2012 Teleseminar Interview 1 - Dr. S . . .
2012 Teleseminar Interview #1 - Dr. Shirley Sahrmann
Dr. Shirley Sahrmann discusses the principles behind Movement System Impairment Syndromes including defining the movement system and why it is so important, how she classifies the syndromes, accessory motion hypermobility, and more. She also discusses some unique assessment and treatment ideas for the cervical spine, thoracic spine, knee, and foot/ankle.
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Shirley Sahrmann, PT, PhD, FAPTA is an associate professor of physical therapy and neurology at Washington University School of Medicine, St Louis Missouri. She received her doctorate in neurobiology from Washington University School of Medicine. Dr Sahrmann is director of the Movement Science Program. She has received Washington University's Outstanding Faculty Award. She is a Catherine Worthington Fellow of the American Physical Therapy Association and is a recipient of the Association's Lucy Blair Service Award and the Marian Williams Research Award. She has served on the APTA's Board of Directors, many committees, task forces, and as President of the Missouri Physical Therapy Association.
Dr Sahrmann, in addition to her numerous national presentations, has been a keynote speaker at the World Confederation of Physical Therapy the Biennial Manipulative Physiotherapist Conference and the Australian and New Zealand annual conferences. Her research interests are control of movement, factors affecting tone, and the classification of patients with movement dysfunction from neurological lesions and with mechanically induced pain syndromes. She maintains an active practice, specializing primarily in patients with musculoskeletal pain syndromes.
You can find Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines at Amazon.com
Cervical Extension Syndrome
In this syndrome, the imprecise movement is cervical extension, and is often associated with loss of ROM and/or pain. There tends to be an altered distribution of extension across the cervical spine, and an imbalance between the cervical extensors and flexors. The extrinsic muscles also tend to create excessive horizontal translation of the vertebrae. A forward head posture with thoracic kyphosis is usually what you will see.
She does mention seeing different movement patterns with age as well. In younger patients she says you may see excessive posterior translation versus sagittal plane rotation and/or excessive motion. For the older folks, especially with some level of spinal degeneration present, its more likely to see a FHP with anterior translation. They are unable to get into an extended position, and what they do get occurs much more in the upper cervical spine than lower.
Movement Impairment Analysis
**Remember as I go through these, that the tests usually become the exercise.
Sitting tests AROM C-spine
Correction of Alignment - correct FHP, if there was pain at rest is it improved or eliminated? What happens with extension ROM and symptoms now?
Passive elevation of the shoulder girdle - the therapist would elevate the shoulder girdle from behind or have the patient rest the arms on pillows on their lap to take away the downward pull of the extremities. Now re-check AROM and assess for changes in ROM and symptoms.
Passive elevation of the ribcage - this is another move that may decrease symptoms and improve motion. They describe using this test with someone with over-developed (stiff) abdominals pulling the ribcage down and contributing to kyphosis. Elevation improves positioning, and decreases tension on the scalenes.
Supine Tests Active cervical flexion - cervical flexion movement impairment is often seen in this syndrome as well due to the FHP so it will also be assessed here. The primary impairment is excessive anterior translation so watch for that as the patient attempts to go 'chin to chest'.
MMT of cervical flexors - watch for the patient to maintain the chin tucked position throughout the chin to chest move. What you will normally see here is a 'chin poke' indicating dominance of the SCM and scalenes over the deep cervical flexors.
Assisted cervical flexion - manually assist the patient through the proper path of movement not allowing for a chin poke. Assess range and symptoms, they should improve.
Prone and Quadruped Tests Active cervical extension - looking for pure sagittal rotation versus posterior translation. This helps to determine the effectiveness of the intrinsics vs extrinsics, and often times the levator will very obviously be overactive.
Correction of cervical extension - this can be done manually or verbally - "pretend there is a pole running between your ears and you are rolling around the pole". Watch for change in ROM quality and symptoms.
Quadruped rocking - have the patient rock back toward the heels and look for compensatory cervical extension. This is believed to occur because of lengthening of the levator as shoulder flexion occurs (and scapular rotation)
Correction during quadruped rocking - facilitate capital flexion (she uses "chin to Adam's apple") throughout the movement, and monitor symptoms.
4pt Rocking with Compensatory Cervical Extension
One of Sahrmann's hallmarks for any MSIS is alteration of postures and activities throughout the day to normalize patterns of movement and decrease forces on the cervical spine. It is definitely a more conscious approach. An obvious correction is that of the forward head posture through correct position of the spine, lumbar up through the cervical. Also finding ways to support the upper extremities while seated and driving to reduce the pull on the neck. Special attention will also need to be given to those who use repetitive arm movements. After completing this chapter, I went back and reviewed her previous book a bit on scapular and shoulder movement impairment which was a big help.
Seated Capital Flexion - back to the wall and pillows on the lap supporting the UE's. Improve spinal alignment as much as possible. The patient may or may not be able to touch the back of the head to the wall. Have the patient 'roll' the chin and head toward the base of the neck while keeping the head on, or close to, the wall. Basically encouraging recruitment of the cervical intrinsics while lengthening the suboccipital muscles.
Supine Strengthening of the Intrinsics (a.k.a. Deep Cervical Flexors) - the patient is placed in hooklying, and with UE's supported on pillows. A small towel roll may be needed under the head if improved alignment is needed. There are three stages to this: Capital flexion (without head lift)
Capital flexion then assisted head lift
Capital flexion with head lift
Prone and Quadruped Strengthening (see videos)
Prone Capital Flexion
Prone Capital Flexion + Cervical Extension
The two previous exercises can be progressed to quadruped as well.
4pt. Rocking + Capital Extension
Seated Shoulder Abduction/Lateral Rotation - the patient is seated with the back to the wall as discussed previously. Begin with capital flexion which must be maintained throughout the movement. The patient then attempts to slide the backs of the hands up the wall behind them, but only to the point they can maintain their positioning. If you've ever attempted this its much easier said than done. I do find most of my patients may be able to get only their fingertips to the wall which is fine.
Seated Shoulder Flexion - same position as above maintaining posture and capital flexion throughout the motion. Begin with the shoulders in 90 degrees of flexion with the palms facing the patient. The patient flexes the shoulders from there but only so far as they are able to maintain alignment. Eventually resistance may be added with theraband or small weights.
Capital Flexion with Wall Slides
Facing the wall would be the next step as in the video above. Posture must be held without the cuing from the wall.
Tibiofemoral Rotation (TFR) w/ valgus (TFRVAL) and w/ varus (TFRVAR)
The principal impairment in this syndrome is knee pain with femoral medial rotation and tibial lateral rotation. The subcategories are w/ valgus or w/ varus. Correction of faulty alignment/movement reduces symptoms. This syndrome is commonly seen in sports or activities that require 'toeing out' such as with ballet dancers, soccer, and skaters. Also see this quite often diagnosed as ITB syndrome with pain at the lateral knee.
Key Tests and Signs -
Standing alignment shows medial rotation of the femur and/or lateral rotation of the tibia.
Valgus collapse with step down, squat, lunge, hopping/jumping
Prone or standing knee flexion will see tibial ER (foot turns out)
Thomas test: short ITB/TFL - if maintain the hip in neutral add/abd, may see the tibia ER. Correcting this decreases pain.
Weak hip external rotators.
Treatment Options -
The ultimate goal is to reduce rotation at the tibiofemoral joint. In standing, unlock the knees if the patient tends to stand in hyperextension, and teach the patient to align the knees over the feet with neutral hip rotation. These strategies should decrease pain.
During gait, avoid knee hyperextension and femoral internal rotation during stance phase. Dr. Sahrmann often cues the patient to contract the glutes during stance phase to promote a more neutral hip alignment. If they have trouble doing this during walking, start with simple weight shifting drills.
Sitting and standing with neutral limb alignment
Walking up stairs, work to maintain neutral limb alignment, ensure the tibia advances over the foot, and avoid pulling the knee back to meet the body (hamstring overuse).
Running on cambered surfaces is asking for ITB syndrome
Exercise Options - Improve muscle performance of the hip external rotators and specifically posterior gluteus medius. From easiest to most difficult:
- prone hip ER isometrics
- prone hip abduction
- Side lying hip abduction w/ hip ER
- Hip ER against resistance
- Lunges using a band to pull the knee into valgus (basically as Gray has described) Improve muscle performance of the gluteus maximus
- prone hip extension with the knee flexed - pt. must be able to control the tibial rotation that often occurs with knee flexion first.
- lunges and squats Quadricep exercises (step ups, lunges, etc) may be appropriate but she warns that increased quadricep activity has been shown to increase the progression of OA in knees with malalignment. Basically, consider the extra compression forces with the exercise, there should be no increase in pain, and the patient should maintain good alignment. If these things can happen, then no problem performing the exercise. Increase extensibility of the TFL and rectus femoris (least aggressive to more aggressive) - abdominal activation may be need to control anterior pelvic tilt.
- prone bilateral knee flexion - knees and feet together to control for tibial rotation
- prone lateral hip rotation - avoid ER of tibia
- Thomas test position stretching - in this case, the femur will tend to abduct so work to bring it into a neutral position preventing tibial ER.
- Ober test position - hip in ER and tibia in neutral to internal rotation Increase extensibility of the Gastrocs and hamstrings - traditional stretches are fine but be picky about alignment.
Other Strategies Orthotics for excessive pronation with valgus or to improve shock absorption for the rigid supinator
Posterior knee X taping - the strips of tape running from the proximal lateral thigh around the back of the knee to the distal medial tibia controls femoral IR and tibial ER. The strips of tape in the opposite direction are added for symmetry and to assist in some cased with preventing knee hyperextension.
Unloader brace for more significant OA