A movement issue might be highlighted where the hip extensors do not recruit adequately during the test, seen by the client moving the trunk forward, as they increase flexion at the hip. This might not be a UCM unless the client has had this movement pattern pointed out to them and been given the chance to correct this potential fault (introducing a cognitive element to the testing process). If the client can prevent this strategy the client passes this part of the test. On occasions, the client may control the hip flexion tendency but swap it for another substitution pattern, so the tester then might need to make sure the client controls both potential movement faults. An uncontrolled movement needs to be proved to be uncontrolled before it can be recorded as such.
Another key question related to this test asks if the client can prevent rotation at the pelvis during the knee swing. For an individual to exhibit good ‘Movement Health’ (McNeill & Blandford, 2015) they are required to display control above (or below) the moving section. What might be visible to the tester is the fact that the pelvis just follows the direction that the knees swing to. The lumbo-pelvic rotation may start immediately the knees start to swing or rotation control might be exhibited during the early phase of the movement but before the knees get to the benchmark 20°, the rotation of the lumbopelvic becomes obvious. This is why reaching the benchmarks of the test are so important. If the client shows this lumbo-pelvic rotation which might only be one direction and not the other, and cannot control it consciously once it has been brought to their attention it is marked as UCM. What might cause this uncontrolled movement? The fundamental reason is that the rotation controllers of the lumbo-pelvic region, primarily the obliques and the gluteals particularly those gluteals with an oblique fibre direction such as the gluteus medius posterior, are not engaged enough to stop the lumbo-pelvic rotation.
The potential influence of synergies
As this test is a low threshold test, looking at controlling of non-fatiguing postural loads, the movement strategy used should suggest an easy recruitment of the obliques and gluteals. In a situation where a client has selectively favoured strengthening aspects of the superficial hip flexors muscles such as the Tensor Fascia Lata (TFL), this structure may become dominant, making it extremely difficult for the obliques and gluteals to work in an easy, low threshold manner to dissociate lumbo-pelvic rotation from hip rotation. Synergy dominance, therefore, may be a key reason for this failure, however there may be adequate length in the superficial hip flexors and the problem may then be related to an under recruitment of the rotation controllers in this area.
Truly client specific
Therefore, in this test, clients may display very different solutions, at the site moved (hip) or at the region above (lumbo-pelvic), to solve the same movement challenge. These are only considered of clinical relevance if they cannot be prevented, once the client is aware of their presence and has had the opportunity to limit their occurrence. This ‘lack of choice’ in movement is a display of compromised Movement Health. The use of multi-joint, multi-directional assessment reveals the choices lost in our client’s movement problem solving strategies.
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Bouillard, K., Jubeau, M., Nordez, A., & Hug, F. (2014). Effect of vastus lateralis fatigue on load sharing between quadriceps femoris muscles during isometric knee extensions. Journal of neurophysiology, 111(4), 768-776.
Comerford, M., & Mottram, S. (2012). Kinetic Control-E-Book: The Management of Uncontrolled Movement. Elsevier Health Sciences.
Hug, F., Hodges, P. W., & Tucker, K. (2014). Task dependency of motor adaptations to an acute noxious stimulation. Journal of neurophysiology, 111(11), 2298-2306.
McNeill, W. (2014). The double knee swing test–a practical example of the performance matrix movement screen. Journal of bodywork and movement therapies, 18(3), 477-481.
McNeill, W., & Blandford, L. (2015). Movement Health. Journal of bodywork and movement therapies, 19(1), 150-159.
Mischiati, C., Comerford. M., Gosford, E., Swart, J., Ewings, S., Botha, N., Stokes, M., Mottram, S. (2015)
Intra And Inter-Rater Reliability of Screening for Movement Impairments: Movement Control Tests from The Foundation Matrix Journal of Sports Science and Medicine, 14, 427-440
Mottram, S., & Comerford, M. (2008). A new perspective on risk assessment. Physical Therapy in Sport, 9(1), 40-51.
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