Screenshot 2022-04-17 at 12.08.10 AM

Kinetic Control
Kinetic Control
The Management of
Uncontrolled Movement
Mark Comerford, BPhty, MCSP, MAPA

Director, Movement Performance Solutions
Sarah Mottram, MSc, MCSP, MMACP

Director, Movement Performance Solutions
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto

Churchill Livingstone
is an imprint of Elsevier
Elsevier Australia. ACN 001 002 357

(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067
© 2012 Elsevier Australia
This publication is copyright. Except as expressly provided in the Copyright Act 1968
and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication
may be reproduced, stored in any retrieval system or transmitted by any means (including
electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior
written permission from the publisher.
Every attempt has been made to trace and acknowledge copyright, but in some cases this
may not have been possible. The publisher apologises for any accidental infringement
and would welcome any information to redress the situation.
This publication has been carefully reviewed and checked to ensure that the content is as
accurate and current as possible at time of publication. We would recommend, however, that
the reader verify any procedures, treatments, drug dosages or legal content described in this
book. Neither the author, the contributors, nor the publisher assume any liability for injury
and/or damage to persons or property arising from any error in or omission from this publication.
National Library of Australia Cataloguing-in-Publication Data
Comerford, Mark
Kinetic control: the management of uncontrolled movement
/Mark Comerford, Sarah Mottram.
9780729539074 (pbk.)
Includes index.
Movement disorders – Classification.
Movement disorders – Diagnosis.
Movement disorders – Treatment.
Mottram, Sarah.
616.8
Publisher: Melinda McEvoy

Developmental Editor: Rebecca Cornell
Publishing Services Manager: Helena Klijn
Project Coordinators: Natalie Hamad and Karthikeyan Murthy
Edited by Stephanie Pickering
Proofread by Forsyth Publishing Services
Cover design by Lisa Petroff
Illustrations by Rod McClean
Index by Robert Swanson
Typeset by Toppan Best-set Premedia Limited
Printed by CTPS
Contents
Preface ............................................................ vii Section 2

Foreword .......................................................... ix
5 The lumbopelvic region .......................... 82
Acknowledgements ......................................... xi
Reviewers ......................................................... xi
6 The cervical spine ................................... 218
Section 1 7 The thoracic spine ................................. 292
1 Uncontrolled movement ........................... 3

8 The shoulder girdle ............................... 362
2 Muscle function and physiology ............ 23 9 The hip .................................................... 414
Index ............................................................. 505

3 Assessment and classification of
uncontrolled movement .......................... 43
4 Retraining strategies for

uncontrolled movement .......................... 63
v
Preface
Preface
This book presents a comprehensive system for the assessment and retraining of
movement control. It has been in evolution for the last 25 years.
Uncontrolled movement has a significant impact on the development of move-
ment disorders and pain. The scientific support for the process of the assessment and
retraining of uncontrolled movement has been steadily expanding particularly in the
last 10 years. The influence of uncontrolled movement on symptoms, especially pain,
movement function, recurrence of symptoms and disability is now well established.
We believe that in the next 10 years the literature will support that the presence of
uncontrolled movement will also be recognised as a predictor of injury risk and as
having an influence on performance.
Uncontrolled movement can be identified by movement control tests. People with
pain demonstrate aberrant movement patterns during the performance of these
movement control tests. A growing body of evidence supports the use of movement
control tests in the assessment and management of chronic and recurrent pain. The
identification of uncontrolled movement in terms of the site, direction and threshold
of movement impairment is a unique subclassification system of musculoskeletal
disorders and pain. The movement testing process proposed enables the classification
of uncontrolled movement into diagnostic subgroups that can be used to develop
client-specific retraining programs. This process can determine management priori-
ties and optimise the management of musculoskeletal pain and injury recurrence.
Subclassification is now recognised as being the cornerstone of movement assess-
ment and the evidence for subclassification of site, direction and threshold is growing.
This book details a structured system of testing, clinical reasoning and specific retrain-
ing. This system does not preclude other interventions as it is designed to enhance
the management of musculoskeletal disorders.
The Kinetic Control process has come a long way in last 25 years. The motivation
for the development of the Kinetic Control process was to find a way to blend the
new and exciting concepts in movement dysfunction into an integrated clinical
process, built on the foundation of a solid clinical reasoning framework. Our aim is
to gain a better understanding into the inter-relationship between the restrictions of
movement function and movement compensations. The breakthrough came with
the realisation that some compensation strategies are normal adaptive coping mecha-
nisms and do not demonstrate uncontrolled movement, while others are maladap-
tive compensation strategies that present with uncontrolled movement. This led us
to develop the structured assessment process detailed in this text including the Move-
ment Control Rating System (Chapter 3). This clinical assessment tool can identify
movement control deficiencies and be valuable for reassessing improvements in
motor control efficiency.
vii
Preface
Recurrent musculoskeletal pain has a significant impact on health care costs,

employment productivity and quality of life. Uncontrolled movement can be identi-
fied by observation, and corrective retraining of this uncontrolled movement may
have an influence on onset and recurrence of symptoms. To date, outcome measures
in terms of changes in range and strength, have not influenced the onset and recur-
rence of injury. The ability to assess for uncontrolled movement and to retrain move-
ment control is an essential skill for all clinicians involved in the management of
musculoskeletal pain, rehabilitation, injury prevention, and those working in health
promotion, sport and occupational environments. Preventing the recurrence of mus-
culoskeletal pain can both influence quality of life and have an economic impact.
Movement control dysfunction represents multifaceted problems in the movement
system. Skills are required to analyse movement, make a clinical diagnosis of move-
ment faults and develop and apply a patient-specific retraining program and manage-
ment plan to deal with pain, disability, recurrence of pain and dysfunction. The
mechanisms of aberrant movement patterns can be complex, so a sound clinical
reasoning framework is essential to determine management goals and priorities. We
present an assessment framework which will provide the option to consider four key
criteria relevant to dysfunctional movement: the diagnosis of movement faults (site
and direction of uncontrolled movement), the diagnosis of pain-sensitive tissues
(patho-anatomical structure), the diagnosis of pain mechanisms and identifying
relevant contextual factors (environmental and personal). This clinical reasoning
framework can help identify priorities for rehabilitation, where to start retraining
and how to be very specific and effective in exercise prescription to develop indi-
vidual retaining programs.
Uncontrolled movement can be reliably indentified in a clinical environment and
related to the presence of musculoskeletal pain, to the recurrence of musculoskeletal
pain and to the prediction of musculoskeletal pain. We hope this text will enable
clinicians worldwide to effectively identify and retrain uncontrolled movement and
help people move better, feel better and do more.
Mark Comerford
Sarah Mottram
2011
viii
Preface
Foreword
Comerford and Mottram are to be commended for their extensive and comprehen-
sive presentation of factors involved in movement dysfunctions. This book shares
several of my own strong beliefs that have implications for the management of mus-
culoskeletal pain conditions. Those beliefs are: 1) recognising and defining the
movement system; 2) identifying and describing pain syndromes based on move-
ment direction; 3) identifying the primary underlying movement dysfunction; 4)
describing the various tissue adaptations contributing to the movement dysfunction;
and 5) developing a treatment program that is comprehensive and based on the
identified contributing tissue adaptations. I also share with the authors a belief that
the treatment program requires the patient’s active participation, which can range
from control of precise, small, low force requiring movements to total body large
force requiring movements. Historically – and still prevalent – is the belief that
tissues become pathological as an inevitable outcome of trauma, overuse and ageing.
The result is a focus on identifying the patho-anatomical structure that is painful
rather than on identifying the possible contributing factors, or even how movement
faults can be an inducer. We are all aware that movement is necessary to maintain
the viability of tissues and bodily systems. Almost daily, studies are demonstrating
the essential role of movement, in the form of exercise or activity, in achieving or
maintaining health. Yet there is very little recognition that there are optimal ways of
moving individual joints and limb segments as well as the total body. Similarly there
is little recognition that painful conditions can be treated by correcting the move-
ment rather than resorting to symptom-alleviating modalities, drugs or surgery.
Optimal alignment when maintaining prolonged postures, such as sitting, is not
considered to be necessary. I believe the situation is analogous to that of diet. For
many years, no one worried about the effect on a person’s health of the type or
amount of food that was consumed. Indeed, more money is still spent on the align-
ment of the teeth than on the alignment of the body, though the function of the
body is more affected by alignment faults than eating is by poor alignment of the
teeth.
This book serves to reinforce and define the characteristics of the movement system
and how they contribute to movement dysfunctions associated with pain syndromes.
The authors have done an extensive review of the relevant literature describing the
dysfunctions of the nervous and muscular systems. They have provided a detailed
description of a key underlying factor, designated as uncontrolled movement, which
then provides a basis for the treatment program. The detailed descriptions of the
syndromes, key observations and examination forms should be most helpful in
guiding the clinician. Building upon the information taken from the examination,
the treatment program is also described in detail. What is particularly noteworthy is
the incorporation of most of the perspectives and methods used by the best known
ix
Foreword
approaches to musculoskeletal pain. The authors have organised the rationale and
methods from these varying approaches into a comprehensive approach. Comerford
and Mottram have done a thorough job of describing all aspects of what could be
considered the ‘psychobiosocial’ model of analysis and treatment of musculoskeletal
pain. The timeliness of this book is reflected by the incorporation of their concepts
to the International Classification of Functioning, Disability, and Health. As stated
previously this book has its particular value in the comprehensiveness and detailed
descriptions of possible tissue dysfunctions as reported in the literature, methods of
analysis and treatment. The reader will be truly impressed by the many complexities
of the movement system and the rigorous analysis that is required to understand,
diagnose and treat the dysfunctions that can develop and contribute to pain syn-
dromes. The authors have truly provided an outstanding text in its inclusive and
thorough discussion of the topic of movement dysfunction.
Shirley Sahrmann, PT, PhD, FAPTA

Professor Physical Therapy, Neurology, Cell Biology and Physiology
Washington University School of Medicine – St. Louis
x
Acknowledgements
The content of this book has been a work in progress since 1988. The background
to the development of the assessment and retraining of uncontrolled movement has
been influenced by the work of Shirley Sahrmann, Vladamir Janda, Gwendolyn Jull,
Paul Hodges, Carolyn Richardson and Maria Stokes. Since 1995 many colleagues
within Kinetic Control and Performance Stability have helped with the development
of the clinical tests and the consolidation of theoretical frameworks. Erik Thoomes
contributed to the clinical reasoning process in Chapter 1. We would very much like
to thank all these people for their contribution through inspiration, advice, support
or feedback. We both appreciate the support of our family and friends and in par-
ticular Mark’s wife Selina, without whom he would not have found the time to devote
to this project.
Reviewers
Technical Reviewer Philippa Tindle BSc. BA. MCSP

Prue Morgan M.App.Sc (Research), B.App.Sc (Physio) Member of Chartered Society of Physiotherapy and
Grad Dip Neuroscience Registered with the Health Professions Council (HPC)
Specialist Neurological Physiotherapist, FACP
Lecturer, Physiotherapy
Monash University
xi
Section 1
1
Chapter 1
Uncontrolled movement
The key to managing movement dysfunction is The movement system comprises the coordi-
thorough assessment. This includes the deter- nated interaction of the articular, the myofascial,
mination of any uncontrolled movement (UCM) the neural and the connective tissue systems of
and a comprehensive clinical reasoning process the body along with a variety of central nervous
by the clinician to evaluate contributing factors system, physiological and psycho-social influ-
which influence the development of UCM. This ences (Figure 1.1). It is essential to assess and
first chapter details the concept of UCM and the correct specific dysfunction in all components of
clinical reasoning process which is the framework the movement system and to assess the mechani-
for assessment and rehabilitation. cal inter-relationships between the articular, myo-
fascial, neural and connective tissue systems. This
chapter will describe a systematic approach to
evaluation of the movement system and identifi-
UNDERSTANDING MOVEMENT cation of the relative contributions of individual
AND FUNCTION components to movement dysfunction.
Normal or ideal movement is difficult to define. Movement faults

There is no one correct way to move. It is normal
to be able to perform any functional task in Identifying and classifying movement faults is
a variety of different ways, with a variety of dif- fast becoming the cornerstone of contemporary
ferent recruitment strategies. Optimal movement rehabilitative neuromusculoskeletal practice
ensures that functional tasks and postural control (Comerford & Mottram 2011; Fersum et al 2010;
activities are able to be performed in an efficient Sahrmann 2002). In recent years clinicians and
way and in a way that minimises and controls researchers have described movement faults and
physiological stresses. This requires the integra- used many terms to describe these aberrant pat-
tion of many elements of neuromuscular control terns. These terms include substitution strategies
including sensory feedback, central nervous (Richardson et al 2004; Jull et al 2008), compen-
system processing and motor coordination. If this satory movements (Comerford & Mottram
can be achieved, efficient and pain-free postural 2001a), muscle imbalance (Comerford & Mottram
control and movement function can be main- 2001a; Sahrmann 2002), faulty movement
tained during normal activities of daily living (Sahrmann 2002), abnormal dominance of the
(ADL), occupational and leisure activities and in mobiliser synergists (Richardson et al 2004;
sporting performance throughout many years of Jull et al 2008), co-contraction rigidity (Comer-
a person’s life. ford & Mottram 2001a), movement impairments

DOI: 10.1016/B978-0-7295-3907-4.00001-3 3
Kinetic Control: The management of uncontrolled movement
Movement system
Articular system
Myofascial system
• physiological/functional
• accessory/translational Active force transmission
• afferent feedback • static controllers of posture
isometric co-contraction
Psycho-social
• dynamic movement
influences
concentric – production and acceleration of movement
Connective eccentric – control and deceleration of momentum
Behavioural and affective tissue system • afferent feedback
‘yellow flags’
proprioception
• movement anxiety Links all systems
• fear-avoidance • structure and support Neurogenic
• poor coping skills • energy storage sensitisation
• depression • passive force transmission
• blame transference • proprioception and feedback Neurogenic sensitisation and associated 2°
• abnormal pain beliefs allodynia and hyperalgesia
• exaggerated pain • altered thresholds of Wide Dynamic Range
behaviour receptors in lamina V dorsal horn
Neural system
• abnormal ion channels within CNS
neurons
• motor control via • abnormal sensitivity of peripheral
sensory-motor integration neurodynamic mobility
• neurodynamics
Figure 1.1 Inter-related components of the movement system
(Sahrmann 2002; O’Sullivan et al 2005) and syndromes are seldom caused by isolated events;
control impairments (O’Sullivan et al 2005; and that habitual movements and sustained
Dankaerts et al 2009). All of these terms describe postures play a major role in the development of
aspects of movement dysfunction, many of which movement dysfunction. These statements have
are linked to UCM. been fundamental in the development of the
The focus of this text is to describe UCM and movement dysfunction model. Clinical situations
explore the relationship of UCM to dysfunction which have a major component of movement
in the movement system (Comerford & Mottram dysfunction contributing to pain include: pos-
2011). Movement dysfunction represents multi- tural pain; pain of insidious onset; static loading
faceted problems in the movement system and or holding pain; overuse pathology (low force
the therapist needs the tools to relate UCM and repetitive strain or high force and/or impact
faults in the movement system to symptoms, repetitive strain); recurrent pain patterns; and
recurrence of symptoms and disability. Skills are chronic pain.
required to analyse movement, make a clinical It is important to identify UCM in the func-
diagnosis of movement faults and apply a patient- tional movement system. It is our hypothesis that
specific retraining program and management the uncontrolled segment is the most likely source
plan to deal with pain, disability, recurrence of of pathology and symptoms of mechanical origin.
pain and dysfunction. There is a growing body of evidence to support
Sahrmann (2002) has promoted the concept the relationship between UCM and symptoms
that faulty movement can induce pathology, not (Dankaerts 2006a, 2006b; Luomajoki et al 2008;
just be the result of it; that musculoskeletal pain van Dillen et al 2009). The direction of UCM
4
Uncontrolled movement Chapter |1|
relates to the direction of tissue stress or strain

and pain producing movements. Therefore it is Symptoms Dysfunction
important in the assessment to identify the site
and the direction of UCM and relate it to the
symptoms and pathology. The UCM identifies the
Disability Recurrence
site and the direction of dynamic stability dysfunc-
tion and is related to the direction of symptom-
producing movement. For example, UCM into
lumbar flexion under a flexion load may place Risk Performance
abnormal stress or strain on various tissues and
result in lumbar flexion-related symptoms. Like-
wise, uncontrolled lumbar extension under exten- Figure 1.3 Factors relating to the site and direction of
sion load produces extension-related symptoms, uncontrolled movement
while uncontrolled lumbar rotation or side-bend
and/or side-shift under unilateral load produces
unilateral symptoms.
Symptoms
Symptoms are what the patient feels and com-
plains of and include pain, paraesthesia, numb-
IDENTIFICATION AND CLASSIFICATION ness, heaviness, weakness, stiffness, instability,
giving way, locking, tension, hot, cold, clammy,
OF UCM nausea and noise. The treatment of symptoms is
often the patient’s highest priority and is a primary
Figure 1.2 illustrates the link between UCM and short-term goal of treatment.
pain. Abnormal stress or strain that exceeds tissue Pain is frequently one of the main symptoms
tolerance can contribute to pain and pathology. that the patient presents with to the therapist and
The relationship between UCM and pain/ is inherently linked to movement dysfunction.
pathology will be explored further in Chapter 3. Contemporary research clearly demonstrates that
In this text the identification and classification individuals with pain present with aberrant
of movement faults are described in terms of site movement patterns (Dankaerts et al 2006a, 2009;
and direction of UCM. These movement faults Falla et al 2004; Ludewig & Cook 2000; Luoma-
will be discussed in Chapter 2 in relation to joki et al 2008; O’Sullivan et al 1997b, 1998).
changes in motor recruitment and strength (Com- Research has demonstrated a consistent finding:
erford & Mottram 2001b, 2011). Scientific litera- in the presence of pain, a change occurs in recruit-
ture and current clinical practice are linking the ment patterns and the coordination of synergistic
site and direction of UCM in relation to symp- muscles. Individuals with pain demonstrate pat-
toms, disability, dysfunction, recurrence, risk and terns of movements that would normally be used
performance (Figure 1.3). only in the performance of high load or fatiguing
tasks (e.g. pushing, pulling, lifting weights) to
perform low load non-fatiguing functional tasks
(e.g. postural control and non-fatiguing normal
movements). Clearly UCM is a feature of many
Uncontrolled
musculoskeletal pain presentations and identify-
movement
ing and classifying these movement faults is
essential if therapists are to effectively manage
Abnormal symptoms by controlling movement faults.
stress or strain
Disability
Disability is the experienced difficulty doing
Pain Pathology activities in any domain of life (typical for one’s
age and sex group, e.g. job, household manage-
Figure 1.2 Uncontrolled movement: the link to pain and ment, personal care, hobbies, active recreation)
pathology due to a health or physical problem (Verbrugge &
5
Jette 1994). Movement faults are related to disa- treatment or therapy over a variable timeframe
bility. For example, Lin et al (2006) demonstrated and subsequent reassessment of dysfunction pro-
that changes in scapular movement patterns (in vides the basis of evidence-based practice. Reduc-
particular a loss of posterior tilt and upward rotation of dysfunction is a primary short-term goal
tion) correlated significantly with self-report and of therapeutic intervention, although the patient
performance-based functional measures indicat- is frequently symptom free before dysfunction
ing disability. The relationship between disability is corrected. Treatment should not cease just
and movement faults has been identified in many because the symptoms have disappeared, but may
other fields of physical therapy (e.g. neurological need to continue until no more dysfunctions are
and amputee rehabilitation). Indeed, in relation measurable.
to gait dysfunction, management and retraining The process of identifying and measuring UCM,
of UCM is a key factor in rehabilitation of people and linking UCM to musculoskeletal pain, and
with lower limb amputations using a prosthesis to changes in muscle function, is a developing
(Hirons et al 2007). area of active research in the field of pain and
Reduction of disability is the primary long-term movement dysfunction (Gombatto et al 2007;
goal of therapy or rehabilitation. Disability is Luomajoki et al 2007, 2008; Mottram et al 2009;
individual and what one person considers disa- Morrissey et al 2008; Scholtes et al 2009; Roussel
bility another person might consider exceptional et al 2009a; van Dillen et al 2009). Muscle dys-
function. For example, an elite athlete’s disability function is most clearly apparent in people with
may be a function that most people do not have pain (Falla & Farina 2008; Hodges & Richardson
the ability to do, do not want to do or need to 1996; Hungerford et al 2003; Lin et al 2005). The
do. Movement dysfunction, however, can affect a changes in muscle function underlying pain can
person’s ability to function independently and present in two ways: 1) as altered control strat-
therefore decrease quality of life. The disablement egies (van Dillen et al 2009; O’Sullivan 2000);
process model in disease as well as in rehabilita- and 2) as physiological peripheral muscle changes
tion is gaining recognition (Escalante & del (Falla & Farina 2008). Physiological changes
Rincon 2002; Verbrugge & Jette 1994) and retrain- associated with muscle dysfunction are discussed
ing movement faults has been shown to improve further in Chapter 2, and altered control strategies
function (O’Sullivan et al 1997a; Stuge et al are discussed further in Chapter 3.
2004).
Recurrence
Dysfunction
The correction or rehabilitation of dysfunction
Dysfunction can imply disturbance, impairment has been shown to decrease the incidence of pain
or abnormality in the movement system. It can recurrence (Hides et al 1996; Jull et al 2002;
be objectively measured and quantified and/or O’Sullivan et al 1997a). This reinforces the need
compared against a normal or ideal standard for therapy to be aimed at correcting dysfunction
or some validated or calculated benchmark. in the management of musculoskeletal disorders
These impairments may present as weakness, and not just relieving symptoms.
stiffness, wasting, sensory–motor changes (includ-
ing proprioception changes, altered coordination
Risk of injury
and aberrant patterns or sequencing of muscle
recruitment) or combinations of several impair- Evidence suggests history of injury is a predictive
ments. Dysfunction measurements include: joint factor for re-injury and therefore outcome meas-
range of motion (physiological or accessory); ures that are defined in terms of normal range of
muscle strength (isometric, concentric, eccentric, joint motion and muscle strength are inadequate
isokinetic, power and endurance); muscle length; to prevent recurrence (Mottram & Comerford
flexibility; stiffness; speed; motor control (recruit- 2008). Making the link between UCM and pain
ment, inhibition, coordination and skill per- is not new, but the concept of linking it to injury
formance); bulk (girth, volume, cross-sectional prevention is.
area); and alignment. Some recent research has highlighted the
A baseline measurement of dysfunction, fol- potential for linking UCM to risk of injury. A
lowed by an intervention with some form of recent study on dancers identified two movement
6
control tests that may be useful for the identifica- risk of injury and performance. This model has
tion of dancers at risk of developing musculo- been developed through the analysis and synthe-
skeletal injuries in the lower extremities (Roussel sis of historical and contemporary research from
et al 2009a). Athletes with decreased neuromus- many sources; however, it is not intended to be a
culoskeletal control of the body’s core (core sta- comprehensive summary of the current level of
bility) are at an increased risk of knee injury knowledge surrounding movement analysis.
(Zazulak et al 2007). Indeed, there is now growing Kendall and colleagues (2005) described muscle
evidence that motor control and physical fitness function in detail. Their now classic text has been
training prevent musculoskeletal injuries (Roussel the foundation for assessment of muscle func-
et al 2009b), highlighting the importance for tion, especially with reference to the graded
therapists to be more knowledgeable about move- testing of muscle strength and analysing the inter-
ment control and function. relationship of strength and function. Janda
(1986) had previously developed the concept of
muscle imbalance and patterns of dysfunction by
Performance
analysing the pattern of movement sequencing.
At present there is little published literature to His primary intervention was to increase extensi-
relate UCM to performance. However, anecdotal bility of short muscles. Sahrmann (2002) and
empirical evidence has shown that retraining co-workers further developed the concept of
movement faults can improve performance in muscle imbalance, again analysing patterns of
athletes. movement, and have developed a diagnostic
The movement dysfunctions associated with framework for movement impairments (direction
pain and disability have been shown to be revers- susceptible to motion).
ible so there is a developing need to identify UCM The 1990s saw a huge advancement in the iden-
in relation to injury risk and performance and to tification of motor control dysfunction (Jull et al
objectively evaluate the outcome of retraining. 2008; Richardson et al 2004). Hodges (Hodges &
Cholewicki 2007) has developed a large body of
evidence linking motor control of deep muscles
A MODEL FOR THE to spinal stability. O’Sullivan and co-workers have
provided objective measurements to support the
ASSESSMENT AND RETRAINING links between altered muscle recruitment and
OF MOVEMENT FAULTS direction-related musculoskeletal pain (Dankaerts
et al 2006a). From this research a classification
Many clinicians and researchers have made a system based on diagnostic subgroups has been
significant contribution to the body of evidence proposed (Vibe Fersum et al 2009).
relating to movement, movement impairments Vleeming et al (2007) and Lee (2004) have
and corrective retraining. Some have described a developed the model of form and force closure
particular approach to assessment and retraining and have linked this to anatomical fascial slings.
and most support each other’s philosophies or McGill’s (2002) research has emphasised the
provide different pieces of the puzzle to enable importance of training more superficial muscles
an understanding of the ‘whole picture’. No single to stabilise the core during loaded and sporting
approach has all the answers but the therapist function and is often referred to as core streng-
who wants to provide ‘best practice’ for clients thening. All these clinicians and researchers
can benefit enormously from a synthesis of the have contributed important aspects to a com-
different approaches and concepts proposed to prehensive and integrated model of movement
date, along with the ongoing development analysis.
and integration of original ideas and applied
principles.
Alternative therapies
Figure 1.4 illustrates the development of the
movement analysis model. The movement analysis In the search to identify the defining characteris-
model identifies UCM in terms of the site (joint), tics of therapeutic exercise, a brief review and
direction (plane of motion) and recruitment analysis of many different approaches and con-
threshold (low or high) and further establishes cepts including alternative therapies is appropri-
links to pain, disability, dysfunction, recurrence, ate. Some of these approaches are supported by
7
Assessment of muscle function

Kendall & McCreary
‘Traditional’ strengthening
Sahrmann Janda
Motor control research
and training model
(Hodges, Jull, Richardson) Flexibility
Muscle balance
Force closure model Analysis and development of

The Performance Matrix
(Mooney, Stoeckart, Movement analysis model
(Comerford & Mottram)
Vleeming, Lee) (Comerford & Mottram)
Model of clinical ‘Alternative’ therapies

movement analysis and ‘Core’ strengthening
movement dysfunction diagnosis (McGill)
• Sahrmann (Direction susceptible to motion)
• Comerford & Mottram — Kinetic Control
(Site and direction of uncontrolled movement) Task-specific training
• O’Sullivan and Dankaerts and functional integration
(Control impairment)
Figure 1.4 The development of the movement analysis model
clinical evidence (Emery et al 2010; Rydeard et al

Box 1.1 Useful alternative therapies in the
2006). Box 1.1 lists some useful approaches to
management of movement dysfunction
pain management and/or movement dysfunction
to explore. Many exercise approaches have either Tai chi
stood the test of time or their popularity suggests The Alexander technique
that people who practise them feel or function Yoga
better. Pilates
Whilst the various exercise concepts feature dis- Physio ball (Swiss ball)
tinctive elements that characterise their approach,
Feldenkrais
there are features that are common to all
Martial arts
approaches (Box 1.2). These common features
GYROTONIC®
may contribute to good function and warrant
closer inspection and further investigation.
Breathing control is a key feature in many of these
therapies. The link between respiratory disorders
8
Box 1.2 Common features in and increased risk of development of back pain
alternative therapies has recently been established (Smith et al 2009)
and altered breathing patterns have been noted
• Multi-joint movements during lumbopelvic motor control tests (Roussel
• Slow movements et al 2009c).
• Low force movements
• Large range movements
• Coordination and control of rotation THE ASSESSMENT AND MANAGEMENT
• Smooth transition of concentric–eccentric movement OF UCM
• Awareness of gravity
• Concept of a ‘core’
Effective intervention requires the therapist to
• Coordinated breathing have a thorough understanding of the mech-
• Awareness of posture anisms of aberrant movement patterns, an ability
• Intermittent static hold of position to confidently diagnose and classify the move-
• Control of the centre of mass of one body segment ment faults and to manage these dysfunctions.
with respect to adjacent segments Guidelines for a comprehensive analysis of move-
• Proximal control for distal movement ment dysfunction have been described with factors
• Positive mental attitude the therapist needs to consider in Box 1.3
Box 1.3 Procedure for analysis of movement dysfunction
Uncontrolled movement: assessment and ii. personal factors (intra-individual) (e.g. lifestyle
retraining guidelines and behavioural changes, psychosocial
1. Assess, diagnose and classify movement in terms of attributes, coping skills).
pain and dysfunction from a motor control and a 5. Make links between uncontrolled movement and pain
biomechanical perspective. and other symptoms, dysfunction, recurrence, risk of
2. Develop a large range of movement retraining injury and performance.
strategies to establish optimal functional control. 6. Make a link between uncontrolled movement and
3. Use a clinical reasoning framework to prioritise the disability through the disablement process model.
clinical decision-making challenges experienced in 7. Make links between uncontrolled movement and
contemporary clinical practice. changes in motor control, strength, joint range of
4. Develop an assessment framework that addresses the motion, myofascial extensibility and functional
four key criteria relevant to dysfunctional movement: activities.
a. diagnosis of movement dysfunction 8. Identify the clinical priorities in terms of retraining
uncontrolled movement and mobilising restrictions of
i. site and direction of uncontrolled movement
normal motion.
ii. uncontrolled translation
9. Use a clinical assessment tool to identify deficiencies
iii. uncontrolled range of motion
and reassess improvements in motor control efficiency.
iv. myofascial and articular restriction
10. Integrate non-functional motor control retraining skills
v. aberrant guarding responses with functionally relevant movement.
b. diagnosis of pain-sensitive tissue(s) 11. Use other techniques and strategies (e.g. taping to
i. patho-anatomical structure support uncontrolled movement or facilitate motor
c. diagnosis of pain mechanisms relearning and strengthening).
i. peripheral nociceptive (inflammatory or 12. Use a clinical reasoning framework to identify priorities
mechanical) for rehabilitation, where to start retraining and how to
ii. neurogenic sensitisation be specific and effective in exercise prescription to
d. identification of relevant contextual factors develop individual retaining programs.
(Verbrugge & Jette 1994) 13. Know which way and how fast to progress, and know
i. environmental factors (extra-individual) (e.g. how to tell when retraining has achieved an effective
physical and social context) end-point independently of symptoms.
(Comerford & Mottram 2011)
9
(Comerford & Mottram 2011). An understanding

Box 1.4 Ten key steps to understanding
of the inter-relationship of the elements of the
movement and pain
movement is needed alongside an understanding
of factors relating to normal movement, function 1. Classify the site and direction of uncontrolled
and dysfunction (Chapter 2). A sound clinical movement.
reasoning process underpins this process to 2. Relate the site and direction of uncontrolled
optimise the assessment and retraining strategy. movement to symptoms.
This process is described in the following 3. Relate assessment findings to disability.
section. 4. Identify the uncontrolled movement in terms of
‘uncontrolled translation’ and ‘uncontrolled range’,
and restrictions in terms of articular restriction and
myofascial restrictions.
THE CLINICAL REASONING PROCESS 5. Management plan for uncontrolled movement and
restrictions.
The efficient and effective management of UCM 6. Relate pain mechanisms to presentation.
in relation to symptoms, disability, dysfunction, 7. Consider tissues or structures that could be
contributing to the patient’s signs and symptoms.
recurrence, risk of injury and performance is
dependent on a comprehensive assessment. This 8. Assess for environmental factors and personal factors
(e.g. lifestyle and behavioural changes, psychosocial
should lead to a specific action plan for the
attributes and coping skills).
individual patient. Exercise protocols do have
9. Integrate other approaches or modalities as
a place in the management of musculoskeletal appropriate.
disorders. However, because of differences in
10. Consider prognosis.
presentation and diagnostic subgroups, effective
management is dependent on assessment analy-
sis and management planning. Exercise protocols
can be effective when dysfunction can be clearly
defined into diagnostic subgroups rather than 1 Classify the site and direction of UCM
based on pathology. The key to identifying these As indicated above, UCM is labelled in terms of
diagnostic subgroups lies in making the link its site and direction. These can be assessed using
between movement dysfunction and symptoms specific tests and evaluated with a clinical rating
(Comerford & Mottram 2001b; Sahrmann 2002; system (Chapter 3). Indeed, the assessment may
Vibe Fersum 2009). well identify more than one direction of UCM in
The following section presents a series of points the same site, or different regions. Some examples
to direct clinical reasoning for the integration of of the site and direction of UCM, as well as the
movement dysfunction assessment and planning appropriate test, are given in Table 1.1. The kinetic
of a targeted rehabilitation strategy for movement medial rotation test has been shown to be valid
dysfunction. (Morrissey et al 2008) and the standing bow test
is considered reliable (Luomajoki et al 2007;
Roussel et al 2009a). These tests are described in
The 10 point analysis and clinical detail in following chapters in this text.
reasoning framework for UCM
A clinical reasoning framework can be used to Table 1.1 Examples of the site and direction of
develop an understanding of the relationships uncontrolled movement
between movement, symptoms, dysfunction, and
other factors that influence the clinical reasoning SITE DIRECTION TEST
process (Comerford & Mottram 2011). Box 1.4 Scapula Downward Kinetic medial
presents 10 key steps to understanding movement rotation rotation test (KMRT)
and pain. The first five steps relate specifically to (T60 page 372)
the site and direction of UCM. The last five steps Forward tilt
relate to other factors necessary to develop a full
Lumbar Flexion Standing trunk lean
understanding of the dysfunction, as well as a spine test (T1 page 93)
management plan.
10
Chapter 3 of this text will explain the process

Box 1.5 Commonly used evaluation measures
used to identify the site and direction of UCM
for disability
using specific tests and evaluation with a system-
atic clinical rating system. Disability questionnaires
• For the cervical spine:
2 Relate UCMs to symptoms – Neck Disability Index (Vernon & Mior 1991)
The link between the site and direction of UCM – Bournemouth Neck Questionnaire (Bolton &
and the presenting symptoms needs to be estab- Humphreys 2002).
lished to direct rehabilitation. For example, in the • For the lumbar spine:
shoulder, less upward rotation and backward tilt – Roland-Morris Disability Questionnaire (Roland &
(which relates to uncontrolled downward rota- Morris 1983)
tion and forward tilt) of the scapula has been – Oswestry Disability Questionnaire (Fairbank et al
1980; Fairbank & Pynsent 2000).
identified in people with symptoms related to
shoulder impingement (Ludewig & Cook 2000). • For the shoulder:
Uncontrolled lumbar flexion has been identified – Shoulder Pain and Disability Index (Heald et al 1997;
Roach 1991)
in people with back pain (Luomajoki et al 2008;
– Disabilities of the Arm, Shoulder and Hand
Roussel et al 2009a).
Questionnaire (Hudak et al 1996).
Outcome measures commonly used to evaluate
• For the hip:
pain symptoms include the visual analogue scale
– Western Ontario and McMaster Universities
(VAS), the numerical rating scale (NRS), the
Osteoarthritis Index (WOMAC) (Bellamy 1988)
verbal numerical rating scale (VNRS) and the
– Hip Outcome Score (Martin & Philippon 2007).
quadruple VAS (Von Korff et al 1993).
3 Relate assessment findings to disability

The link between functional disabilities and Table 1.2 Uncontrolled movements and restrictions
movement faults needs to be identified. Func- (Comerford & Mottram 2001b)
tional disabilities as a result of pain or movement Uncontrolled Intersegmental Range
dysfunction may relate to reduced ability to par- movement translation
ticipate in work, leisure or relationships. For
Translation Physiological or
example, Long et al (2004) showed that subjects movement at a functional range
with back pain and a direction preference to pain- single motion of movement at
relieving postures (e.g. flexion provoked lumbar segment one or more
pain relieved by extension movements or pos- motion segments
tures) who were treated with exercises matched
Restriction Articular Myofascial
to their direction preference had significant
improvements in outcomes of rapidly decreased +/− neurodynamic
pain, decreased medication use, reduced dis- influence
ability, reduced depression and decreased work
interference.
A standard procedure to record disability is to
Mottram 2001a). This is shown in Table 1.2.
interview individuals about difficulties by means
Restriction can be described as articular restric-
of self-reports or proxy reports, with simple
tion and/or myofascial restriction (Comerford &
ordinal or interval scoring of degree of difficulty
Mottram 2001a). Neural sensitivity is linked with
(Verbrugge & Jette 1994). Examples of commonly
a neurophysiological response in the myofascial
used outcome measures are listed in Box 1.5.
system presenting as a myofascial restriction
(Coppieters et al 2001, 2002, 2006; Edgar et al
4 Identify the UCM and restrictions 1994; Elvey 1995).
UCM can be described in terms of uncontrolled Table 1.3 gives examples of UCM in terms of
translation (e.g. uncontrolled intersegmental translation and range at the shoulder girdle, and
translation) and uncontrolled physiological or joint and myofascial restrictions. Uncontrolled
functional range of movement (Comerford & anterior translation can be measured in people
11
Table 1.3 Example of uncontrolled movement and 5 Management plan for UCM and
restrictions at the shoulder girdle restrictions
Uncontrolled Intersegmental Range Following the assessment of the UCM and restric-
movement translation tions, a management plan can be established. In
this text, we describe the retraining of the site and
Uncontrolled anterior Uncontrolled
translation at the scapula
direction of UCM but specific retraining strategies
glenohumeral joint forward tilt can also target the local stability muscle systems
(to control intersegmental translation) (Comer-
Restriction Articular Myofascial ford & Mottram 2001a) and the global muscle
Posterior translation Restriction of systems (to control range) (Comerford & Mottram
at glenohumeral joint medial rotation 2001a). Restrictions need to be mobilised with
(infraspinatus/ appropriate (manual) therapy, to regain extensi-
teres minor) bility of the myofascial systems (Comerford &
Mottram 2001a).
To cover all aspects of motor control assessment
and retraining, four principles of assessment and
Table 1.4 Example of uncontrolled movement and retraining are proposed (Comerford & Mottram
restrictions at the lumbar spine 2001a):
1. Control of direction: the assessment and
Uncontrolled Intersegmental Range
movement translation
retraining of the site and direction of
uncontrolled movement (see Chapters 3
Uncontrolled Uncontrolled and 4).
intersegmental lumbar flexion 2. Control of translation: specific assessment
translation (e.g.
and retraining strategies to target the local
at L4 or L5)
stability muscle system to control translation.
Restriction Articular Myofascial 3. Control through range: specific assessment
Restriction of Restriction in hip and retraining strategies to target the global
intersegmental flexion (hamstrings, stability muscle system to control range of
translation superficial gluteus movement.
maximus) 4. Control of extensibility: specific assessment
and retraining strategies to target the global
mobility muscle system to regain
extensibility and control the active
with shoulder pain (Morrissey 2005), as can lengthening of these muscles.
uncontrolled range, illustrated with uncontrolled In addition, manual therapy can address any
forward tilt (Lin et al 2005, 2006). Interestingly, articular restrictions and neural issues that may
this uncontrolled forward tilt (and loss of back- cause muscle overactivity and restrictions. Elvey
ward tilt) corresponds to a decrease in serratus (1995) has described how ‘muscles protect nerves’
anterior activity, which confirms the role of ser- so these issues need to be explored in relation to
ratus in producing backward tilting of the scapula any restrictions (for more detail see Butler 2000;
(and controlling forward tilting). Shacklock 2005).
Table 1.4 provides examples of UCM in terms Figure 1.5 illustrates the management plan
of translation and range at the lumbar spine. outline indicating the targeted interventions
UCM in the lumbar spine has been described in applied where uncontrolled translation, uncon-
terms of uncontrolled lumbar flexion (Dankaerts trolled range, UCM site or direction, articular or
et al 2006a; Luomajoki et al 2008; Sahrmann myofascial restriction are identified. An example
2002; Vibe Fersum et al 2009). Uncontrolled of a management plan developed for a person
lumbar flexion has been associated with either presenting with shoulder pain and dysfunction is
uncontrolled range of lumbar flexion relative to illustrated in Figure 1.6; and an example of a
hip flexion, or abnormal segmental initiation of management plan developed for a person pre-
lumbar motion during forward bending and senting with back pain and lumbar dysfunction
other flexion-related activities. is given in Figure 1.7.
12
Uncontrolled translation Uncontrolled range
Target local muscle system Target global muscle system
Site and direction of

uncontrolled movement
Retrain site and direction of

Articular restriction Myofascial restriction
Manual therapy Regain extensibility of global mobility

muscle system and address any neural
sensitivity
Figure 1.5 The management planning outline

Retraining of the glenohumeral Retraining of the scapula
local stability muscles to global stability muscles to
retrain control of translation at Site and direction of retrain control of range at the
the glenohumeral joint (e.g. uncontrolled movement scapulothoracic joint (e.g.
the rotator cuff) retrain efficiency of serratus
Retrain site and direction of anterior to control anterior tilt
uncontrolled movement and produce posterior tilt)
(e.g. site: scapulothoracic, direction:

forward tilt)
Manual therapy Regain extensibility of global mobility muscle

system and address any neural sensitivity
Articular mobilisation of joint restrictions
(e.g. anterior posterior glide at the Regain extensibility of infraspinatus
glenohumeral joint)
Figure 1.6 The management plan developed for a person with shoulder pain and uncontrolled scapula forward tilt
6 Relate pain mechanisms to presentation movement control (e.g. the influence on proprio-
Pain mechanisms can have a significant influence ception, allodynia and motor control). Useful
on movement control and consideration of screening tools for neuropathic pain could include
changes within the nervous system is a key com- the S-LANSS (Bennett et al 2005) or the pain
ponent of the clinical reasoning process (for more DETECT questionnaire (Freynhagen et al 2006),
detail see Breivik & Shipley 2007; Butler & Moseley while the McGill Pain Questionnaire (Melzack
2003). It is essential to consider the influence of 1975; Melzack & Katz 1992) also evaluates the
mechanical nociceptive or inflammatory pain in affective aspects of pain for a patient.
13

Retraining of the lumbar Retraining of the lumbar
spine local stability muscles global stability muscles to
to retrain control of Site and direction of retrain control of range (e.g.
translation (e.g. the uncontrolled movement retrain efficiency of
integrated inner cylinder, superficial multifidus and
transversus abdominis, Retrain site and direction of spinalis to control flexion and
segmental lumbar multifidus, uncontrolled movement produce extension)
posterior fasciculi of psoas,
diaphragm, pelvic floor) (e.g. site: lumbar, direction: flexion)
Manual therapy Regain extensibility of global mobility muscle

system and address any neural sensitivity
Articular mobilisation of joint restrictions
Regain extensibility of hamstrings and
superficial gluteus maximus
Figure 1.7 The management plan developed for a person with back pain and uncontrolled lumbar flexion
7 Consideration of tissues or structures objectively assessed (and reassessed) with valid

contributing to symptoms and reliable questionnaires such as the Pain
Coping Inventory (PCI; Kraaimaat & Evers 2003),
The site and direction of UCM may match the
Tampa Scale of Kinesiophobia (TSK; Swinkels-
pathology identified. For example, people with a
Meewisse et al 2003; Vlaeyen et al 1995), Fear
shoulder impingement demonstrate UCM at the
Avoidance Beliefs Questionnaire (FABQ; Waddell
scapula (Morrissey 2005). Abnormal quality of
1998) and the Pain Self-Efficacy Questionnaire
motion in spinal lumbar segments has been dem-
(PSEQ; Nicholas 2007; Nicholas et al 2008).
onstrated to be associated with spondylolisthesis
Once the site and direction of UCM have been
pathology (Schneider et al 2005). The link
established, effective rehabilitation should ensure
between tissue stress resulting in pathology and
that movement dysfunction is addressed through-
abnormal range or quality of movement is becom-
out functional tasks. Control of movement during
ing more evident. The therapist needs to find a
functional activities, and awareness of the UCM
link between the UCM and any presenting
during posture, daily activities, sport and training
pathology.
programs should be promoted. For example, a
person with uncontrolled scapula downward
8 Assess for environmental and rotation needs to be aware of this movement
personal factors fault during daily activities such as reaching for a
cup in a cupboard. A person with uncontrolled
Personal factors (e.g. lifestyle and behavioural lumbar flexion needs to be aware of this move-
changes, psychosocial attributes, coping and ment fault when bending forwards to tie up their
activity accommodations) and environmental shoelaces.
factors (e.g. medical care and rehabilitation, med-
ications and other therapeutic regimens, external
supports, physical and social environment) 9 Integrate other approaches or modalities
should also be assessed. Personal factors com- There are many other therapeutic modalities that
monly assessed within the context of physical can influence the correction of movement faults.
therapy include items such as depression, anxiety, Table 1.5 details some examples. This is not
coping skills and cognition. These can be intended to be an exhaustive list but illustrates
14
Table 1.5 Examples of therapeutic modalities that can influence the correction of movement faults
OTHER THERAPEUTIC EXAMPLES

APPROACHES
Pathophysiological approaches Ice, heat, electrotherapy, medication
Articular approaches Joint mobilisation and manipulation (Maitland et al 2005; Cyriax 1980;
Kaltenborn et al 2003)
Ergonomic and environmental factors Work place assessment, postural advice
Neurodynamic approaches Neurodynamic mobilisation (Butler 2000; Shacklock 2005)
Sensory-motor approaches Neuromuscular facilitation (Rood in Goff 1972), Bobath ‘normal movement’
(Bobath 1990), neurofunctional training (Carr & Shepherd 1998),
neurosensory approach (Homstøl 2009)
Soft tissue approaches Massage therapy (Chaitow 2003)
Psychosocial approaches Behavioural evaluation and therapy (Waddell 1998; Woby et al 2008)
Biomechanical approaches Taping, orthotics, bracing
useful adjuvant modalities in retraining UCM, and work disability proved to be the most
managing pain, mobilising restrictions or treating consistent predictors for poor recovery in these
pathology. studies.
The relative influence of factors beyond physi-
10 Consider prognosis ological processes is a contemporary research
subject and there is a growing body of evidence
Although the management of symptoms has been indicating that socio-demographic, physical and
the primary aim in the treatment of musculoskel- psychological factors strongly affect short- and
etal disorders, research has also demonstrated long-term outcomes. These factors must be taken
links between UCM and dysfunction, disability into consideration when establishing a realistic
and the recurrence of symptoms. It is therefore timeframe for when dysfunction, symptoms and
appropriate that dysfunction and disability are disability could be expected to improve and by
also considered, along with symptoms, when pro- how much.
viding a prognosis for recovery in the manage-
ment of musculoskeletal disorders. The timeframe
for expected improvement in symptoms should
be considered independently of the timeframes CLINICAL REASONING IN A DIAGNOSTIC
for recovery of dysfunction and disability when
FRAMEWORK
making prognostic judgments for recovery.
Physiological tissue repair timelines have been
well researched and are reasonably well defined. As noted in Box 1.3, when a patient presents with
In more acute (less than 6 weeks) conditions, neuromusculoskeletal pain and dysfunction, it is
these provide a useful guideline. In more chronic good clinical practice to assess and identify four
(more than 12 weeks) conditions, other prognos- key criteria:
tic factors become more important. A systematic 1. diagnosis of movement dysfunction
review on prognostic factors in whiplash- 2. diagnosis of pain-sensitive or pain-generating
associated disorders established that factors structures
related to poor recovery included: female gender; 3. diagnosis of presenting pain mechanisms
a low level of education; high initial neck pain; – peripheral nociceptive and neurogenic
more severe disability; higher levels of somatisa- sensitisation
tion and sleep difficulties (Hendriks et al 2005; 4. evaluation and consideration of contextual
Scholten-Peeters et al 2003). Neck pain intensity factors.
15
1 Diagnosis of movement with chronic pain suggests it is more appropriate

dysfunction (site and direction of to explore factors affecting impairment of func-
tion and participation than to attempt to diag-
uncontrolled motion)
nose specific structures or tissues as a source of
The initial priority is to identify the site and direc- nociception.
tion of UCM that best correlates with the patient’s
presenting mechanical symptoms. In complex
3 Clinical diagnosis of presenting
presentations, there is frequently more than one
site of UCM. When this is the case, it is useful to pain mechanisms
identify whether one site is the site of primary It is essential to have an understanding of the
dysfunction and whether the other site is com- relevant pain mechanisms contributing to any
pensating for the primary one. individual’s pain presentation. In a person with
If there are obvious restrictions that are causing chronic or recurrent pain it is common to find
compensatory UCM, it is very effective for the different mechanisms contributing to their symp-
therapist to work to achieve normal mobility of toms. Melzack’s (1999) neuromatrix theory of
these restrictions early in the management plan pain proposes that pain is a multidimensional
(see Chapter 4). experience produced by characteristic ‘neurosig-
The therapist should also identify if there is a nature’ patterns of nerve impulses generated by
priority to retrain local stability muscle function a widely distributed neural network in the brain.
early or if this can be retrained later in the reha- It proposes that the output patterns of the neu-
bilitation process. Similarly, the therapist should romatrix activate perceptual, homeostatic, and
identify any contributing muscle imbalance issues behavioural responses after injury, pathology
related to the dysfunction, such as altered length or chronic stress. The resultant pain experience
and recruitment relationships between mono- is produced by the output of a widely distributed
articular stabiliser muscles and multi-articular neural network in the brain rather than solely by
mobiliser muscles. If these imbalances are identi- sensory input evoked by injury, inflammation or
fied, the global stabiliser muscle recruitment effi- other pathology (Moseley 2003). Therefore, pain
ciency should be retrained to recover active is a multi-system output that is produced when
control through the full available range of motion, a cortical pain neuromatrix is activated.
and the global mobility muscle extensibility Ideally, an attempt should be made to deter-
should be restored. mine the relevant proportions of these mech-
anisms; that is, the degree to which peripheral
nociceptive (mechanical/inflammatory) elements
2 Clinical diagnosis of pain-sensitive contribute to the pain experience and the degree
or pain-generating structure(s) to which neurogenic sensitisation is present.
Behavioural, social and psychosomatic influences
The therapist should identify the structure or further contribute to the multidimensional
tissue that is the source of the symptoms or pain nature of chronic and recurrent pain. The
that the patient complains of. Patients who dominant mechanisms need to be addressed
present with a chronic or recurrent condition fre- as a priority. A multidisciplinary and multidi-
quently report more than one tissue contributing mensional approach can be more effective in
to the pain experience. The clinical reasoning managing symptoms, both in the short and long
process that identifies a variety of pain-sensitive term.
tissues requires a thorough understanding of
tissue anatomy and physiology, a knowledge of
the mechanism of injury (if there is one) and an 4 Evaluation and consideration of
understanding of the typical responses of differ-
contextual factors
ent tissues to stress and strain and injury. All avail-
able therapeutic skills, tools or modalities can be The therapist should assess for the influence of
utilised to best provide an optimal environment contextual factors – both personal and environ-
to allow and promote tissue healing and to mental – on the patient’s signs and symptoms
control or manage the presenting signs and symp- and explore how these might relate to UCM
toms. Contemporary clinical reasoning in patients (Figure 1.8).
16
Health condition
Four key criteria within clinical reasoning framework
(disorder or disease)
1. Diagnosis of movement dysfunction
– site and direction of uncontrolled motion.
2. Diagnosis of pain-sensitive tissue(s) (linked to pathology).
3. Diagnosis of pain mechanisms
– peripheral nociceptive
– neurogenic sensitisation.
4. Evaluation and consideration of contextual factors. Body functions
Activities Participation
and structures
Figure 1.8 Four key criteria within a clinical reasoning
framework
THE DISABLEMENT
ASSESSMENT MODEL
Environmental Personal
factors factors
Researchers and clinicians have become increas-
ingly aware that there is frequently little corre- Figure 1.10 Model of functioning and disability,
lation between pathology and (functional) International Classification of Functioning Disability and
limitations in activities and participation. This is Health, ICF. World Health Organization, Geneva, 2001
even more evident for chronic complaints. Con-
temporary clinical reasoning has seen a paradigm
shift from a biomedical to a bio-psychosocial functions and ADL are limited. These are defined
model. For instance, in the analysis of movement as ‘disabilities’ and can be evaluated by valid and
dysfunction model presented in Box 1.3, a modi- reliable questionnaires and performance tests.
fied version of a disablement process model This provides the opportunity to reassess the
(Verbrugge & Jette 1994) is included. Such a disa- patient in an objective way and evaluate efficacy
blement assessment model uses the same theo- of interventions. Within the clinical reasoning
retical construct as a starting point for assessment process the therapist evaluates the four factors in
and treatment (Figure 1.9). the diagnostic framework criteria (see Figure 1.8),
In a disablement process model, the therapist, and relates these to the functional limitations.
together with the patient, determines which In this partially reversible system, the functional
limitations are continuously influenced by extra-
and intra-individual factors. These existing and
potential risk factors are the reason why path-
ology presents as or evolves into impairments.
Using a clinical decision-making process, the
therapist is able to assess and determine if a
Disability Pathology
normal or aberrant course is present.
Different terminology is used in the Interna-
Risk tional Classification of Functioning, Disability,
Intra-individual and Health (ICF 2001) model of functioning and
factors
factors
disability (Figure 1.10). However, essentially the
intra-individual factors in the disablement process
Functional model are comparable with the ICF’s personal
Impairments
limitations factors and the extra-individual factors are com-
parable with the environmental factors.
The rehabilitation problem solving (RPS) form
Extra-individual (Figure 1.11) was developed to address patients’
factors perspectives and to enhance their participation
in the decision-making process during their
Figure 1.9 Disablement assessment model: modified from assessment. The RPS form is based on the
Disablement Process Model (Verbrugge & Jette 1994) ICF model of functioning and disability and
17
In the ICF model the horizontal dimension of

Disorder a health status or profile is illustrated as being
influenced by elements in the vertical dimension.
The ICF model could be considered a method of
classification, describing a health condition at a
particular moment, such as a picture or ‘freeze
Patient
frame’. In contrast, the disablement process rep-

resents constructs within the ICF model under the
constant influence of risk factors and hence could
Body structures/ be described as more like a ‘film’.
Activities Participation
functions To summarise, ‘health’ can be described in
terms of:
• health condition (using ICF terminology)
Therapist
• course (normal or aberrant)

• prognostic profile
• patient’s perspective.
Clinical decision-making should start from the
Personal Environmental patient’s perspective and interventions should be
factors factors primarily aimed at those aspects of impairment
that have a direct bearing on disability and/or
functional limitations. In the subjective examina-
tion, the patients will define their perspective in
terms of disability and functional limitations; for
Figure 1.11 The rehabilitation problem solving form,
example, the inability (due to low back pain) to
adapted from Steiner et al 2002
bend over from standing to tie shoelaces or the
inability (due to shoulder pain) to reach into a
cupboard above the shoulders. These self-reported
facilitates the analysis of patient problems, focus- symptoms are explored further within the phy-
ing on specific targets, and relating salient disa- sical examination to inform the clinical decision-
bilities to relevant and modifiable variables. making process. For example, if patients with
This form can include the diagnostic criteria low back pain are unable to actively control
within the clinical reasoning framework described movements of the low back, especially flexion
in Figure 1.8 in order to assess the key criteria control while performing a waiters’ bow (Luoma-
that relate to the functional limitations. This joki 2008), then clinicians should direct their
process identifies links between factors in the intervention towards correcting the neuromus-
diagnostic framework and subsequent functional cular impairment underpinning this. Similarly, if
limitations so that the mechanism behind the patients with shoulder pain are unable to actively
dysfunction can be addressed to optimise efficacy control the (re-) positioning of the scapula during
of intervention. The form in Figure 1.11 can functional movements (Tate et al 2008; von
include the diagnostic framework as described in Eisenhart-Rothe 2005), then clinicians should
Figure 1.8. aim their intervention strategy at regaining this
The essence of both the ICF model of function- control. Therapists should not solely focus on
ing and disability and the RPS form is that an addressing an isolated pathology, but use frame-
individual’s (dys-)functioning or disability repre- works such as the disablement assessment
sents an interaction between the health condition model to facilitate effective intervention. The
(e.g. diseases, disorders, injuries, traumas and all link between specific movement retraining and
factors in the diagnostic framework) and the con- improvement in functional tasks is now well
textual factors (i.e. ‘environmental factors’ and supported by evidence (Jull et al 2009; Roussel
‘personal factors’). The interactions of the com- et al 2009b).
ponents in the model are two-way, and interven- Practitioners need to have the skills to identify
tions in one component can potentially modify and retrain movement faults. These skills should
one or more other components. be integrated into current practice and the patient
18
managed in a holistic way with consideration of neuromusculoskeletal disorders. To assist in this

all aspects of the human motion system, and the reasoning process the anatomical and physiologi-
influence of both intra- and extra-individual cal principles are reviewed in Chapter 2 and how
factors. An understanding of how UCM can influ- pain, dysfunction and pathology can effect UCM
ence pain is essential in the management of is explored in Chapter 3.
REFERENCES
Bellamy, N., Buchanan, W.W., Comerford, M.J., Mottram, S.L., 2001b. subclassification. Spine 31 (17),
Goldsmith, C.H., Campbell, J., Stitt, Movement and stability dysfunction. 2017–2023.
L.W., 1988. Validation study of Manual Therapy 6, 15–26. Dankaerts, W., O’Sullivan, P., Burnett,
WOMAC: a health status instrument Comerford, M.J., Mottram, S.L., 2011. A., Straker, L., Davey, P., Gupta, R.,
for measuring clinically important Understanding movement and 2009. Discriminating healthy
patient relevant outcomes to function – assessment and retraining controls and two clinical subgroups
antirheumatic drug therapy in of uncontrolled movement. Course of nonspecific chronic low back pain
patients with osteoarthritis of the Notes Kinetic Control, UK. patients using trunk muscle
hip or knee. Journal of Coppieters, M.W., 2006. Shoulder activation and lumbosacral
Rheumatology 15 (12), 1833–1840. restraints as a potential cause for kinematics of postures and
Bennett, M.I., Smith, B.H., Torrance, N., stretch neuropathies: biomechanical movements: a statistical classification
Potter, J., 2005. The S-LANSS score support for the impact of shoulder model. Spine 34 (15), 1610–1618.
for identifying pain of girdle depression and arm abduction Edgar, D., Jull, G., Sutton, S., 1994.
predominantly neuropathic origin: on nerve strain. Anesthesiology 104 The relationship between upper
validation for use in clinical and (6), 1351–1352. trapezius muscle length and upper
postal research. Journal of Pain 6 Coppieters, M.W., Stappaerts, K.H., quadrant neural tissue extensibility.
(3), 149–158. Everaert, D.G., Staes, F.F., 2001. Australian Journal of Physiotherapy
Bobath, B., 1990. Adult hemiplegia: Addition of test components during 40, 99–103.
evaluation and treatment. neurodynamic testing: effect on Elvey, R.L., 1995. Peripheral neuropathic
Butterworth-Heinemann, range of motion and sensory disorders and neuromusculoskeletal
London. responses. Journal of Orthopaedic pain. In: Shacklock M (Ed.), Moving
Bolton, J.E., Humphreys, B.K., 2002. and Sports Physical Therapy 31 (5), in on pain. Butterworth Heinemann,
The Bournemouth Questionnaire: a 226–235. Sydney.
short-form comprehensive outcome Coppieters, M., Stappaerts, K., Janssens, Emery, K., De Serres, S.J., McMillan, A.,
measure. II. Psychometric properties K., Jull, G., 2002. Reliability of Côté, J.N., 2010. The effects of a
in neck pain patients. Journal of detecting ‘onset of pain’ and Pilates training program on
Manipulative and Physiological ‘submaximal pain’ during neural arm–trunk posture and movement.
Therapeutics 25 (3), 141–148. provocation testing of the upper Clinical Biomechanics 25 (2),
Breivik, H., Shipley, M., 2007. Pain. quadrant. Physiotherapy Research 124–130.
Elsevier, London. International 7 (3), 146–156. Escalante, A., del Rincon, I., 2002. The
Butler, D., 2000. The sensitive nervous Cyriax, J.H., 1980. Textbook of disablement process in rheumatoid
system. NOI Publications, Adelaide, orthopaedic medicine, vol. 2. arthritis. Arthritis and Rheumatism
Australia. Treatment by manipulation, massage 47 (3), 333–342.
Butler, D., Moseley, L., 2003. Explain and injection. Ballière Tindall, Fairbank, J.C., Couper, J., Davies, J.B.,
pain. NOI Publications, Adelaide, London. O’Brien, J.P., 1980. The Oswestry low
Australia. Dankaerts, W., O’Sullivan, P.B., Straker, back pain disability questionnaire.
Carr, J., Shepherd, R., 1998. L.M., Burnett, A.F., Skouen, J.S., Physiotherapy 66 (8), 271–273.
Neurological rehabilitation 2006a. The inter-examiner reliability Fairbank, J.C.T., Pynsent, P.B., 2000. The
– optimizing motor performance. of a classification method for Oswestry disability index. Spine 25
Butterworth Heinemann, Oxford. non-specific chronic low back pain (22), 2940–2953.
Chaitow, L., 2003. Modern patients with motor control Falla, D., Bilenkij, G., Jull, G., 2004.
neuromuscular techniques – impairment. Manual Therapy 11 (1), Patients with chronic neck pain
advanced soft tissue techniques. 28–39. demonstrate altered patterns of
Churchill Livingstone, Edinburgh. Dankaerts, W., O’Sullivan, P., Burnett, muscle activation during
Comerford, M.J., Mottram, S.L., 2001a. A., Straker, L., 2006b. Altered performance of a functional upper
Functional stability retraining: patterns of superficial trunk muscle limb task. Spine 29, 1436–1440.
principles and strategies for activation during sitting in Falla, D., Farina, D., 2008.
managing mechanical dysfunction. nonspecific chronic low back pain Neuromuscular adaptation in
Manual Therapy 6, 3–14. patients: importance of experimental and clinical neck pain.
19
Journal of Electromyography and Livingstone, Edinburgh, pp. the spine, 4th edn. OPTP,
Kinesiology 18 (2), 255–261. 489–512. Minneapolis.
Fersum, K.V., Dankaerts, W., O’Sullivan, Hodges, P.W., Richardson, C.A., 1996. Kendall, F.P., McCreary, E., Provance, P.,
P.B., et al., 2010. Integration of Inefficient muscular stabilisation of Rodgers, M., Romanic, W., 2005.
subclassification strategies in the lumbar spine associated with Muscle testing and function with
randomised controlled clinical trials low back pain: a motor control posture and pain. Lippincott
evaluating manual therapy treatment evaluation of transversus abdominis. Williams Wilkins, Baltimore.
and exercise therapy for non-specific Spine 2 (22), 2640–2650. Kraaimaat, F.W., Evers, A.W., 2003.
chronic low back pain: a systematic Homstøl, G.M., Homstøl, B.O., 2009. Pain-coping strategies in chronic
review. British Journal of Sports Changes in mechanosensitivity due pain patients: psychometric
Medicine 44 (14), 1054–1062. to lumbopelvic and ankle characteristics of the pain-coping
Freynhagen, R., Baron, R., Gockel, U., positioning. 3rd International inventory (PCI). International
Tölle, T.R., 2006. painDETECT: a Conference on Movement Journal of Behavioral Medicine 10
new screening questionnaire to Dysfunction, Edinburgh, UK. (4), 343–363.
identify neuropathic components Manual Therapy 14 (1), S38. Lee, D., 2004. The pelvic girdle. Elsevier;
in patients with back pain. Current Hudak, P.L., Amadio, P.C., Bombardier, Edinburgh.
Medical Research and Opinion 22 C., 1996. Development of an upper Lin, J.J., Hanten, W.P., Olson, S.L.,
(10), 1911–1920. extremity outcome measure: the Roddey, T.S., Soto-quijano, D.A.,
Goff, B., 1972. The application of recent DASH (disabilities of the arm, Lim, H.K., Sherwood, A.M., 2005.
advances in neurophysiology to Miss shoulder and hand) [corrected]. The Functional activity characteristics of
R Rood’s concept of neuromuscular Upper Extremity Collaborative individuals with shoulder
facilitation. Physiotherapy 58 (2), Group (UECG). American Journal dysfunctions. Journal of
409–415. of Industrial Medicine 29 (6), Electromyography and Kinesiology
Gombatto, S.P., Collins, D.R., 602–608. Erratum in: American 15 (6), 576–586.
Sahrmann, S.A., Engsberg, J.R., Van Journal of Industrial Medicine 1996; Lin, J.J., Hanten, W.P., Olson, S.L.,
Dillen, L.R., 2007. Patterns of 30 (3), 372. Roddey, T.S., Soto-quijano, D.A.,
lumbar region movement during Hungerford, B., Gilleard, W., Hodges, P., Lim, H.K., Sherwood, A.M., 2006.
trunk lateral bending in 2 subgroups 2003. Evidence of altered Shoulder dysfunction assessment:
of people with low back pain. lumbopelvic muscle recruitment in self-report and impaired scapular
Physical Therapy 87 (4), 441–454. the presence of sacroiliac joint pain. movements. Physical Therapy 86 (8),
Heald, S.L., Riddle, D.L., Lamb, R.L., Spine 28 (14), 1593–1600. 1065–1074.
1997. The shoulder pain and International Classification of Long, A., Donelson, R., Fung, T., 2004.
disability index: the construct Functioning, Disability, and Does it matter which exercise? A
validity and responsiveness of a Health (ICF), 2001. ICF full version. randomized control trial of exercise
region-specific disability measure. World Health Organization, for low back pain. Spine 29 (23),
Physical Therapy 77 (10), 1079– Geneva. 2593–2602.
1089. Janda, V., 1986. Muscle weakness and Ludewig, P., Cook, T.M., 2000.
Hendriks, E.J., Scholten-Peeters, G.G., inhibition (pseudoparesis) in low Alterations in shoulder kinematics
van der Windt, D.A., Neelemen-van back pain. In: Grieve, G.P. (Ed.), and associated muscle activity in
der Steen, C.W., Oostendorp, R.A., Modern manual therapy of the people with symptoms of shoulder
Verhagen, A.P., 2005. Prognostic vertebral column. Churchill impingement. Physical Therapy 80
factors for poor recovery in acute Livingstone, Edinburgh. (3), 276–291.
whiplash patients. Pain 114 (3), Jull, G., Sterling, M., Falla, D., et al., Luomajoki, H., Kool, J., de Bruin, E.D.,
408–416. 2008. Whiplash, headache and neck Airaksinen, O., 2007. Reliability of
Hides, J.A., Richardson, C.A., Jull, G.A., pain. Elsevier, Edinburgh. movement control tests in the
1996. Multifidus muscle recovery is Jull, G., Trott, P., Potter, H., Zito, G., lumbar spine. BMC Musculoskeletal
not automatic after resolution of Niere, K., Shirley, D., et al., 2002. Disorders 8, 90.
acute, first-episode low back pain. Randomized controlled trial of Luomajoki, H., Kool, J., D de Bruin, E.,
Spine 21 (23), 2763–2769. exercise and manipulative therapy Airaksinen, O., 2008. Movement
Hirons, C.A., Mottram, S.L., Tisdale, L., for cervicogenic headache. Spine 27 control tests of the low back;
2007. Controlling the compensation. (17), 1835–1843. evaluation of the difference between
12th World Congress of the Jull, G.A., Falla, D., Vicenzino, B., patients with low back pain and
International Society for Prosthetics Hodges, P.W., 2009. The effect of healthy controls. BMC
and Orthotics Vancouver, Canada, therapeutic exercise on activation of Musculoskeletal Disorders 9, 170.
July 29–August 3. the deep cervical flexor muscles in McGill, S., 2002. Low back disorders.
Hodges, P.W., Cholewicki, J., 2007. people with chronic neck pain. Evidence-based prevention and
Functional control of the spine. In: Manual Therapy 14 (6), 696–701. rehabilitation. Human Kinetics
Vleeming, A., Mooney, V., Stoeckart, Kaltenborn, F., Evjenth, O., Kaltenborn, Europe, Champaign.
R. (Eds.), Movement stability and T., Morgan, D., Vollowitz, E., 2003. Maitland, G., Hengeveld, E., Banks, K.,
lumbopelvic pain. Churchill Manual mobilization of the joints: English, K., 2005. Maitland’s
20
vertebral manipulation. Butterworth O’Sullivan, P.B., 2000. Lumbar control and physical fitness training
Heinemann, Oxford. segmental ‘instability’: clinical to prevent msculoskeletal injuries in
Martin, R.L., Philippon, M.J., 2007. presentation and specific stabilizing professional dancers. 3rd
Evidence of validity for the hip exercise management. Manual International Conference on
outcome score in hip arthroscopy. Therapy 5 (1), 2–12. Movement Dysfunction, Edinburgh,
Arthroscopy 23 (8), 822–826. O’Sullivan, P., 2005. Diagnosis and UK. 30 October–1 November.
Erratum in: Arthroscopy 2007;23 classification of chronic low back Manual Therapy 14 (1), S22.
(11), 1252. pain disorders: maladaptive Roussel, N.A., Nijs, J., Mottram, S., van
Melzack, R., 1975. The McGill pain movement and motor control Moorsel, A., Truijen, S., Stassijns, G.,
questionnaire: major properties and impairments as underlying 2009a. Altered lumbopelvic
scoring methods. Pain 1, 277–299. mechanism. Manual Therapy 10 (4), movement control but not
Melzack, R., 1999. From the gate to the 242–255. generalised joint hypermobility is
neuromatrix. Pain Suppl 6, O’Sullivan, P.B., Beales, D.J., Beetham, associated with increased injury in
S121–S126. J.A., Cripps, J., 2002. Altered motor dancers. A prospective study. Manual
Melzack, R., Katz, J., 1992. The McGill control strategies in subjects with Therapy 14 (6), 630–635.
pain questionnaire: appraisal and sacroiliac joint pain during the active Roussel, N., Nijs, J., Truijen, S.,
current status. In: Turk D., Melzack straight leg raise test. Spine 27 (1), Vervecken, L., Mottram, S., Stassijns,
R. (Eds.), Handbook of pain E1–E8. G., 2009c. Altered breathing patterns
assessment. Guildford Press, New O’Sullivan, P.B., Twomey, L., Allison, G., during lumbopelvic motor control
York, pp. 35–52. 1997a. Evaluation of specific tests in chronic low back pain: a
Morrissey, D., 2005. Development of stabilising exercises in the treatment case-control study. European Spine
the kinetic medial rotation test of of chronic low back pain with Journal 18 (7), 1066–1073.
the shoulder: a dynamic clinical radiological diagnosis of spondylosis Rydeard, R., Leger, A., Smith, D., 2006.
test of shoulder instability and or spondylolisthesis. Spine 22 (24), Pilates-based therapeutic exercise:
impingement. PhD thesis, University 2959–2967. effect on subjects with nonspecific
of London. O’Sullivan, P.B., Twomey, L., Allison, G., chronic low back pain and
Morrissey, D., Morrissey, M.C., Driver, Sinclair, J., Miller, K., Knox, J., functional disability: a randomized
W., King, J.B., Woledge, R.C., 2008. 1997b. Altered patterns of controlled trial. Journal of
Manual landmark identification and abdominal muscle activation in Orthopaedic and Sports Physical
tracking during the medial rotation patients with chronic low back pain. Therapy 36 (7), 472–484.
test of the shoulder: an accuracy Australian Journal of Physiotherapy Sahrmann, S.A., 2002. Diagnosis and
study using three dimensional 43 (2), 91–98. treatment of movement impairment
ultrasound and motion analysis O’Sullivan, P., Twomey, L., Allison, G., syndromes. Mosby, St Louis.
measures. Manual Therapy 13 (6), 1998. Altered abdominal muscle Schneider, G., Pearcy, M.J., Bogduk, N.,
529–535. recruitment in back pain patients 2005. Abnormal motion in
Moseley, G.L., 2003. A pain neuromatrix following specific exercise spondylolytic spondylolisthesis.
approach to patients with chronic intervention. Journal of Orthopaedic Spine 30 (10), 1159–1164.
pain. Manual Therapy 8 (3), and Sports Physical Therapy 27 (2), Scholten-Peeters, G.G., Verhagen, A.P.,
130–140. 114–124. Bekkering, G.E., van der Windt, D.A.,
Mottram, S.L., Comerford, M., 2008. A Richardson, C., Hodges, P., Hides, J., Barnsley, L., Oostendorp, R.A., et al.,
new perspective on risk assessment. 2004. Therapeutic exercise for 2003. Prognostic factors of whiplash-
Physical Therapy in Sport 9 (1), lumbopelvic stabilization – a motor associated disorders: a systematic
40–51. control approach for the treatment review of prospective cohort studies.
and prevention of low back pain. Pain 104 (1–2), 303–322.
Mottram, S., Warner, M., Chappell, P.,
Morrissey, D., Stokes, M., 2009. Churchill Livingstone, Edinburgh. Scholtes, S.A., Gombatto, S.P., Van
Impaired control of scapular rotation Roach, K.E., Budiman-Mak, E., Dillen, L.R., 2009. Differences in
during a clinical dissociation test in Songsiridej, N., Lertratanakul, Y., lumbopelvic motion between people
people with a history of shoulder 1991. Development of a shoulder with and people without low back
pain. 3rd International Conference pain and disability index. pain during two lower limb
on Movement Dysfunction Arthritis Care and Research 4 (4), movement tests. Clinical
Edinburgh, UK. Manual Therapy 143–149. Biomechanics 24 (1), 7–12.
14 (1), S20. Roland, M.O., Morris, R.W., 1983. A Shacklock, M., 2005. Clinical
Nicholas, M.K., 2007. The pain study of the natural history of back neurodynamics: a new system of
self-efficacy questionnaire: taking pain. Part 1: Development of a neuromusculoskeletal treatment.
pain into account. European Journal reliable and sensitive measure of Elsevier Butterworth Heinmann,
of Pain 11, 153–163. disability in low back pain. Spine 8, Edinburgh.
Nicholas, M.K., Asghari, A., Blyth, F.M., 141–144. Smith, M.D., Russell, A., Hodges, P.W.,
2008. What do the numbers mean? Roussel, N.A., Daenen, L., Vissers, D., 2009. Do incontinence, breathing
Normative data in chronic pain Lambeets, D., Schutt, A., Van difficulties, and gastrointestinal
measures. Pain 134, 158–173. Moorsel, A., et al., 2009b. Motor symptoms increase the risk of future
21
back pain? Journal of Pain 10 (8), modifying patient-preferred scapular positioning correlates with
876–886. movement and alignment strategies humeral head centering. Clinical
Steiner, W.A., Ryser, L., Huber, E., in patients with low back pain Orthopaedics and Related Research
Uebelhart, D., Aeschlimann, A., during symptomatic tests. Manual 433, 82–89.
Stucki, G., 2002. Use of the ICF Therapy 14 (1), 52–60. Von Korff, M., Deyo, R.A., Cherkin, D.,
model as a clinical problem-solving Verbrugge, L.M., Jette, A.M., 1994. The Barlow, S.F., 1993. Back pain in
tool in physical therapy and disablement process. Social Science primary care. Outcomes at 1 year.
rehabilitation medicine. Physical and Medicine 38 (1), 1–14. Spine 18 (7), 855–862.
Therapy 82 (11), 1098–1107. Vernon, H., Mior, S., 1991. The neck Waddell, G., 1998. The back pain
Stuge, B., Veierod, M.B., Laerum, E., disability index: a study of reliability revolution. Churchill Livingstone,
Vollestad, N., 2004. The efficacy of a and validity. Journal of Manipulative Edinburgh.
treatment program focusing on and Physiological Therapeutics 14
Woby, S.R., Roach, N.K., Urmston, M.,
specific stabilizing exercises for (7), 409–415.
Watson, P.J., 2008. Outcome
pelvic girdle pain after pregnancy: a Vibe Fersum, K., O’Sullivan, P.B., Kvåle, following a physiotherapist-led
two-year follow-up of a randomized A., Skouen, J.S., 2009. Inter-examiner intervention for chronic low back
clinical trial. Spine 29 (10), reliability of a classification system pain: the important role of cognitive
E197–E203. for patients with non-specific low processes. Physiotherapy 94 (2),
Swinkels-Meewisse, E.J., Swinkels, R.A., back pain. Manual Therapy 4 (5), 115–124.
Verbeek, A.L., Vlaeyen, J.W., 555–561.
Ostendorp, R.A., 2003. Psychometric World Health Organization, 2001. ICF:
Vlaeyen, J.W., Kole-Snijders, A.M., International Classification of
properties of the Tampa scale for Boeren, R.G., van Eek, H., 1995. Fear
kinesiophobia and the fear- Functioning, Disability and Health.
of movement/(re)injury in chronic WHO, Geneva.
avoidance beliefs questionnaire in low back pain and its relation to
acute low back pain. Manual behavioral performance. Pain 62 (3), Zazulak, B.T., Hewett, T.E., Reeves, N.P.,
Therapy 8 (1), 29–36. 363–372. Goldberg, B., Cholewicki, J., 2007.
Tate, A.R., McClure, P.W., Kareha, S., Deficits in neuromuscular control
Vleeming, A., Mooney, V., Stoeckart, R., of the trunk predict knee injury
Irwin, D., 2008. Effect of the scapula 2007. Movement, stability and
reposition test on shoulder risk: a prospective biomechanical-
lumbopelvic pain. Integration of epidemiologic study. American
impingement symptoms and research and therapy. Churchill
elevation strength in overhead Journal of Sports Medicine 35 (7),
Livingstone, Edinburgh. 1123–1130.
athletes. Journal of Orthopaedic
and Sports Physical Therapy 38 (1), von Eisenhart-Rothe, R., Matsen 3rd.,
4–11. F.A., Eckstein, F., Vogl, T., Graichen,
H., 2005. Pathomechanics in
van Dillen, L.R., Maluf, K.S., Sahrmann,
a-traumatic shoulder instability:
S.A., 2009. Further examination of
22
Chapter 2
Muscle function and physiology
INTRODUCTION: ANALYSIS OF MUSCLE FUNCTION

MOVEMENT CONTROL
All muscles have four broad functions:
There has been much interest in and reference 1. to concentrically shorten to produce joint
to stability of the spine over the last few decades. range of motion and accelerate body motion
One of the first texts to explore therapeutic segments, which will be termed ‘mobility
exercise for spinal segmental stabilisation in low function’
back pain was published in 1998 (Richardson 2. to isometrically hold position, which will be
et al 1998). These authors referred to Panjabi’s termed ‘postural control function’
model of spinal stabilisation which incorporates 3. to eccentrically lengthen under tension to
a passive subsystem (the osseous and articular decelerate motion and control excessive
structures), the active subsystem (the force gener- range of motion, which will be termed
ating capacity of muscles which provide mechani- ‘stability function’
cal stability) and the neural subsystem (providing 4. to provide afferent proprioceptive feedback
control to the muscles) (Panjabi 1992). to the central nervous system (CNS) for
The concept of stability, movement control and coordination and regulation of muscle
the process of how it is achieved, has different stiffness and tension.
interpretations depending on the background of
the authors (Hodges & Cholewicki 2007; McGill
Stabiliser and mobiliser function
2007). To date there is still debate as to whether
spinal stability exists but there is no debate that Rood, in Goff (1972), Janda (1996) and
the spine must be stable to function (Reeves & Sahrmann (2002) have described and developed
Cholewicki 2010). This text considers the control functional muscle testing based on stabiliser and
of movement and assessment and retraining mobiliser muscle roles. Table 2.1 describes sta-
of uncontrolled movement (UCM) (as described biliser and mobiliser muscle role characteristics.
in Chapters 1, 3 and 4) rather than simply a Some muscles are more efficient at one of these
model of stability. roles and less efficient in the other role. For
Aspects of both muscle function and physiol- example: latissimus dorsi is a powerful multi-
ogy are important when assessing and retraining joint medial rotator of the shoulder to accelerate
UCM and will be explored in this chapter. the arm in the sagittal plane during throwing

DOI: 10.1016/B978-0-7295-3907-4.00002-5 23
Table 2.1 Characteristics of muscles with stabiliser and mobiliser roles
STABILITY MUSCLE ROLE CHARACTERISTICS MOBILITY MUSCLE ROLE CHARACTERISTICS

• One-joint (monoarticular) • Two-joint (biarticular or multisegmental)
• Deep (short lever and short moment arm) • Superficial (longer lever, larger moment arm and greatest
• Broad aponeurotic insertions (to distribute and absorb bulk)
force and load) • Unidirectional fibres or tendinous insertions (to direct
• Leverage for load maintenance, static holding and force to produce movement)
joint compression • Leverage for range and speed and joint distraction
• Postural holding role associated with eccentrically • Repetitive or rapid movement role and high strain/force
decelerating or resisting momentum (especially in the loading
axial plane – rotation)
EXAMPLES OF STABILISER MUSCLES EXAMPLES OF MOBILISER MUSCLES

• External oblique /internal oblique • Rectus femoris
• Semispinalis • Pectoralis major
• Deep gluteus maximus • Levator scapula
• Subscapularis • Rectus abdominis
actions. Latissimus dorsi is biomechanically identified as a common movement-related change

suited to large range, high speed, high force move- in people with low back pain (O’Sullivan et al
ment at the shoulder. This muscle obviously has 1997).
a power role acting as a mobiliser or sagittal plane
movement accelerator. Conversely, subscapularis Implications of stabiliser–mobiliser
co-activates synergistically but its co-activation characteristics
force acts to stabilise the humeral head from
excessive translation, while the arm is medially 1. Muscles with predominantly stability role
rotating in a throwing action. Subscapularis, with characteristics (one-joint) optimally assist
its short lever, small moment arm and capsular postural holding/anti-gravity/stability and
attachments, is best suited to non-fatiguing, func- control function. Muscles that have a
tional movements in postural control tasks. It is stability function (one-joint stabiliser)
also ideally placed to resist or decelerate excessive demonstrate a tendency to inhibition,
lateral rotation of the shoulder. This muscle has excessive flexibility, laxity and weakness in
a greater stabilisation role and is less suited biome- the presence of dysfunction (Kendall et al
chanically to a power movement role. A muscle’s 2005). Janda (1983) described these muscles
role must also be customised to its function. as ‘phasic’ muscles.
Generating high force may be detrimental in 2. Muscles with predominantly mobility role
some instances. For example: rectus abdominis is characteristics (multi-joint) optimally assist
a flexor of the lumbar spine. If it is over-trained rapid/accelerated movement and produce
and inappropriately strengthened it contributes high force or power. Muscles that have a
to pain-related changes in the movement system. mobility function (two-joint or multi-joint
It is often over-trained in a misguided belief that mobiliser) demonstrate a tendency to
it is important to strengthen the abdominals to overactivity, loss of extensibility and excessive
stabilise and protect the low back or to acquire stiffness in the presence of dysfunction
an abdominal ‘six pack’. However, if this muscle (Kendall et al 2005). Janda (1983) described
becomes excessively dominant in comparison to these muscles as ‘postural’ muscles.
the lateral abdominal muscles it increases flexion
and compression forces on the lumbar spine and
Local and global function
rotation stress and strain is inadequately control-
led. This imbalance between rectus abdominis Bergmark (1989) developed a model to describe
and the lateral abdominal stabilisers has been the muscle control of load transfer across the
24
Muscle function and physiology Chapter |2|
Table 2.2 Local and global muscle system characteristics and general features
LOCAL MUSCLE SYSTEM CHARACTERISTICS GLOBAL MUSCLE SYSTEM CHARACTERISTICS

• Deepest layer of muscles that originate and insert • Superficial or outer layer of muscles lacking segmental
segmentally on lumbar vertebrae insertions
• Controls the spinal curvature • Large torque producing muscles for range of movement
• Maintains the mechanical stiffness of the spine • Global muscles and intra-abdominal pressure transfer
controlling intersegmental motion load between the thoracic cage and the pelvis
• Responds to changes in posture and to changes in • Responds to changes in the line of action and the
low extrinsic load magnitude of high extrinsic load
GENERAL FEATURES GENERAL FEATURES

• Deepest, one-joint • Deep one-joint or superficial multi-joint
• Minimal force, stiffness • Force efficient
• No/min. length change • Concentric shortening to produce range
• Does not produce or limit range of motion • Eccentric lengthening or isometric holding to control
• Controls translation range
• Maintains control in all ranges, all directions, all • No translation control
functional activities • Direction-specific/antagonist influenced
• Tonic recruitment with low load and high load
activities
• No antagonists
EXAMPLES OF LOCAL MUSCLES EXAMPLES OF GLOBAL MUSCLES

• Transversus abdominis • Rectus abdominis
• Single segment fibres of lumbar multifidus • Hamstrings
• Longitudinal fibres of longus colli • Sternocleidomastoid
• Vastus medialis obliquus • Splenius capitis
lumbar spine. He introduced the concept of local to controlling translatatory or accessory

and global systems of muscle control. The local motion. Local muscles maintain this
and global muscle system characteristics and translatatory control during all functional
general features are described in Table 2.2 with activities such as postural control tasks,
examples. non-fatiguing functional movements,
fatiguing high load and high speed activities.
Implications of local and global Local muscles maintain activity in the
characteristics background of all functional movements.
Their recruitment is independent of the
3. Local muscle ‘system’: the small deep direction of loading or movement and is
segmental muscles in the local muscle biased for non-fatiguing low load function,
system are responsible for increasing the although they maintain the role of
segmental stiffness across a joint and controlling intersegmental displacement
decreasing excessive intersegmental motion. during fatiguing high load function as well.
The relevance of this is that these muscles The local muscles do not significantly change
are ideally situated to control displacement length during normal activation and
of the path of the instantaneous centre of therefore do not primarily contribute to
motion and reduce excessive intersegmental range of motion. The one-joint
translatatory motion during functional (monoarticular) global muscles have a
movements. At end range of motion the primary stability role, while the multi-joint
passive restraints of motion (e.g. ligaments (biarticular) global muscles have a primary
and joint capsules) contribute significantly mobility role.
25
4. Global muscle ‘system’: the muscles that make titin filaments which anchor the myosin chain to
up the global muscle system are responsible the Z band. Other connective tissue structures
for the production and control of the range within muscle only contribute partially to passive
and the direction of movement. The global tension. Figure 2.1 illustrates the actin–myosin
muscles can change length significantly and filament cross-bridges and titin attachments.
therefore are the muscles of range of motion. The position in range (usually mid-range)
The global muscles participate in both where the active length–tension curve is maximal
non-fatiguing low load and fatiguing high is known as the muscle’s resting length. In this
load activities. position, the maximum number of actin–myosin
Both the local and global muscle systems must cross-bridge links can be established. In a mus-
work together for efficient normal function. cle’s shortened or inner range position, the passive
Neither system in isolation can control the func- elastic components do not contribute to muscle
tional stability of body motion segments. tension. Passive tension only begins to play a role
after a muscle starts to lengthen or stretch into the
muscle’s outer range, beyond its resting length or
Functional efficiency
mid-range position. Muscles are most efficient
The functional efficiency of a muscle is related to and generate optimal force when they function in
its ability to generate tension. A muscle’s tension a mid-range position near resting length. Muscles
is not constant throughout a contraction, espe- are less efficient and appear functionally weak
cially if the muscle is changing length to produce when they are required to contract in a shortened
movement. Length and tension properties of a or lengthened range relative to their resting length
muscle are closely related. The tension or force a because of physiological or mechanical insuffi-
muscle produces is the resultant force arising ciency (Figure 2.2).
from a combination of both active and passive Physiological insufficiency occurs when a
components of the muscle. The active compo- muscle actively shortens into its inner range
nent of muscle tension is determined by the where the actin filaments overlap each other, thus
number of actin–myosin cross-bridges that are reducing the number of cross-bridges that can
linked at any point in time. The passive tension link to the myosin filament. As the muscle pro-
property of muscle is largely due to the elastic gressively shortens, there are fewer cross-bridges
Inner range Outer range

Middle range ‘neutral’
‘shortened’ ‘lengthened’
or resting position
Tension
Physiological Mechanical
insufficiency Optimal force insufficiency
efficiency
Force inefficiency
‘functionally weak’
Joint range
Figure 2.1 Actin–myosin filaments within the sarcomeres
26
Muscle test
position
Tension
Lengthened
Shortened
Control
Inner range Outer range

Length
Figure 2.2 Active (contractile) component of a muscle length–tension curve changes when muscles change length: changes
in muscle length affect force efficiency in different positions of joint range. Adapted from Goldspink & Williams 1992
able to be linked, and the muscle is unable to muscle test position (inner to middle range), the
generate optimal force. Mechanical insufficiency lengthened muscle is inefficient due to physiolo-
occurs when a muscle actively contracts in its gical insufficiency, and consequently tests ‘weak’
lengthened or outer range. In this range, the actin during muscle testing and fatigues more readily
filaments do not adequately overlap the myosin in postural control tasks. A persistently shortened
filament and again a reduced number of cross- muscle, on the other hand, loses sarcomeres in
bridges are linked. Consequently the muscle series and increases in connective tissue (the
cannot generate optimal force. Mechanical insuf- dotted line in Figure 2.2). Because of the reduced
ficiency during an outer range contraction is number of sarcomeres, the shortened muscle
offset somewhat by the increase in passive tension generates less peak force than normal. Interest-
from titin filaments. ingly, a shortened muscle’s resting length may
However, when a muscle habitually functions at coincide with the muscle test position. Even
an altered length (either lengthened or shortened), though the shortened muscle is weaker than its
its length–tension relationships adapt accord- normal control, muscle testing is performed at
ingly. The position in range where it generates the point in range where it is optimally efficient.
optimal force efficiency changes to match the sub- Consequently, shortened muscles frequently
sequent lengthening or shortening (Goldspink & demonstrate good strength during muscle testing
Williams 1992), as illustrated in Figure 2.2. (Gossman et al 1982). This explains the clinical
When a muscle is persistently elongated or observation that ‘short muscles test strong and
lengthened, it adds sarcomeres in series (the long muscles test weak’.
broken line in Figure 2.2). Because the sarcom- A muscle’s structure also affects its ability to
eres are the force generating units within a muscle, generate force. Muscles that have long lever arms,
a lengthened or elongated muscle is stronger and such as the multi-joint rectus femoris or ham-
is able to generate a higher peak force than strings, can contract through a greater range and
normal. This higher peak force, however, is pro- are biomechanically advantaged to produce range
duced in an outer range position and not at its of movement during concentric shortening. These
usual resting length, mid-range position. At the muscles primarily have a mobility role. These
27
multi-joint mobilisers are not particularly effi-

cient at preventing or controlling excessive move-
ment during eccentric lengthening. The smaller
one-joint muscles with short lever arms, such as
subscapularis or iliacus, are not biomechanically
efficient to produce forceful or high speed move-
ment during concentric shortening. However,
they are more efficient during eccentric lengthen-
ing to control excessive movement and to deceler-
ate momentum and therefore are more able to
protect tissues from overstrain. These muscles pri-
marily have a stability role.
When a muscle has such a short lever arm
that it produces minimal length change when Global
contracted, it has a greater potential to control Global
mobility role stability role
intersegmental translation, for example the single
segment fibres of lumbar multifidus.
Functional classification of
muscle roles
Local
The concepts of local and global muscle systems stability role
and stabiliser and mobiliser muscles provide
useful frameworks to classify muscle function.
However, alone, they have some clinical deficien- Figure 2.3 Anatomical inter-relationships between the
different muscle roles in the lumbar spine
cies. By interlinking these two concepts a clini-
cally useful model of classification of muscle
functional roles has been developed (Comerford to achieve optimal function better than others. An
& Mottram 2001). analysis of a muscle’s ideal role should
Table 2.3 summarises this classification in terms consider the co-relation of the features listed in
of function and characteristics and dysfunction. Table 2.4.
Postural adjustments are anticipatory and This model of reviewing and analysing muscle
ongoing and all muscles can have an anticipatory function and recruitment provides an opportu-
timing to address displacement and perturba- nity to develop a greater understanding of a
tions to equilibrium. All muscles provide reflex muscle’s role in functional activities. By analys-
feedback reactions under both low and high ing the inter-relationships between a muscle’s
threshold recruitment tasks and demonstrate anatomy and histology, its biomechanical poten-
anticipatory feedforward recruitment when tial, its recruitment physiology and consistent
appropriate. However, only muscles with a local changes in the muscle related to pain and pathol-
stability role exhibit anticipatory timing that is ogy (see Table 2.4), we can be more critical of
independent of the direction of loading or dis- some of the oversimplified roles that have previ-
placement. Muscles recruited in a global range ously been ascribed to some muscles.
related role are direction-specific in their anti- If an analysis of all four of these features sup-
cipatory feedforward responses (Hodges & ports a consistent conclusion, we can be reason-
Richardson 1997; Hodges 2001; Hodges & ably confident that a particular muscle’s primary
Moseley 2003). Figure 2.3 illustrates an example function or role is understood. Such support is
of the anatomical inter-relationships between available only for a limited number of the muscles
the different muscle roles in the lumbar spine. that therapists work with on a regular basis,
such as transversus abdominis, external obliquus
abdominis, rectus abdominis and hamstrings.
Muscle characterisation If analysis of these four features provides con-
Although all muscles can perform all basic abili- flicting conclusions then there may be confusion,
ties, some muscles are ideally suited to some roles misunderstanding or misinterpretation of this
28
Table 2.3 Classification of muscle functional roles in terms of function, characteristics and dysfunction
LOCAL STABILITY GLOBAL STABILITY GLOBAL MOBILITY

MUSCLE ROLE/STRATEGY MUSCLE ROLE/STRATEGY MUSCLE ROLE/STRATEGY
Function and characteristics Function and characteristics Function and characteristics
• Increase muscle stiffness to • Generates force to control range of • Generates torque to produce range
control segmental motion/ motion of joint movement
translation • Contraction = eccentric length • Contraction = concentric length
• Controls the neutral joint position change ∴ control throughout change ∴ concentric production of
• Contraction = no/min. length range movement (rather than eccentric
change ∴ does not produce • Functional ability to: i) shorten control)
range of movement through the full inner range of • Concentric acceleration of
• Activity is often anticipatory (or at joint motion; ii) isometrically hold movement (especially sagittal plane:
the same instant) to expected position; iii) eccentrically control the flexion/extension)
displacement or movement to return against gravity and control • Shock absorption of high load
provide protective muscle stiffness hypermobile outer range of joint • Muscle activity is very direction
prior to motion stress motion if present dependent
• Recruitment is not anticipatory if • Deceleration of low load/force • Intermittent muscle activity (very
the muscle is already active or momentum (especially axial plane: on:off phasic patterns of activity
loaded rotation) – often brief bursts of activity to
• ± Muscle activity is independent • Non-continuous activity accelerate the motion segment then
of direction of movement • Muscle activity is direction momentum maintains movement)
• ± Continuous activity throughout dependent ∴ powerfully influenced
movement by muscles with antagonistic
• Proprioceptive input re: joint actions
position, range and rate of • High threshold activation under
movement situations of load and speed
Dysfunction Dysfunction Dysfunction
• Motor control deficit associated • Muscle lacks the ability to: i) • Loss of myofascial extensibility
with delayed timing or shorten through the full inner – limits physiological and/or
recruitment deficiency range of joint motion; ii) accessory motion (which must be
• Reacts to pain and pathology isometrically hold position; iii) compensated for elsewhere)
with inhibition eccentrically control the return • Overactive low threshold, low load
• Decrease muscle stiffness and • Inefficient low threshold tonic recruitment
poor segmental control recruitment • Reacts to pain and pathology with
• Loss of control of joint neutral • Poor rotation dissociation spasm
position • If hypermobile – poor control of • Demonstrate uncontrolled sagittal
excessive range movement under high threshold
• Inhibition by dominant antagonists recruitment testing
• Altered recruitment patterns and
uncontrolled movement with high
threshold recruitment
• Strength deficits on high threshold
recruitment
Table 2.4 Features of muscle function used for muscle’s function. Several possibilities exist to
reviewing muscle roles explain this apparent conflict:
1. Some discrepancies between biomechanics
FUNCTION DYSFUNCTION and neurophysiology need to be explained
with some muscles. For example, training
1. Anatomical location 4. Consistent and
and structure characteristic changes
latissimus dorsi co-activation with the
2. Biomechanical potential in the presence of pain contralateral gluteal muscles (often referred
3. Neurophysiology or pathology to as the posterior sacroiliac sling) to
stabilise the sacroiliac joint has been
29
proposed by various authors (Vleeming et al They state that the upper trapezius muscle
2007). This training would be appropriate to cannot elevate the scapula above C6. It is
help manage sacroiliac joint pain associated suggested that the reason for the high levels
with high load or high speed activities such of EMG activation may be to assist the
as running or throwing because these two clavicular rotation (necessary for full shoulder
muscles are automatically recruited in these elevation), or an attempt to stabilise the
activities. However, for patients who have cervical spine during arm load activities.
sacroiliac joint pain associated with non- Similarly, vastus medialis obliquus
fatiguing functional movements (e.g. normal demonstrates high levels of EMG activity in
gait) and postural control activities (e.g. terminal extension of the knee. Lieb & Perry
static standing), this training is unlikely to (1968) demonstrated that vastus medialis
be beneficial. There is often an assumption obliquus has no biomechanical potential to
that the muscles used in strength training extend the knee in this last 30°. The high
will be used in all functional activities. level of vastus medialis obliquus recruitment
However, this is not the case as there is is best explained by its role of maintaining
minimal automatic activation of latissimus alignment tracking of the patella during the
dorsi in these low load activities. last 30° of full extension.
Another example of measurement 3. The muscle is designed to participate in
discrepancy occurs following the assumption more than one primary functional role; for
that psoas major is a hip flexor. example, Hodges (2003) suggests that a
Biomechanical modelling of psoas major muscle may have three functional roles:
often assumes that it is a fusiform muscle (i) control of inter-segmental motion
with a straight line of action from the upper (ii) control of posture and alignment
lumbar spine to the femur. This is not the (iii) to produce and control movement.
case. Psoas major is a pennate muscle with Some muscles can effectively perform all
obliquely orientated fibres. A more detailed three of these functional roles. Gluteus
mechanical evaluation of its pennate maximus is an example of a muscle that
orientation (Gibbons 2007) suggests that its multitasks all three functional roles
maximum shortening potential is (Gibbons 2007). Gluteus maximus has deep
approximately 2.25 cm. This is insufficient to sacral fibres that run from the inferior lateral
produce the flexion range of motion of the corner of the sacrum to the posterior inferior
hip. The posterior fascia of psoas major is ischial spine. It is believed that these fibres
anchored to the anterior rim of the pelvis perform a local stability role and have the
(Gibbons 2007). This attachment would function of controlling intersegmental
produce posterior tilt of the pelvis. Posterior translation at the sacroiliac joint. Gluteus
tilt of the pelvis is a conjoined movement maximus also has fibres that run from the
with hip flexion, and interestingly the range medial aspect of the ileum to the gluteal
of movement of the pelvis at the psoas trochanter on the femoral neck. These deep
attachment point during posterior tilt fibres constitute the one-joint part of a
perfectly matches the predicted range of muscle that performs a global stability role
shortening of psoas major. at the hip joint. The most superficial fibres
2. There may be misinterpretation of research of gluteus maximus run from the iliac crest
measurement technology; for example, upper and attach into the posterior aspect of the
trapezius, lower trapezius, psoas major, vastus iliotibial band and eventually insert on the
medialis obliquus. Upper trapezius has been anterior aspect of the lateral tibial condyle,
assumed to elevate the shoulder because it below the knee. This multi-joint part of
demonstrates high levels of EMG activity gluteus maximus has a global mobiliser role
during scapular elevation tasks. Johnson and produces movement at the hip joint and
et al (1994) demonstrate that 90% of the the knee joint.
contractile fibres of upper trapezius insert on
the ligamentum nuchae below C6 and are For many of the muscles that therapists work
horizontally orientated (the vertical fibres are with on a regular basis there is currently insuffi-
predominantly fascial and connective tissue). cient information on all four of these features
30
(see Table 2.4) to enable thorough understanding evidence to support the muscle having both
of the primary function or role of these a local role and a global role, or the evidence may
muscles (e.g. serratus anterior, adductor magnus, support the muscle having a contribution to both
subscapularis). stability and mobility roles (e.g. gluteus maximus,
infraspinatus and pelvic floor). Such muscles
appear to be able to contribute to combinations
MUSCLE FUNCTION: PRIMARY ROLE of local stabiliser, global stabiliser and global
mobiliser roles when required in normal
function.
Identifying a muscle’s primary role is not always
simple. Some muscles appear to have a single, • In the presence of pathology and/or pain, a
very specific primary role (single task/specific variety of different dysfunctions may
muscle) while other muscles appear to be more develop. These dysfunctions can be identified
versatile and contribute to more than one primary as being associated with either or all of the
role (multitasking muscle). multitasking roles and are related to the
‘weak links’ in an individual’s integrated
stability system. Because these contribute to
Single task-specific muscles more than one functional role, different
Single task muscles have a specific task orientated dysfunctions can present with pain.
role associated with having only a local stabiliser Therefore, dysfunction in these muscles is
role (e.g. transversus abdominis, vastus medialis not predictable and a more detailed
obliquus), a global stabiliser role (e.g. external assessment is required with a clinical
obliquus abdominis) or a global mobiliser role reasoning process.
(e.g. rectus abdominis, hamstrings, iliocostalis • Treatment and retraining has to address the
lumborum). particular dysfunction that presents, usually
needs to be multifactorial and should
• In the presence of pathology and/or pain, emphasise integration into ‘normal’
very specific dysfunctions can develop and function.
are associated with the recognised specific
primary role. These dysfunctions are As well as a consideration of the macro function(s)
consistent and predictable. and role(s) of the muscle, the therapist should
consider the physiological or micro basis of the
• Very specific retraining or correction has
been advocated in treatment of this muscle with respect to its potential for recruit-
dysfunction (Hodges & Richardson 1996, ment in single or multifunction roles.
1997; Hodges & Richardson 1999; Jull 2000;
O’Sullivan 2000; Hides et al 1996, 2001).
This specific training or corrective MOTOR RECRUITMENT
intervention is typically non-functional and
as such is designed to correct very specific
elements of dysfunction. This specific
The motor unit
retraining or correction may or may not A single motor unit consists of the motor neurone
integrate into normal functional activity. plus the muscle fibres it innervates. All muscle
There is currently no method to predict or fibres in a single motor unit are of the same fibre
clinically measure automatic integration into type. All skeletal muscle fibres do not have the
normal function. In many patients this same mechanical and metabolic characteristics.
integration has to be facilitated. All human muscles are composed of different
motor unit types interspersed with each other.
The maximal contraction speed, strength and fati-
Multitasking muscles guability of each muscle depend on the propor-
Some muscles appear less specific and seem to tions of fibre types (Widmaier et al 2007).
participate in a variety of roles without demon- Most muscles are composed predominantly of
strating dysfunction. They appear to have a mul- two different types of motor units (Figure 2.4).
titasking function associated with the potential to There are slow low threshold motor units (SMU)
perform more than one role. That is, there is good and fast high threshold motor units (FMU). Other
31
Spinal cord
SMU
FMU
Muscle fibres
Figure 2.4 Slow and fast motor units (with permission of Movement Performance Solutions)
Table 2.5 Summary of slow and fast motor unit characteristics
FUNCTION SLOW MOTOR UNITS FAST MOTOR UNITS

Contraction speed Slow Fast
Contraction force Low High
Recruitment dominance Primarily recruited at low % of Increasingly recruited at higher % of maximum
maximum voluntary contraction voluntary contraction (MVC) (> 40+% MVC) or if
(MVC) (<25% MVC) plan to perform a fast movement
Recruitment threshold Low threshold (sensitive) – easily High threshold (insensitive) – requires higher
activated stimulus
Fatiguability Fatigue resistant Fast fatiguing
Role Control of normal non-fatiguing Rapid or accelerated movement and high load
functional movements and unloaded activity
postural control tasks
types of motor units have been identified, but this as slow motor units in non fatiguing function.
basis classification is useful for rehabilitation pur- They are predominantly recruited as load
poses (Lieber 2009). increases, with fatiguing functional activities or if
Slow motor units are fatigue resistant with a the central nervous system plans to preform a fast
slow speed of contraction and a low contraction movement (Monster 1978).
force. Significantly they have a low threshold for
activation and as such are predominately recruited
in non fatiguing postural control tasks and non LOW VERSUS HIGH THRESHOLD
fatiguing functional movements. Fast motor units RECRUITMENT
are fast fatiguing when recruited (for example
with fast movements or loaded activities). Signifi- Table 2.6 summarises functional activities that
cantly they have a higher threshold for activation stimulate dominant slow and fast motor unit
and as such are not recruited to the same extent recruitment patterns.
32
Table 2.6 Functional activities that stimulate dominant slow and fast motor unit recruitment patterns
Low threshold (tonic) recruitment of slow motor High threshold (phasic) recruitment of fast
units (SMU) (related to low load/force and slow motor units (FMU) (related to high load/
speed) force and high speed)
• Alignment and postural adjustment • fatiguing high force or load
• Control of non fatiguing postural activities • bracing co-contraction
• Non-fatiguing movements of the unloaded limbs and • initiating fast or accelerated movement
trunk at a natural comfortable speed
Recruitment is modulated by the higher central Stability function: Mobility function:

nervous system (CNS) and is powerfully influ- anti-gravity Functional role resisted or
or activity
enced by the afferent proprioceptive system along postural control fast movement
with some behavioural and psychological contex-
Stabiliser muscles Ideal Mobiliser muscles
tual factors such as fear of pain. Hypertrophy,
muscle
however, is a peripheral structural adaptation in
muscle in response to demand along with CNS
adaptation and is the result of overload training
(Widmaier et al 2007). Recruitment of Recruitment of
Hodges (2003) argues that high threshold slow motor units Ideal slow fast motor units
strengthening of the global muscles of range and (low threshold stimulus) recruitment (low threshold stimulus)
force potential and low threshold motor control
training of deeper (force inefficient) local muscles Figure 2.5 The relationship between the biomechanical and
are two distinctly separate processes, both of physiological characteristics of muscles in stability and
mobility function
which are required to perform to high levels of
activity such as competitive sport. One analogy
for this is to think of the musculoskeletal system
as a computer:
• High speed or high load strength training changes

muscle structure (hypertrophy) and can be likened to In an ideal or normal situation, a one-joint
upgrading the computer’s hardware. This can make muscle performing a non-fatiguing anti-gravity or
the computer work faster and run more complex postural holding function and possessing stabil-
programs. Upgrading the hardware does not require iser characteristics demonstrates greater recruit-
specific cognitive retraining – the same software is ment of slow motor units (Figure 2.5). Slow
used but more efficiently. motor units are sensitive to low threshold stimuli
• Low threshold motor control training does not change and should react efficiently to low force loading
the peripheral muscle structure to any great extent,
situations such as postural sway, maintenance of
but instead improves the central nervous system’s
recruitment of muscles to fine-tune muscle
postural positions and normal functional move-
coordination and improve the efficiency of movement. ments of the unloaded limbs or trunk.
This can be likened to upgrading the software in a Similarly, for a fast, repetitive movement or
computer to perform its tasks more efficiently and to power function, muscles with mobiliser charac-
get the most out of the hardware already present. teristics would demonstrate greater recruitment of
Upgrading the software, though, always requires fast motor units (although the slow motor units
cognitive operator training and familiarisation. are also still recruited). Fast motor units are less
• In this analogy, pain is best represented as a computer sensitive, have higher recruitment thresholds and
virus, which primarily affects the software, causing the activate more efficiently in response to high force
computer to run slowly and crash more often. In the loading such as accelerated movement, rapid
human body pain has more consistent effects on the movement, a large or sudden shift of the centre
motor control aspects of movement rather than
of gravity, high force or heavy loads and con-
directly affecting muscle structure.
scious maximal contraction.
33
Functional implications of Spindle afferents

recruitment within stabiliser and
mobiliser roles
Stabiliser roles and slow motor unit
recruitment
• Dynamic postural control and normal low
load functional movement is primarily a
function of slow motor unit (tonic)
recruitment.
• Functionally, efficient recruitment of slow
motor units will optimise postural holding/
anti-gravity and stability function.
• Normal postural control and functional
movement of the unloaded limbs and trunk
should ideally demonstrate efficient
recruitment of deeper, segmentally attaching Gamma
muscles that provide a stability role. motor
neurone
Mobiliser roles and fast motor

unit recruitment
• Functionally, efficient recruitment of fast
Intrafusal fibres
motor units will optimise rapid/accelerated
movement and the production of high force
or power. Extrafusal fibres
• High load activity or strength training Figure 2.6 Muscle spindle (with permission of Movement
(endurance or power overload training) is a Performance Solutions)
function of both slow (tonic) and fast
(phasic) motor unit recruitment.
• High load or high speed activities normally
demonstrate a dominance of recruitment of
more superficial, multi-joint muscles that are contribute significantly to the regulation and
biomechanically advantaged for high load, control of muscle stiffness and therefore segmen-
large range and high speed. tal stability.
The clinical interpretation of ‘stiffness’ is often
portrayed as a negative outcome. Clinically,
‘stiffness’ often refers to a loss of motion or func-
MUSCLE STIFFNESS tion. Biomechanical ‘stiffness’ on the other hand
usually describes a process of providing strength
Muscle spindles have both sensory and motor and support. A simple but appropriate way of
functions and are sensitive to changes both in describing stiffness biomechanically relates to the
length and in force (Figure 2.6). The information passive or active tension that may resist a displac-
from muscle spindles contributes to propriocep- ing force.
tion. This allows the central nervous system to be Muscle stiffness (i.e. the ratio of force change
aware of the position of joints, how far they are to length change) consists of two components:
moving, how fast they are moving, how much intrinsic muscle stiffness and reflex mediated
force is being used, and relates to the sensation muscle stiffness (Johansson et al 1991).
of effort required for particular activities. Muscle 1. Intrinsic muscle stiffness is dependent on the
spindles play a primary role in proprioception viscoelastic properties of muscle and the
and afferent feedback for motor control but also existing actin–myosin cross-bridges. This can
34
be affected by hypertrophy or strength

training. Hypertrophy, which increases
muscle size, muscle fibres in parallel and
also increases muscle connective tissue,
results in increased muscle stiffness which in
turn provides increased resistance to
displacement and a mechanism of
resisting UCM. This mechanism, however,
is largely passive and does not provide
dynamic responses to movement
challenges.
2. Reflex mediated stiffness is determined by
the excitability of the alpha motor neurone
pool, which in turn is dependent on
descending commands and reflexes which
are facilitated by the muscle spindle afferent
input (refer again to Figure 2.6). This
mechanism is dynamic and provides reflex
automatic activation of muscles to provide
dynamic responses to postural displacement.
For example, in sitting or standing, during
activities of leaning forwards at the trunk,
the posterior paraspinal stabiliser muscles
(multifidus) up-regulate their activation in
response to postural loading. During forward
leaning, the position of the trunk creates a
flexion loading force on the lumbar spine
which, in order to maintain spinal neutral
alignment, must be resisted by posterior Figure 2.7 Palpation of multifidus activation (rear leg) during
muscles such as multifidus. Likewise, when weight transfer
the trunk returns to an upright position
(vertically aligned above the pelvis) the
flexion loading force on the lumbar spine is the rear leg side during forward weight transfer
reduced and the posterior muscles down- can be palpated by the therapist or the patient. If
regulate their activity because they are no multifidus is palpated when full weight is sup-
longer required to work as hard to resist or ported on the rear leg, the muscle is unloaded
stabilise the spine against flexion loading. and relaxed. During the transfer of body weight
forwards onto the front leg (Figure 2.7) the multi-
fidus muscle on the rear leg side will automati-
Low threshold recruitment and timing cally activate as it is required to support the pelvis
The timing of the automatic reflex activation in from dropping in preparation to lift the rear leg
response to movement and postural displace- for the swing phase of gait.
ment is influenced by the threshold (or sensitiv- The timing of the onset of activation of multi-
ity) of muscle recruitment. For example, during fidus is not always consistent. Some people dem-
forward weight transfer in normal gait, the mul- onstrate automatic activation early in weight
tifidus muscle on the rear leg side activates in transfer, while others demonstrate a delayed acti-
response to loading. As weight shifts forwards (off vation response. Ideally, the activation of multi-
the rear leg and towards the front foot) the pelvis fidus on the rear leg side should coincide with the
on that side has to be supported from dropping initiation of weight transfer, and its onset activa-
down into lateral tilt. Multifidus and the lateral tion can be palpated as the weight shifts from the
trunk muscles on that side play a role in provid- heel of the rear foot to the metatarsal heads of
ing pelvic stabilisation and support while that leg that same foot. If multifidus has sufficient low
swings through. The activation of multifidus on threshold recruitment it should activate before
35
any significant weight is transferred to the front of independent research groups are all reporting
foot. If efficient low threshold recruitment of a common finding (Lee 2011; Jull 2000; Sahr-
multifidus is inhibited, multifidus does not pal- mann 2002; Hodges 2003; Hodges & Moseley
pably activate until body weight is transferred to 2003; Richardson et al 2004; Falla et al 2004a, b;
the front foot and body weight is unloaded from Sterling et al 2001, 2005; Dankaerts et al 2006;
the rear foot. This observed delay in automatic Moseley & Hodges 2006; O’Sullivan et al 2006;
recruitment is associated with altered low thresh- O’Leary et al 2001). They have all consistently
old activation. It is a very common observation observed that, in the presence of chronic or recur-
that patients with a history of recurrent low back rent pain, subjects change the patterns or strate-
or pelvic girdle pain consistently demonstrate a gies of synergistic recruitment that are normally
timing delay in multifidus activation during used to perform low load functional movements
forward weight transfer compared to people who or postures. They have demonstrated that these
have no history of low back pain. This is not an subjects employ strategies or patterns of muscle
issue of muscle weakness, as it is consistently recruitment that are normally reserved for high
observed in athletes with back pain who have load function (e.g. lifting, pushing, pulling,
hypertrophy of the paraspinal muscle groups due throwing, jumping, running, etc.) for normal
to strength and conditioning training programs. postural control and low threshold functional
This delay may be related to a change in the activities. The common observation is that the
threshold of automatic activation of low thresh- multi-joint muscles with a primary mobility role
old slow motor units. for force and speed functions inappropriately
become the dominant synergists in non-fatiguing
normal functional movements and for low thresh-
old postural control tasks. At the same time, the
PAIN AND RECRUITMENT one-joint muscles that should be dominant in
non-fatiguing function and postural control,
Recruitment is altered in the presence of pain. demonstrate down-regulation of their activation
Pain affects slow motor unit recruitment more and are less active than controls with no pain
significantly than fast motor unit recruitment. history. Figure 2.8 illustrates graphically the dif-
Pain does not appear to significantly limit an ferences in recruitment patterns of stabiliser and
athlete’s ability to generate power and speed, so mobiliser synergists in the pain-free state and the
long as they can mentally ‘put the pain aside’. It chronic pain state.
has been suggested anecdotally that up to 90% of These pain-related changes in the patterns or
sporting world records are broken by athletes the thresholds of recruitment between one-joint
with a chronic or recurrent musculoskeletal pain stabilisers and their multi-joint mobiliser syner-
problem. gists can only be demonstrated during unloaded
In the pain-free state, research (Hodges & or low threshold testing. Under high load or high
Moseley 2003; Moseley & Hodges 2005) indicates threshold function it is normal, in both the pain-
that the brain and the central nervous system free state and in the presence of pain, to demon-
(CNS) are able to utilise a variety of motor control strate mobiliser dominance (with respect to
strategies to perform functional tasks and main- stabiliser activation). Therefore, tests based on
tain control of movement, equilibrium and joint strength or endurance cannot consistently iden-
stability. However, in the pain state, the options tify if there is a pain-related change in recruitment
available to the CNS appear to become limited. thresholds or patterns of recruitment.
These altered (or limited) motor control strate- These altered strategies or patterns have been
gies present as consistent co-contraction patterns described in the research and clinical literature
usually with exaggerated recruitment of the as ‘substitution strategies’, ‘compensatory move-
multi-joint muscles over the deeper segmental ments’, ‘muscle imbalance’ between inhibited/
muscles. lengthened stabilisers and shortened/overactive
Recent research on musculoskeletal pain has mobilisers, ‘faulty movements’, ‘abnormal domi-
focused on motor control changes associated nance of the mobiliser synergists’, ‘co-contraction
with the pain state. This research has provided rigidity’ and ‘control impairments’. The inconsist-
important new information regarding chronic or ent terminology used in the clinical and academic
recurrent musculoskeletal pain. A large number literature has contributed to a lack of universal
36
Pain-free/normal/ideal
Table 2.7 Recruitment changes associated with
100
90 With uncontrolled movement (UCM), inhibition and
80 dysfacilitation present as:
• Poor recruitment under low Inhibition and
70
threshold stimulus – inefficient dysfacilitation
60 slow motor unit (SMU) ≠ ‘off’
50 recruitment ≠ ‘weak’
40 – (evidence in both the local
Mobiliser and global muscle systems)
30 • Delayed recruitment timing
Stabiliser
20 – (evidence in the local muscle
10 system)
• Altered recruitment sequencing
0 – (evidence in the global muscle
Low High
load load system)
Chronic musculoskeletal pain of altered motor control strategies. These altered

strategies contribute to changes in thresholds of
100 facilitation and inefficient pattern of muscle
90 activation.
80 Example 1: Pain causes active inhibition of SMU
70
recruitment. The pain may resolve and the
mechanism of inhibition may be removed, but
60
dysfacilitation may persist.
50 Example 2: Behavioural and psychological
40 factors such as fear of pain or anxiety of
Mobiliser
30 movement also have the potential to contribute
20
Stabiliser to recruitment/inhibition.
10
0
Low High ALTERED STRATEGIES IN A
load load DYSFUNCTIONAL SITUATION
Figure 2.8 Graphical representation of recruitment
differences related to chronic or recurrent musculoskeletal pain Clinically, one-joint stabiliser muscles demon-
strate a recruitment problem. They appear to
recognition of this consistent and almost predict- increase their threshold, become less responsive
able change related to pain. to low load stimulus and respond best when the
load becomes greater (Figure 2.9). Therefore the
stability muscles respond mainly to higher load
activities such as accelerated movement, rapid
RECRUITMENT DYSFUNCTION: movement, high force and a large shift of the
INHIBITION AND DYSFACILITATION centre of gravity.
As a consequence, the multi-joint mobilisers
Inhibition and dysfacilitation can be identified as take over the stability role. They appear to decrease
abnormal alteration of normal recruitment (Table their threshold and become more reactive to a
2.7). Inhibition relates to a process of neural dis- low load stimulus. Therefore the mobilising
charge being actively suppressed by another muscles appear to respond to low load activities
neural influence. This process is part of normal such as postural sway, maintained postural posi-
movement but it may become abnormal in certain tion and slow movement of the unloaded limb
situations. Dysfacilitation relates to the utilisation (Figure 2.10). The decrease in threshold and
37
Stability function: Mobility function: (Grimby & Hannerz 1976). Indeed, propriocep-
anti-gravity resisted or tive information from the primary muscle spindle
postural control fast movement endings (especially the gamma spindle system
loops) is essential for efficient facilitation of tonic
Stabiliser muscles Mobiliser muscles
or slow motor unit recruitment (Eccles et al 1957;
Grimby & Hannerz 1976).
Grimby & Hannerz (1976) reported that when
less responsive to low proprioception is diminished, the sense of effort
responds efficiently threshold but responds necessary for efficient activation of slow motor
to a low threshold efficiently to a high units is increased. That is, during low load activity,
stimulus threshold stimulus the subject feels that they must try harder (even if
it feels like maximum effort) to achieve tonic
Figure 2.9 Dysfunctional stabiliser recruitment – down- recruitment of slow motor units. It feels much
regulation, inhibition and dysfacilitation easier to contract the same muscle against high
load or resistance (where fast motor unit recruit-
Stability function: Mobility function:
ment is significant).
anti-gravity resisted or
postural control fast movement When maximum or high sensation of effort is needed to
perform a low load activity or movement then it is most
Stabiliser muscles Mobiliser muscles likely that there is inefficient facilitation of slow motor
unit recruitment and dysfunction of normal spindle
responses.
For the same reasons though, when less sensation of
effort is needed to perform that same low load activity or
becomes more responds primarily to movement (and it feels easier), then it is likely that there
responsive to a low a high threshold is better facilitation of slow motor unit recruitment.
threshold stimulus stimulus This decrease in the sense of effort required is a good
indicator of improving motor control stability function.
Figure 2.10 Dysfunctional mobiliser recruitment –
up-regulation and overactivity The sensation of high effort to perform a low
load task may be due to:
increased tonic activity of SMU recruitment in • recruitment dysfunction (common, with
mobiliser muscles contributes to their observed multiple contributing factors), or
dominance in postural control (O’Sullivan et al • disuse atrophy and weakness (uncommon,
1998; Jull 2000; Sahrmann 2002). but if present, with wasting and functional
deficits).
During low threshold motor control stability
SENSATION OF EFFORT, AFFERENT INPUT training it is permissible for the patient to ‘feel’
AND RECRUITMENT or experience the sensation that they are working
hard (even maximally) during low load exercise
The concept of ‘sensation of effort’ has significant so long as they do not show signs of fatigue of
relevance to the clinical assessment of threshold the stability muscle or substitute with a different
changes in recruitment functions and subsequent muscle. It is not appropriate to progress the exer-
implications for the re-assessment of recruitment cise until that low load exercise feels easy.
after exercise interventions. The sense of effort has • Peripheral fatigue occurs when a muscle can
been defined as a judgment on the effort required maintain a level of contraction force for
to generate a force (Enoka & Stuart 1992). This longer because of peripheral factors (e.g.
is processed in higher centres in the central ner- depleted muscle glycogen, phosphagen, and
vous system and relates to the mental challenge calcium) even though the CNS may be
required to perform a task in the periphery. increasing neural discharge to the motor
The relative recruitment of slow and fast motor neurone pool. The muscle runs out of fuel.
units in sustained voluntary contraction is partly This is best improved by strength training
due to the influence of proprioceptive activity programs.
38
• Central fatigue relates to alterations in the efficiency and the altered sensation of effort in
way that the CNS drives the motor neurone low load testing. This recruitment inhibition
pool. The muscle has the ability (and fuel) affects both local and global muscle stability func-
to generate more force but an inadequate tion. Articular or myofascial restrictions create
neural stimulus is provided by the CNS. This compensatory patterns of movement. Pain and
is a motor control issue. the resultant muscle spasm and guarding also
contribute to these dysfunctional compensatory
movement patterns. Compensation that is effi-
Clinical differentiation between central fatigue ciently controlled does not appear to contribute
and peripheral fatigue to the development of musculoskeletal pain.
However, there is abundant evidence to support
When a functional task feels like hard work: the link between UCM (uncontrolled interseg-
• If added or increased resistive load: mental translation or uncontrolled range of
→ easier = central fatigue (responds to facilitation) motion) and the development of musculoskeletal
→ harder = peripheral fatigue or weakness pain and degenerative pathology.
This dysfunction loop acts like a ‘vicious circle’
Implications for training: and contributes to the maintenance of chronicity
When a low load exercise feels or looks like hard work and insidious recurrence of musculoskeletal pain.
this usually indicates a motor control recruitment
dysfunction (not weakness) and needs specific assessment
and specific low threshold retraining.
MUSCLE RECRUITMENT TRAINING
Low threshold recruitment

THE DYSFUNCTION LOOP dominance
Low threshold motor control training is primarily
Figure 2.11 illustrates some of the inter-related directed towards restoring normal or ideal recruit-
changes in muscle physiology associated with pain ment thresholds and strategies. This can be
and dysfunction. Pain, inflammation and swelling related to upgrading the software in the computer
contribute to impaired proprioception which is analogy referred to earlier. It is not based on
in turn related to inhibition of SMU recruitment directly restoring function. Improvements in
Movement control
dysfunction
uncontrolled translation
uncontrolled range
Pain and pathology

Inefficient recruitment
nociceptive (peripheral)
of local and global
neurogenic (CNS)
stability muscles
behavioural
Abnormal strategies and
dysfunction patterns
• compensation
• stabiliser inefficiency
• mobiliser substitution
• restriction
Inhibition
of slow motor unit Diminished
recruitment efficiency proprioception
(high sense of effort)
Figure 2.11 The dysfunction loop
39
function are an indirect consequence of recover- Table 2.8 Key threshold differences between low
ing SMU recruitment thresholds and restoring and high threshold recruitment strategies
more ideal patterns of recruitment. Low thresh-
old motor control training strategies usually KEY THRESHOLD DIFFERENCES
require practising a highly cognitive, very specific,
non-functional movement skill until the activa- Low threshold High threshold
tion strategy feels more ‘familiar’ and less ‘unnat- recruitment recruitment
ural’ and has a low sensation of effort (feels easy) Slow motor unit dominant Fast motor unit dominant
during its performance. Once this low threshold
Slow / Static Fast
motor control recruitment skill has been estab-
lished it can be progressed in several ways: and or
• While maintaining the cognitive activation, Sustained Fatiguing
progressively remove or decrease load
(non-fatiguing, low load) (high load)
facilitation (unloading). For example, the
multifidus has increased load facilitation in
standing with forward leaning of the trunk.
Load facilitation is decreased by moving the
trunk backwards over the pelvis in sitting
and is maximally unloaded by lying
supported in prone. Retraining low threshold
• While maintaining the cognitive activation, recruitment dominance
impose a low threshold (non-fatiguing)
perturbation. This perturbation should If the patient is able to perform an exercise or task
consist of small range, low force, non- slowly and consistently for 4 minutes or more
predictable displacements. For example, this without fatigue or needing recovery time, then at
can be achieved while sitting upright on an least the first 1–2 minutes of that exercise or task
unstable base (such as an inflatable disc or will be performed with low threshold recruitment
round balance board) while maintaining the dominance.
trained cognitive activation.
High threshold recruitment Retraining high threshold

dominance recruitment dominance
High threshold strength training affects structure If the load of the exercise or task is such that it
(hardware) of muscle tissue over time. When cannot be performed continually for 2 minutes
muscle tissue is loaded and stressed it adapts to because the load is sufficient to cause fatigue
stress and hypertrophies and increases the poten- then that exercise or task will be performed
tial to generate force and power. This structural with high threshold recruitment dominance.
change occurs over a timeframe of 6–8 weeks If an exercise or task is performed at high
or more: speed, then it will be performed with high
threshold recruitment dominance (even if it is
• Strength training is progressed by low load).
progressively increasing resistive load, using
In between these two regions there is a ‘grey’
fast alternating movements or progressively
area that can be significantly influenced by train-
increasing holding endurance to the point
ing responses.
of fatigue.
These aspects of physiology and muscle recruit-
ment function underpin the processes used in
developing assessment principles (Chapter 3).
CLINICAL GUIDELINE FOR RECRUITMENT The application of this knowledge to the design
TRAINING and implementation of retraining strategies to
address UCM and for the integration of low
Table 2.8 lists the key differences between low and threshold motor control training into function is
high threshold recruitment retraining strategies. further explored and demonstrated in Chapter 4.
40
REFERENCES
Bergmark, A., 1989. Stability of the physiotherapy. Butterworth movement. Experimental Brain
lumbar spine. A study in mechanical Heinemann, Oxford. Research 114, 362–370.
engineering. Acta Orthopaedica Gossman, M.R., Sahrmann, S.A., Hodges, P.W., Richardson, C.A., 1999.
Scandinavica 230 (60), 20–24. Rose, S.J., 1982. Review of length- Transversus abdominis and the
Comerford, M.J., Mottram, S.L., 2001. associated changes in muscle. superficial abdominal muscles are
Movement and stability dysfunction Physical Therapy 62 (12), controlled independently in a
– contemporary developments. 1799–1808. postural task. Neuroscience Letters
Manual Therapy 6, 15–26. Grimby, L., Hannerz, J., 1976. 265 (2), 91–94.
Dankaerts, W., O’Sullivan, P., Burnett, Disturbances in voluntary Horak, F.B., Esselman, P., Anderson,
A., Straker, L., 2006. Altered patterns recruitment order of low and high M.E., Lynch, M.K., 1984. The effects
of superficial trunk muscle activation frequency motor units on blockades of movement velocity, mass
during sitting in nonspecific chronic of proprioception afferent activity. displaced, and task certainty on
low back pain patients: importance Acta Physiologica Scandinavica 96, associated postural adjustments
of subclassification. Spine 207–216. made by normal and hemiplegic
(Philadelphia Pa 1976) 31 (17), individuals. Journal of Neurology,
Hides, J.A., Richardson, C.A., Jull, G.A.,
2017–2023. Neurosurgery, and Psychiatry 47 (9),
1996. Multifidus muscle recovery is
Eccles, J.C., Eccles, R.M., Lundberg, A., 1020–1028.
not automatic after resolution of
1957. The convergence of acute, first-episode low back pain. Janda, V., 1983. On the concept of
monosynaptic excitatory afferents Spine 21 (23), 2763–2769. postural muscles and posture in
onto many different species of alpha man. Australian Journal of
Hides, J.A., Jull, G.A., Richardson, C.A.,
motorneurons. Journal of Physiology Physiotherapy 29 (3), 83–84.
2001. Long term effects of specific
(London) 137, 22–50. Janda, V., 1996. Evaluation of muscle
stabilizing exercises for first episode
Enoka, R.M., Stuart, D.G., 1992. low back pain. Spine 26 (11), imbalance. In: Liebenson, C. (Ed.),
Neurobiology of muscle fatigue. 243–248. Rehabilitation of the spine. Williams
Journal of Applied Physiology 72 and Wilkins, Baltimore.
(5), 1631–1648. Hodges, P.W., 2001. Changes in motor
Johansson, H., Sjolander, P., Sojka, P.,
planning of feedforward postural
Falla, D., Jull, G., Hodges, P., 2004a. 1991. Receptors in the knee joint
responses of the trunk muscles in
Patients with neck pain demonstrate ligaments and their role in the
low back pain. Experimental Brain
reduced electromyographic activity biomechanics of the joint. Critical
Research 141, 261–266.
of the deep cervical flexor muscles Reviews in Biomedical Engineering
during performance of the Hodges, P.W., 2003. Core stability 18 (5), 341–368.
craniocervical flexion test. Spine 29, exercise in chronic low back pain. Johnson, G., Bogduk, N., Nowitzke, A.,
2108–2114. Orthopedic Clinics of North America House, D., 1994. Anatomy and
34 (2), 245–254. actions of trapezius muscle. Clinical
Falla, D., Bilenkij, G., Jull, G., 2004b.
Patients with chronic neck pain Hodges, P.W., Cholewicki, J., 2007. Biomechanics 9, 44–50.
demonstrate altered patters of Functional control of the spine. In: Jull, G.A., 2000. Deep cervical flexor
muscle activation during Vleeming, A., Mooney, V., Stoeckart, muscle dysfunction in whiplash.
performance of a functional upper R. (Eds.), Movement, stability and Journal of Musculoskeletal Pain 8
limb task. Spine 29, 1436–1440. lumbopelvic pain. Elsevier, (1/2), 143–154.
Gibbons, S., 2007. Clinical anatomy Edinburgh, ch. 33. Kendall, F.P., McCreary, E., Provance, P.,
and function of psoas major and Hodges, P.W., Moseley, G.L., 2003. Pain Rodgers, M., Romanic, W., 2005.
deep sacral gluteus maximus. In: and motor control of the lumbo- Muscles: testing and function with
Vleeming, A., Mooney, V., Stoeckart, pelvic region: effect and possible posture and pain. Lippincott
R. (Eds.), Movement, stability and mechanisms. Journal of Williams Wilkins, Baltimore.
lumbopelvic pain. Elsevier, Electromyography and Kinesiology Lee, D., 2011. The pelvic girdle: an
Edinburgh, ch. 6, p. 95. 13 (4), 361–370. integration of clinical expertise and
Goff, B., 1972. The application of recent Hodges, P.W., Richardson, C.A., 1996. research, 4th edn. Churchill
advances in neurophysiology to Miss Inefficient muscular stabilisation of Livingstone, Edinburgh.
R Rood’s concept of neuromuscular the lumbar spine associated with Lieb, F., Perry, J., 1968. Quadriceps
facilitation. Physiotherapy 58 (2), low back pain: a motor control function – an anatomical and
409–415. evaluation of transversus abdominis. mechanical study using
Goldspink, G., Williams, P.E., 1992. Spine 21 (22), 2640–2650. amputated limbs. Journal of Bone
Muscle fibre and connective tissue Hodges, P.W., Richardson, C.A., 1997. and Joint Surgery 50A (8),
changes associated with use and Feedforward contraction of 1535–1548.
disuse. In: Ada, L., Canning, C. transversus abdominis is not Lieber, R.L., 2009. Skeletal muscle
(Eds.), Key issues in neurological influenced by the direction of arm structure, function and
41
plasticity. Lippincott Williams neck pain. Manual Therapy Mar 9 Richardson, C., Jull, G., Hodges, P.,
and Wilkins, Baltimore. [Epub ahead of print] Hides, J., 1998. Therapeutic exercise
McGill, S.M., 2007. The painful and O’Sullivan, P.B., 2000. Lumbar for spinal segmental stabilization
unstable lumbar spine: a foundation segmental ‘instability’: clinical in low back pain. Churchill
and approach for restabilization. In: presentation and specific stabilizing Livingstone, Edinburgh, pp. 12.
Vleeming, A., Mooney, V., Stoeckart, exercise management. Manual Richardson, C., Hodges, P., Hides, J.,
R. (Eds.), Movement, stability and Therapy 5 (1), 2–12. 2004. Therapeutic exercise for
lumbopelvic pain. Elsevier, lumbopelvic stabilization, 2nd edn.
O’Sullivan, P.B., Twomey, L., Allison, G.,
Edinburgh, ch. 35. Churchill Livingstone, Edinburgh.
Sinclair, J., Miller, K., Knox, J., 1997.
Monster, A.W., Chan, H., O’Connor, D., Altered patterns of abdominal Sterling, M., Jull, G., Wright, A., 2001.
1978. Activity patterns of human muscle activation in patients with The effect of musculoskeletal pain
skeletal muscles: relation to muscle chronic low back pain. Australian on motor activity and control.
fiber type composition. Science 200 Journal of Physiotherapy 43 (2), Journal of Pain 2 (3), 135–145.
(4339), 314–317. 91–98. Sterling, M., Jull, G., Vicenzino, B.,
Moseley, G.L., Hodges, P.W., 2005. Are
O’Sullivan, P.B., Twomey, L., Allison, Kenardy, J., Darnell, R., 2005.
the changes in postural control
G.T., 1998. Altered abdominal Physical and psychological factors
associated with low back pain caused
muscle recruitment in patients with predict outcome following whiplash
by pain interference? Clinical Journal
chronic back pain following a injury. Pain 114 (1–2), 141–148.
of Pain 21 (4), 323–329.
specific exercise intervention. Journal Sahrmann, S.A., 2002. Diagnosis and
Moseley, G.L., Hodges, P.W., 2006.
of Orthopaedic and Sports Physical treatment of movement impairments
Reduced variability of postural
Therapy. syndromes. Mosby, St Louis.
strategy prevents normalization of
motor changes induced by back Panjabi, M.M., 1992. The stabilising Vleeming, A., Mooney, V., Stoeckart, R.,
pain: a risk factor for chronic system of the spine. Part 1. Function, 2007. Movement, stability and
trouble? Behavioral Neuroscience dysfunction adaption, and lumbopelvic pain. Integration of
120 (2), 474–476. enhancement. Journal of Spinal research and therapy. Churchill
O’Leary, S., Falla, D., Jull, G., 2011. The Disorders 5, 383–389. Livingstone, Edinburgh.
relationship between superficial Reeves, N.P., Cholewicki, J., 2010. Widmaier, E., Raff, H., Strang, K., 2007.
muscle activity during the cranio- Expanding our view of the spine Vander’s human physiology: the
cervical flexion test and clinical system. European Spine Journal mechanisms of body function.
features in patients with chronic DOI: 10.1007/s00586-009-1220-5. McGraw Hill, Boston.
42
|3|
Chapter 3
Assessment and classification

of uncontrolled movement
The development of valid classification methods however, it has yet to be established if CPR can
to assist therapists in the management of neuro- change symptoms as well as function and dys-
musculoskeletal disorders has been recognised as function or correlate to changes in muscular
a clinical priority (Fritz & Brennan 2007; Fritz recruitment. The following section explores issues
et al 2007). Identifying and classifying movement relating to the classification of subgroups in
faults is fast becoming an essential tool neuromusculoskeletal pain management.
in contemporary rehabilitative neuromusculo-
skeletal practice (Comerford & Mottram 2001a;
Sahrmann 2002; O’Sullivan 2005). Traditionally, CLASSIFICATION OF SUBGROUPS IN
assessment of musculoskeletal problems is based
NEUROMUSCULOSKELETAL PAIN
on the clinical history, mechanism of injury and
symptom responses to examination procedures.
Symptoms are assessed during active movements Non-specific musculoskeletal pain often has a
(Cyriax 1980; McKenzie & May 2003; Maitland history of chronicity or recurrence along with
et al 2005), passive movements (Kaltenborn multiple tissues being diagnosed as contributory
2003; Maitland et al 2005), combined move- elements to the pain presentation. Significant
ments (Edwards 1999) or sustained positions pain mechanisms are often present (Chapter 1)
(McKenzie & May 2003). A mechanism-based and there may or may not be identifiable ele-
approach has now been proposed (Schafer et al ments of behavioural adaptation. If mechanical
2007) with contemporary assessment moving subgroups can be identified within the broad
away from individual symptom responses to group known as non-specific neuromusculoskel-
exploring movement impairments and how these etal pain, then manual therapy and therapeutic
relate to symptoms (Comerford & Mottram exercise interventions have a better rationale for
2001a; Sahrmann 2002; Burnett et al 2004; predicting positive outcomes.
Dankaerts et al 2006b; Comerford & Mottram Classification and categorisation of subgroups
2011, Van Dillen et al 2009). can be based on a variety of systems of analysis,
Given the complexity of neuromuscular dys- for example:
function, therapists have continued to search for • Non-specific musculoskeletal pain: no single
a systematic framework to assist clinical assess- anatomical based pathology can account for
ment and management. One focus is on identify- the presenting symptoms. The evaluation of
ing clinical prediction rules (CPR) that determine movement-related dysfunction can be used
subgroups within patient presentations that may to explain some of the symptoms presenting
respond to certain treatments (Hicks et al 2005); in multiple tissues. These movement-based

DOI: 10.1016/B978-0-7295-3907-4.00003-7 43
Box 3.1 Classification of subgroups based on non-specific mechanical pain related to movement
dysfunction
Subgroups within non-specific (iii) psoas (Gibbons 2005; Comerford & Mottram
musculoskeletal pain 2011)
1. Site and direction of uncontrolled (iv) pelvic floor (Peng et al 2007; Whittaker 2007).
movement 3. Muscle imbalance
(a) Site and direction of uncontrolled motion (Comerford (a) Sahrmann (relative flexibility) (Sahrmann 2002).
& Mottram 2001a).
(b) Kinetic Control (restriction and compensation)
(b) Direction susceptible to motion (Sahrmann 2002). (Comerford & Mottram 2011).
(c) Control impairments and movement impairments (c) Janda (recruitment sequencing) (Janda 1986).
(O’Sullivan 2005).
4. Patterns of movement provocation and
2. Recruitment efficiency of local muscle relief with postural positioning
stability system
(a) McKenzie (derangement patterns) (McKenzie & May
(a) Changes in feedforward mechanism, for example: 2006).
(i) transversus abdominis, multifidus, pelvic floor, (b) Jones positional release (strain–counterstrain) (Jones
diaphragm (Richardson et al 2004) et al 1995).
(ii) deep neck flex (Jull et al 2008)
5. Positional diagnosis
(iii) upper trapezius (Wadsworth & Bullock-Saxton
1997). (a) Osteopathic process (muscle energy technique).
(b) Recruitment efficiency changes: 6. Patterns of symptom relief associated with
(i) deep neck flex (Jull et al 2008) manual mobilisation
(ii) psoas, subscapularis, upper trapezius, lower (a) Mulligan (Nags, Snags, MWM) (Mulligan 2003).
trapezius, posterior neck ext. (Gibbons 2007; (b) DonTigny (pelvic dysfunction) (DonTigny 1997).
Comerford & Mottram 2010) (c) Cyriax (1980), Maitland et al (2005), Kaltenborn
(iii) deep sacral glut. max. (Gibbons 2007) (2003).
(iv) clinical rating system (Comerford & Mottram (d) Patterns of symptom relief with manual mobilisation
2011). (Fritz et al 2005).
(c) Ultrasound changes:
(i) transversus abdominis (Richardson et al 2004)
(ii) multifidus (Stokes et al 1992; Hides et al 2008)
dysfunctions include the evaluation of the • Classification by pain mechanisms in particular

site and direction of uncontrolled movement identifying components of inflammatory/
(UCM), recruitment efficiency of local biochemical sensitisation, neurogenic
muscle stability system, muscle imbalance, sensitisation and behavioural or
patterns of movement provocation and relief psychosomatic issues (Watson & Kendall
with postural positioning, positional 2000; Butler & Moseley 2003; Sterling et al
diagnosis, patterns of symptom relief 2003, 2004; Waddell 2004).
associated with manual mobilisation. Box
3.1 illustrates some of these subgroups. Classification based on movement
• Specific musculoskeletal pain – classification by dysfunction
implying a patho-anatomical source: definite
pathology is identified that accounts for the In the absence of reliable diagnostic tests for
presenting signs and symptoms, for example: musculoskeletal disorders, classifying movement
spondylolisthesis, disc herniation and nerve control faults is gaining recognition and accept-
root compression, spinal stenosis, bony ance (Comerford & Mottram 2001a; Sahrmann
injury/fracture, articular derangement 2002; Dankaerts et al 2006b; Mottram &
(meniscal/labral tear, chondral defect), Comerford 2008). For example, identifying sub-
muscle haematoma and osteoligamentous categories of movement faults to guide interven-
damage (ligament sprain). tions has been applied to the lumbar spine and
44
Assessment and classification of uncontrolled movement Chapter |3|
the reliability of some tests has been established strained or are ‘weak’ and lack the ability to ade-
(Luomajoki et al 2007; Trudelle-Jackson et al quately shorten, they demonstrate increased flex-
2008). Comerford & Mottram (2001a, 2011) ibility. This increased flexibility can contribute to
contend that the observation of aberrant move- uncontrolled or excessive motion at that joint.
ment in itself may not be the most critical factor Similarly, if multi-joint muscles lack extensibility
influencing pain and dysfunction. It could be or generate excessive tension they develop
argued that some observations of excessive or increased stiffness. This increased stiffness then
reduced range of movement may just be variations has the potential to limit or restrict normal
within the normal distribution of the population. motion at that joint. When increased stiffness
People who have no pain and no history of pre- limits motion at a joint, then in order to maintain
vious symptoms may present with range of normal function, the restriction must be compen-
motion that may be considered excessive or hyper- sated for elsewhere in the movement system. If
mobile. It is possible that this ‘excessive’ range of these muscles are linked in functional move-
movement is controlled well by automatic and ments then excessive or uncontrolled motion
cognitive recruitment mechanisms during move- develops at the joint that is inadequately con-
ment and postural tasks (Roussel et al 2009). The trolled by the one-joint muscles relative to the
ability to cognitively recruit appropriate move- adjacent restriction. Relatively more flexible
ment control strategies may be a better indicator structures compensate for relatively stiffer struc-
of whether there is UCM or whether the aberrant tures in function, creating direction-specific
movement is merely a bad habit at one extreme of stress and strain. During functional movements
the normal distribution curve. Not only is the direction-specific hypermobility is re-enforced
observation of aberrant movement important but and if repetitively loaded, tissue pathology results
it is important to be able to test for the ability to (Comerford & Mottram 2001a).
control it. An example of this concept can be observed in
The identification of aberrant movement and the active prone knee extension test (Woolsey
the evaluation of the control of movement is et al 1988). If the rectus femoris is relatively stiffer
complex. The following section will discuss a than the abdominals, then in order to achieve
range of elements that should be considered 120° of knee flexion, the pelvis tilts anteriorly,
during the observation and quantification of and the spine extends. Sahrmann (2002) suggests
aberrant movement. These include the assess- that the abdominals are relatively more flexible
ment of relative stiffness/relative flexibility, move- than the rectus femoris, which is relatively stiffer,
ment control dysfunction, movement system creating uncontrolled or abnormal spinal exten-
impairments and motor control impairments. sion, which in turn contributes to mechanical
back pain (Figure 3.1).
Sahrmann (2002) also identified a similar
Relative stiffness – relative flexibility pattern during forward bending manoeuvres. If
Sahrmann (2002) proposes the concept of ‘rela- the hamstrings are relatively stiffer than the back
tive flexibility’ or ‘relative stiffness’. If one-joint extensors (which are relatively more flexible),
muscles become excessively lengthened and then during forward bending the hip lacks
(a) (b)
Prone knee flexion. (a) Ideally, there should be approximately 120° knee flexion without significant lumbopelvic motion.
(b) To achieve 120° knee flexion with a relatively stiffer rectus femoris, the pelvis will anteriorly tilt and the relatively flexible
lumbar spine will extend.
Figure 3.1 Relative stiffness and relative flexibility influencing lumbar extension
45
sufficient flexion but the spine hyperflexes to Increased forward tilt of the scapula compensates
compensate. This may predispose to mechanical for shortness or stiffness of the lateral rotator
back pain. Esola et al (1996) reported that sub- muscles during shoulder medial rotation.
jects with a history of low back pain, in early Increased anterior translation of the humeral
forward bending, flex more at their lumbar spine head compensates for restriction of glenohumeral
and have stiffer hamstrings than do subjects with medial rotation. She further suggests that these
no history of low back pain. This is supported by compensations are associated with the develop-
Hamilton & Richardson (1998) who show that ment of pathology.
subjects who have no low back pain can actively A test of shoulder girdle relative stiffness/
maintain spinal neutral alignment through 30° flexibility (the kinetic medial rotation test –
of forward leaning (hip flexion) in sitting, but Chapter 8) identifies a restriction of shoulder
subjects with low back pain cannot. The low back medial rotation, which is compensated for by
pain subjects lost neutral alignment earlier and to relatively increasing scapular forward tilt or gleno-
a greater extent, indicating that the spine was rela- humeral translation to maintain a functional
tively more flexible than the hips in low back pain range of arm rotation. It is suggested that the
subjects. compensatory motion at the scapula correlates
Similar evidence has been reported in cervical with impingement pathology, while gleno-
spine dysfunction. The normal ranges of segmen- humeral compensatory motion correlates with
tal flexion–extension range of motion for C5–6 instability pathology. This test has been further
is 18° and 17° for C4–5 with 3.2 mm of inter- validated and quantified by Morrissey (2005) and
segmental translation at both levels (Bhalla & Morrissey et al (2008).
Simmons 1969; Dvorak et al 1988). Singer et al The clinical implication is that in ideal or
(1993) reported that subjects with neck pain and ‘normal’ function, complex motor control proc-
discogenic pathology demonstrated changes in esses exist. These processes regulate muscle
range of segmental motion and intersegmental relative stiffness or relative flexibility in linked
translation. The C5–6 motion segment became multi-joint movements. The movement system
relatively stiff. It demonstrated reduced range of has a remarkable ability to adapt to change.
flexion–extension from 18° to 8° and interseg- Minor variations are acceptable and tolerated by
mental translation reduced from 3.2 mm to the tissues involved. However, when significant
1 mm. In order to maintain functional range of restriction of motion occurs at a joint, the body
motion of the head and neck, the C4–5 motion adapts and in the attempt to maintain function,
segment increased flexibility. It demonstrated some other joint or muscle must compensate by
increased range of flexion–extension from 17° to increasing relative mobility. The cost of compen-
23° and intersegmental translation increase from sating with uncontrolled movement is often
3.2 mm to 6 mm. This paper demonstrated that insidious pathology.
a significant restriction of motion at one vertebral
level could be compensated for by relatively
increasing range at an adjacent level.
Norlander & Nordgren (1998) suggest that Movement control dysfunction
deviation from synchronous distribution of A common feature of movement control faults is
normal mobility between motion segments might reduced control of active movements, or move-
be a factor causing provocation of joint mech- ment control dysfunction, termed MCD by
anoreceptors and subsequent pain. They meas- Luomajoki et al (2007). The MCD is identified by
ured segmental relative flexion mobility between a series of clinical tests. These tests have been
C5 and T7 and identified that hypomobility of shown to be reliable in the lumbar spine (Luoma-
C7–T1 with hypermobility of T1–2 significantly joki et al 2007; Roussel et al 2009) and have been
predicted neck–shoulder pain. promoted in clinical practice (Mottram 2003;
Relative stiffness/flexibility changes have also Comerford & Mottram 2011). The tests are based
been measured at the shoulder girdle. Sahrmann on the concept known as dissociation, defined as
(1992, 2002) identifies several clinical patterns the inability to control motion at one segment
of dysfunction. Increased glenohumeral motion while concurrently producing an active move-
compensates for insufficient upward rotation of ment at another joint segment (Comerford &
the scapula during shoulder flexion or abduction. Mottram 2001a; Sahrmann 2002). A dissociation
46
test evaluates the ability to actively control move- 2009). The MSI diagnosis is based on identifying,
ment and demonstrates MCD. firstly, a consistent pattern of movement which is
Once a MCD has been identified it can guide associated with the patient’s symptoms and, sec-
the choice of therapeutic exercise (Comerford & ondly, a decrease in pain when the MSI is cor-
Mottram 2001b; Mottram 2003). In the case of rected. For the lumbar region the clinician makes
shoulder dysfunction, muscles around the shoul- a judgment as to whether the patient moves his
der girdle may be unable to control the scapula or her lumbopelvic region early in the test. For
during arm function. In the lumbar spine, trunk example, in a forward bending movement it may
muscles may be unable to control lumbar align- be observed that the lumbar spine initiates the
ment during movements of the hip or thoracic forward bending movement, with hip flexion
spine. The distinctive features of these tests start contributing to the forward bending much later.
with the positioning of the spine or segment in The person usually notes that their symptoms are
its ‘neutral position’ by the therapist, which is provoked by and are linked to the lumbar flexion
then actively controlled by the patient while phase of the movement. The therapist also
they move the joint region either above or below observes whether a significant reduction in the
the joint system being tested. These clinical dis- symptoms is achieved if the person can learn to
sociation tests can identify the site (e.g. scapula initiate forward bending with hip flexion, while
or lumbar spine) and direction (e.g. downward actively preventing the lumbar spine flexion. On
rotation/forward tilt, and flexion) of movement this basis a diagnosis of lumbar flexion move-
control faults (Luomajoki et al 2008; Barr & ment impairment is made.
Burden 2009; Mottram et al 2009). Adapting the People with low back pain (LBP) demonstrate
principles associated with dissociation testing, early lumbopelvic movement with clinical tests
UCM can be identified and classified by the (Scholte et al 2000; Gombatto et al 2007; van
therapist using palpation and visual observation. Dillen et al 2001 2009). The inter-rater reliability
These clinical tests are described in Chapters between two physical therapists classifying
5–9. patients with chronic LBP into lumbar spine
movement impairment strategies has substantial
agreement (Trudelle-Jackson et al 2008). The sug-
Movement impairments gestion is that this links to the pattern of move-
A standardised clinical examination, based on ment during everyday activities and relates to LBP.
Sahrmann’s conceptual model of movement The hypothesis here is that early lumbopelvic
impairment, has been described for the lumbar movement during everyday activities suggests an
spine (Scholtes & Van Dillen 2007; Van Dillen increase in frequency of movement of a specific
et al 2009), the knee (Harris-Hayes & Van Dillen region which may contribute to increased stress
2009) and the shoulder (Caldwell et al 2007). on tissue resulting in pain (Mueller & Maluf
The underlying assumption is that movement 2002). This becomes the diagnosis of movement
faults and abnormal resting postures are associ- impairment.
ated with musculoskeletal tissue changes (Sahr-
mann 2002). For example, muscle dysfunction in
relation to: i) muscle length changes; ii) altered Motor control impairments (MCI)
recruitment patterns between synergistic or antag- O’Sullivan (2000) proposed a classification
onistic muscles; and iii) direction specific system based on motor control impairments
increased motion which arises as compensation (MCI). His classification system of clinical sub-
for relative restrictions of motion at adjacent groups is based on altered strategies for postural
joints may be determined. Movement system and movement control. The inter-tester reliably
impairments (MSI) may present as abnormal of this classification system has been established
alignment and impaired movement during testing (Vibe Fersum et al 2009). O’Sullivan describes a
or functional activities (Sahrmann 2002; Trudelle- subgroup of patients presenting with impair-
Jackson et al 2008; van Dillen et al 2009). ments in control of spinal segments in the direc-
The lumbar spine examination includes a tion of pain which are associated with deficits in
number of clinical tests of trunk, limb or com- motor control (O’Sullivan et al 2006). Interest-
bined trunk and limb movements to ascertain ingly, Dankaerts (2006a), in applying this system,
movement impairments (Van Dillen et al 1998, did not identify differences in superficial trunk
47
muscle activation between a group of healthy ability to actively control or prevent movement
controls and non-specific chronic LBP subjects (or lack of ability to learn how to control move-
in sitting. The authors stressed the importance ment) in a particular direction at a particular
of the ‘washout effect’ when interpreting this joint or motion segment. The UCM can be identi-
finding. When results from all subjects with fied in the presence or in the absence of a symp-
chronic LBP were pooled the findings in one tomatic episode. The UCM is independent of
subgroup of patients were ‘washed out’ by the hypermobile or hypomobile range of motion.
others. However, once subjects were grouped by That is, some people may demonstrate UCM
flexion and extension control impairment pat- even in situations of reduced functional range,
terns, clear differences in muscle activation pat- while other people with hypermobile range of
terns were identified. motion may demonstrate good active control of
The classification of a flexion control impair- their excessive range of motion. The presence
ment pattern, for example, is based on linking of UCM is a powerful indicator of symptomatic
several clinical observations: i) patients relate function associated with recurrence and chron-
their symptoms to flexion activities or postures; icity of musculoskeletal pain.
ii) they are unable to maintain a neutral lumbar
lordosis and habitually position their lumbar
spine in postures of increased flexion and poste- The development of motion restrictions
rior pelvic tilt; iii) they initiate forward bending
in function
or flexion activities with movement at their symp-
tomatic segments; iv) specific muscle testing The development of restrictions within normal
identifies an inability to activate lumbar multi- motion is common. The body acquires restric-
fidus appropriately at the symptomatic segments tions over time for a variety of reasons, as
(bracing or co-contraction strategies are utilised described in Box 3.2. Motion restrictions may be
instead); v) palpation examination reveals passive or active, affecting either the accessory
increased flexion mobility at the symptomatic translation or the physiological range available to
segments. The research in this area highlights the a joint. Passive restrictions may involve: i) a loss
usefulness and importance of sub-classification of extensibility of normal contractile structures
models in chronic LBP and suggests that thera- (e.g. muscle shortening); ii) connective tissue
peutic management may be different between structures (e.g. capsule shortening); iii) the devel-
groups. opment of abnormal connective tissue (e.g.
fibrotic adhesions); or iv) bony changes (osteo-
phytes or spurs) that contribute to a reduction of
Uncontrolled movement (UCM) available passive joint motion. Active restrictions
may involve neurally mediated changes in
and pain
The identification of UCM should be made in
terms of site and direction based on the ability
to cognitively control the movement, not just Box 3.2 Common causes of acquired movement
on observation of altered range of motion. The restriction
consideration that a significant amount of pain
• Injury and increased scar tissue.
in the neuromusculoskeletal system is a result of
cumulative microtrauma caused by uncontrolled • Protective or guarding responses.
movement is gaining credibility (Sahrmann • Postural shortening associated with habitual
positioning and a lack of movement.
2002; Luomajoki et al 2007; Van Dillen et al
• Degenerative changes over time.
2009). The uncontrolled motion leads to
increased loading and pain (Cholewicki & McGill • Overuse.
1996; Mueller & Maluf 2002). UCM is not identi- • Hypertrophy and excessive increases in intrinsic muscle
stiffness.
fied by merely noting hypermobile range of
motion or relative flexibility. Furthermore, UCM • Recruitment dominance (often associated with
habitual overuse).
is not solely identified by habitual postures or
• Behavioural and psychological contextual factors.
initiation of function with movement at one
segment. UCM is identified by a lack of the • Environment and occupational contextual factors.
48
contractile (muscle) tissues. This may occur as a A proposition for the aetiology of UCM
result of: i) muscle guarding or spasm in response UCM is defined as a lack of efficient active
to pain sensitive movement; or ii) increased recruitment of the local or global muscle’s ability
muscle tension/stiffness due to altered patterns to control motion at a particular motion segment
(strategies) of muscle recruitment between syner- in a specific direction (Comerford & Mottram
gistic muscle groups or increased muscle tension 2001a). For example, uncontrolled lumbar flexion
in response to emotional, behavioural or envi- demonstrates a lack of efficient active recruitment
ronmental stressors. These altered patterns of of spinal muscles to control or prevent movement
muscle recruitment may in turn be reinforced due of the lumbar spine into flexion when attempting
to overuse, overtraining, postural loading or to do so.
maladaptive responses to pain, stress and psycho- The development of UCM may have several
social factors. contributing factors:
Because restrictions of normal motion are
common, the body normally compensates for 1. Compensation for restriction to maintain
these restrictions by increasing motion elsewhere function. The UCM most commonly develops
to maintain function. In normal functional move- insidiously to compensate for an articular or
ment, the central nervous system (CNS) has a myofascial restriction in order to maintain
variety of strategies available to perform any func- normal function. This is commonly observed
tional task or movement and, ideally, the CNS as lack of control of hypermobile range;
determines the most appropriate strategy for the however, it can also present as a lack of
demands of the functional task. So long as the control of normal range. For example,
trajectory or path of motion is well controlled by uncontrolled lumbar flexion compensates for
the coordination of forces in the local and global a restriction of hip flexion (hamstrings) to
synergists, the movement system appears to cope maintain the normal function of forward
well (Hodges 2003). bending. The back extensor stabiliser muscles
Compensation that demonstrates effective lack efficient control of the lumbar spine
active control is a normal adaptive process and during flexion loading. Therefore, the UCM
does not constitute a stability dysfunction, and is is in the lumbar spine in the direction of
usually non-symptomatic. However, inefficient flexion.
active control (uncontrolled movement) identi-
fies a dynamic stability dysfunction and has
greater potential to accumulate microtrauma Restriction → Compensation → UCM → Pathology →
within a variety of tissues and if this exceeds tissue Pain
tolerance may contribute to the development of
pathology and pain (Comerford & Mottram
2001a) (Figure 3.2). 2. Direct overfacilitation. Occasionally the UCM
develops because excessive range of
movement is habitually performed (without
compensating for restrictions). A particular
muscle pulls too hard on a joint in a
Restriction particular direction due to dominant
Normal adaptive recruitment, active shortening or
Compensation process overtraining. This develops slowly as a
progressive insidious process. This is due to
an active process of overuse and shortening
Uncontrolled movement
of a particular muscle that holds a joint
towards its end-range position (away from
Pathology
Maladaptive process neutral or mid-range positions). For
(Pathology) example, uncontrolled lumbar flexion
Pain develops due to overtraining of rectus
abdominis with repetitive trunk curls. Rectus
Figure 3.2 The restricted segment may be a cause of abdominis actively holds the lumbar spine
compensatory uncontrolled movement excessively flexed at rest and during flexion
49
load activities and postures. The back Trauma → UCM → Pathology → Pain
extensor stabiliser muscles lack efficient
control of the lumbar spine during flexion
loading. Therefore, the UCM is in the lumbar The UCM can be present within normal ranges of
spine in the direction of flexion. functional motion, hypermobile range or even
within a segment with reduced range. It may be
Overpull vs underpull → Compensation → UCM → identified in the physiological or functional
Pathology → Pain movements of joint range, or it may be identified
in the accessory segmental translational gliding
movements of a joint.
3. Sustained passive postural positioning. The UCM
Movement dysfunction may present as a disor-
may also be a result of a passive process
der of translation movements at a single motion
where sustained postural positioning
segment; for example, abnormal segmental
habitually maintains the joint or region
translational motion and/or a range disorder in
towards its end-range position (away from
the functional movements across one or more
neutral or mid-range positions). This usually
motion segments, abnormal myofascial length
results in a lengthening strain of the
and recruitment or as a response to neural mech-
controlling stabiliser muscles and passive
anosensitivity (Comerford & Mottram 2001b).
postural or positional shortening of the
These two components of the movement system
underused but unstretched mobiliser
are inter-related and consequently translation
muscles. Body weight and gravity combine to
and range UCM dysfunctions often occur
create a sustained, direction-specific loading
concurrently.
mechanism. This process is passive and
UCM often develops to compensate for a loss
mainly insidious. For example, uncontrolled
of motion or restriction and this relationship is
lumbar flexion is the result of passive,
illustrated in Table 3.1. The restriction may be
habitual or sustained sitting in a slouched
associated with limitation of articular translation
(flexed) posture. The back extensor stabiliser
and a lack of extensibility of the connective tissue
muscles lack efficient control of the lumbar
(intra-articular or periarticular) at a motion
spine during flexion loading. Therefore, the
segment. This presents with a loss of translational
UCM is in the lumbar spine in the direction
motion at a joint and is confirmed with manual
of flexion.
palpation assessment (Maitland et al 2005). The
restriction may be associated with a lack of exten-
Postural strain → UCM → Pathology → Pain sibility of contractile myofascial tissue or neural
tissue. The muscles may lose extensibility: i)
because of increased low threshold recruitment
4. Trauma. The functional stability of the (overactivity) (Janda 1985; Sahrmann 2002); ii)
movement system may be very efficient but
an injury may occur where load or strain
exceeds the tolerance of normal tissues and
damage to the normal restraints of motion
results. Hence the UCM may be unrelated Table 3.1 Key elements of UCMs and restrictions
to habitual movements and postures or
compensation for restriction, and be the sole Translation Range
result of trauma due to normal tissue being Uncontrolled Uncontrolled Uncontrolled range
overloaded. For example, uncontrolled movement intra-articular and of motion (in
lumbar flexion may be the result of a forced interarticular joint myofascial system)
flexion injury to the lumbar spine such as hypermobility
may occur in a collapsing rugby scrum or a Articular Myofascial
motor vehicle accident. The back extensor
stabilisers lack efficient control of the lumbar Restriction Intra-articular and Lack of myofascial
interarticular joint extensibility
spine during flexion loading. Therefore, the
hypomobility restricting range of
UCM is in the lumbar spine in the direction motion
of flexion.
50
due to a lack of range because of length-associated efficiency of myofascial tissue to control range of
changes (Gossman et al 1982; Goldspink & Wil- motion. This uncontrolled range of movement is
liams 1992); or iii) due to a lack of normal neural a potential compensation for three mechanisms
compliance and a protective response associated of restriction (Table 3.2): i) myofascial restriction
with abnormal neural mechanosensitivity. This at an adjacent region (restriction and UCM at a
restriction is confirmed with myofascial extensi- regional level); ii) abnormal mechanosensitivity
bility tests. at an adjacent region (restriction and UCM at a
If the UCM is translation related, it may be regional level); or iii) segmental articular transla-
associated with laxity of articular connective tion restriction at an adjacent joint (restriction
tissue and a lack of local muscle control. Panjabi and UCM at an interarticular level).
(1992) defined spinal instability in terms of laxity The complex inter-relationships between restric-
around the neutral position of a spinal segment tions and potential compensation strategies can
called the neutral zone. Maitland et al (2005) be observed presenting in three distinct ways.
have described joint hypermobility. The end These three compensations are detailed in
result of this process is abnormal development of Table 3.2.
UCM and a loss of functional or dynamic stabil-
ity. Uncontrolled translation can compensate for 1. Intra-articular UCM
three mechanisms of restriction (Table 3.2): i) The UCM and the restriction may both be
articular restriction in the same joint (restriction in the same joint segment. A loss of
and UCM at an intra-articular level); ii) articular translational movement in one direction
restriction in an adjacent joint (restriction and may be compensated for by increased
UCM at an interarticular level); or iii) myofascial uncontrolled translation in another direction
restriction (restriction and UCM at a regional in the same joint. As a result the restriction,
level). the UCM and the pain may all be in the
If the UCM is range related, it may be associated same joint.
with elongation or a change in recruitment Example 1: the shoulder may have limited
sequencing of global muscles resulting in a lack A-P (posterior) translation and posterior
of myofascial coordination or a lack of force restriction and compensate with excessive
Table 3.2 Restriction and compensation relationships that present as UCM
UCM CHARACTERISTICS
Intra-articular Interarticular
Translational/articular dysfunction • Occurs within the same joint • Occurs between adjacent joints
• In different or opposing • Usually in the same direction
directions
• Associated with abnormal accessory or translational movement
• UCM and restriction primarily involve connective tissue changes
Relates to a displaced path of the instantaneous centre of motion and uncontrolled
translation
(Can confirm the articular or translation UCM and restriction by manual palpation
assessment and muscle recruitment tests)
Regional
Range/myofascial dysfunction • Occurs between adjacent regions
• In the same direction
• Associated with abnormal physiological or functional range
• UCM and restriction primarily involve myofascial tissue changes
Relates to relative flexibility – relative stiffness and uncontrolled range
(Can confirm the myofascial/range UCM and restriction with movement analysis
and muscle length and recruitment tests)
51
P-A (anterior) translation and anterior lengthening or overstrain of the spinal

overstrain to keep function. extensor muscles (lumbar spinalis and
Example 2: C3–4 may have limited A-P superficial multifidus).
(posterior) translation while the same joint Example 2: a lack of extensibility of
segment may excessive P-A (anterior) glenohumeral lateral rotator muscles
translation. (infraspinatus and teres minor) contributes
Example 3: the sacroiliac joint that tests to limiting glenohumeral medial rotation
positive for motion restriction may have a range. However, function is maintained by
restriction of anterior glide along the long excessively increasing scapular motion
arm and may have uncontrolled posterior (forward tilt and downward rotation) to
glide along the long arm. compensate with resultant lengthening or
2. Interarticular UCM overstrain of the scapular stabiliser muscles
The UCM may have adjacent joint articular (middle and lower trapezius).
stiffness. A loss of physiological range or Example 3: a lack of extensibility of hip
translational movement at one joint (in any flexor muscles (tensor fasciae latae and rectus
one direction) may be compensated for by femoris) contributes to limiting hip
increased uncontrolled physiological range extension range. However, function is
or uncontrolled translation at an adjacent maintained by excessively increasing lumbar
joint in the same direction. As a result the spine extension range to compensate with
restriction may be in one joint and the UCM resultant lengthening or overstrain of the
and the pain may all be in an adjacent joint. abdominal muscles (oblique abdominis).
Example 1: L4–5 may be restricted in Example 4: a lack of extensibility of
extension or P-A (anterior) direction while anterior scalene muscles contributes to
L5–S1 may compensate by increasing limiting lower cervical extension range.
extension or P-A (anterior) movement. However, function is maintained by
Example 2: C5–6 may have a restriction of excessively increasing upper or middle
extension and P-A (anterior) translation, cervical spine extension range to compensate
which may be compensated for by increased with resultant lengthening or overstrain of
extension and P-A (anterior) translation at the longus colli muscles.
C4–5. It is possible for translational or range UCM to
Example 3: the left sacroiliac joint may present in isolation without restriction. Examples
test positive for motion restriction while the of this type of presentation are: i) a traumatic inci-
right sacroiliac joint may compensate and as dent (capsular/ligamentous laxity or instability);
a result become the painful side. ii) inhibition associated with pain and pathology;
3. Regional UCM or iii) sustained postural strain positioning.
The UCM may have adjacent joint soft
tissue restriction. A loss of physiological
range (due to a lack of extensibility or Integrated model of mechanical
reactivity of myofascial or neural tissue) at movement dysfunction
one joint region in any particular direction
may be compensated for by increased In a pyramid model of musculoskeletal pain there
physiological range (due to excessive are several factors that require consideration
myofascial length or a lack of dynamic (Figure 3.3).
control) in an adjacent joint region in the The mechanical components of restriction
same direction. As a result the restriction may and compensation form the base of the pyramid
be in one joint and the UCM and the pain and the foundation of movement assessment.
may all be in an adjacent joint. These mechanical components of the dysfunction
Example 1: a lack of extensibility of need to be evaluated. This includes identifying
hamstring muscles contributes to limiting and understanding the relationships between
hip flexion range during forward bending. articular and myofascial restrictions and the com-
However, function is maintained by pensations that develop to maintain good func-
excessively increasing lumbar spine flexion tion. The compensations require more detailed
range to compensate with resultant assessment and the ability to actively control
52
han
Non-mec ical pain (Comerford & Mottram 2001a). The MSI and
MCI classification systems rely on observations
of aberrant movements during spinal and limb
activities and functional tasks. A typical feature
Pathology of impaired motor control is reduced control of
active movement (Luomajoki et al 2007). The
n
assumption is this loss of active control causes

ctio
un
physical stress on tissue and leads to pain (Mueller

ysf
& Maluf 2002).

al d
nic
cha
Me
Translational Range Neutral training region

UCM UCM
Establishment of the neutral training region is a
key requirement of the assessment process. The
Articular Myofascial neutral training region is not a single specific
restriction restriction point within range. It is a relative region within
Figure 3.3 Overview of the ‘pyramid’ of mechanical
joint mid-range, within Panjabi’s conceptual
movement dysfunction ‘neutral zone’, where there is minimal support or
restraint of motion from the passive restraints
(Panjabi 1992). It may be more appropriate to
call this the ‘neutral training region’ rather than
compensations needs to be identified in terms of neutral joint position. The ‘anatomical or pos-
the site and direction of UCM. The UCM can tural ideal’ joint position or ‘loose pack’ joint
present as uncontrolled translation which is best position is often arbitrarily chosen as the refer-
controlled by local muscle retraining or uncon- ence for ‘neutral’. There is currently debate and
trolled range which is best controlled by global lack of consensus as to precisely where this point
muscle retraining. The top of the pyramid involves is. The control of a single static position or point
diagnosing the pain-sensitive tissues that develop in range is not the answer to normal function
in response to being overloaded with compres- where stability is required dynamically at variable
sion stresses of tensile strain. If the dysfunction is points within the whole of the available range of
longstanding (chronic or recurrent), then ‘yellow motion. There may be too much emphasis on a
flag’ issues also need consideration. ‘Yellow flag’ single static position when function requires
issues may include peripheral and central neuro- control of more than one isolated point and is
genic sensitisation and behavioural or psycho- never so specific.
social contextual factors that can affect both the The defining characteristic of a motor control
perception of pain and the prognosis for symptom test of dissociation that identifies UCM, is the
change. It is important to relate the site and direc- repositioning of the region to be tested in its
tion of UCM to symptoms and pathology and ‘neutral position’ by the therapist, which is then
to the mechanisms of provocation of symptoms. maintained as the patient moves the relevant
The dysfunctions can be labelled and classified joint either above or below or a joint in the same
by the site and direction of UCM and are des- region in a different direction. The neutral posi-
cribed in Section 2. tion is controlled by myofascial support (from
the interaction of the local and global muscle
system – Chapter 2), with minimal support from
the passive osteoligamentous system. The passive
PRINCIPLES OF ASSESSMENT osteoligamentous system provides considerable
OF UCM support and control of motion at end range when
those passive restraints are loaded. Neutral cannot
As described earlier in this chapter, tests to iden- be end of range, just as the neutral position of the
tify UCM are based on the concept of dissocia- lumbar spine is a region between anterior and
tion, defined as the ability to control motion at posterior tilt (Dankaerts et al 2006a). It is crucial
one joint segment while concurrently producing for the assessment and retraining of motor
an active movement at another joint segment control that the spine be initially positioned in
53
the neutral training region (O’Sullivan et al 2002; address this need. This rating system is described
O’Sullivan et al 2006). This supports the concept in the following section.
of the stabilising muscle system working within
the neutral zone to support the spine (Panjabi Movement control rating
1992).
system (MCRS)
Most exercises for retraining movement control,
whether performed isometrically or dynamically This MCRS does not rate or measure inhibition
through range, usually use a recommended start- of muscle function. A certain amount of inhibi-
ing position. The suggested ‘neutral’ starting position or dysfunction due to pain and pathology is
tion is best defined as somewhere within the consistent and predictable. These changes are reli-
neutral training region, as close as possible to the able and can be assumed to be present when the
anatomical or postural ideal alignment. However, pain or pathology are present (Hodges & Richard-
if a joint system has significant loss of normal son 1996; Hodges 2001; Hodges & Moseley 2003;
functional range, the ‘anatomical ideal’ joint posi- Richardson et al 2004; Falla et al 2004a, b; Jull
tion may also be that person’s end-range posi- et al 2004, 2008). Instead, this MCRS evaluates
tion. In this situation the ‘neutral’ joint starting low threshold voluntary recruitment efficiency. It
position for assessment and retraining of UCM is is probable that if low threshold voluntary recruit-
modified to a place within the region of that per- ment efficiency is effective in the presence of pain
son’s mid-range where end-range restraints are no inhibition, then, when the pain or pathology
longer providing stiffness to support or restrain resolves, the muscle recruitment patterns and
motion and preferably close to the anatomical or thresholds may automatically return to normal
postural ideal alignment. (ideal) function. The observation that when some
people recover from pathology and their symp-
toms resolve they return to ideal function and
normal physiology without any specific retraining
CLINICAL ASSESSMENT OF UCM supports this contention. However, if the evalua-
tion of low threshold voluntary recruitment effi-
Dysfunction can be evaluated, quantified and ciency is poor, then when the pain or pathology
compared against a normal measure, ideal stand- resolves, the dysfunction in the muscle physiol-
ard or some validated benchmark. The measure- ogy is more likely to persist. An assessment of
ment of dysfunction, followed by intervention recruitment efficiency would help to determine
with some form of treatment or therapy over an priorities of clinical management while reassess-
appropriate timeframe and the reassessment of ment helps guide progression.
dysfunction to demonstrate a positive outcome of Two parameters are evaluated in the application
intervention, provides the framework of good of the MCRS. The first parameter tests the ability
clinical practice. Dysfunction is indirectly related to correctly perform a specific motor control
to pathology but as the pathology heals and recruitment pattern or movement. The second
the symptoms subside, the dysfunction does parameter assesses the efficiency of low threshold
not always automatically return to a normal recruitment in the performance of that motor
baseline. control skill. It is essential that the patient under-
To date, measurement of motor control-related stand the test movement or activation required.
stability dysfunction has required complex meas- To pass the test (✓✓) the subject needs to dem-
urement tools (EMG and imaging ultrasound) onstrate the correct recruitment pattern or move-
and highly specific training to use and interpret ment without substitution (for the first ✓) and
the results. There has been a need to develop demonstrate that it can be easily controlled to
a ‘clinic friendly’ measurement system that is benchmark standards without fatigue or high
simple, easy to learn, quick and can be used to sensation of effort (for the second ✓). Because
assist clinical decision-making about when to many of these tests are not habitual or ‘familiar’
progress and when there is no longer a need movement skills there needs to be a short learn-
to continue training a particular exercise or ing or familiarisation process before rating the
muscle. A rating system for assessment and test movement. If the patient fails a test (i.e. rates
reassessment of UCM and motor control-related ✓✗ or ✗✗), it is important that this is because they
stability dysfunction has been developed to cannot perform the test, not because they are not
54
sure what to do. Verbal description, visual dem- Performance of some of these unfamiliar move-
onstration, hands-on facilitation and visual or ments is a test of motor control (recruitment
tactile self-feedback should be used to ensure skill and coordination). The ability to activate
that the patient understands and has experienced muscles to isometrically hold a position or
the movement or activation required before prevent motion at one joint system, while concur-
rating the efficiency of low threshold voluntary rently actively producing a movement at another
recruitment. joint system in a specific direction, is a test of
motor recruitment skill. The process of dissociat-
ing movement at one joint from movement at
The correction or rehabilitation of motor control another joint, or controlling the pattern or path
dysfunction has been shown to decrease the incidence of of movement about the same joint, has potential
recurrence of pain (Hides et al 1996; O’Sullivan et al benefits for retraining the stability muscles to
1997; Jull et al 2002). Along with symptom management enhance their recruitment efficiency to control
this is a primary short-term goal of therapeutic direction-specific stress and strain. The global and
intervention. The patient frequently becomes symptom-
the local stability muscle systems can be trained
free before dysfunction is fully corrected. Treatment
should not necessarily cease just because the symptoms
to recruit in co-activation patterns to prevent
have disappeared if measurable dysfunction persists. A movement in a specific direction at a vulnerable
rating system (such as the MCRS) for the assessment and (or unstable) joint while an adjacent joint is
reassessment of dysfunction is necessary to justify this in loaded in that direction. In this way the stability
clinical practice. system can be trained to control a specific UCM
(site and direction). Box 3.3 summarises some
key points to consider when using dissociation
Testing for the site and direction movements to test for UCM or to retrain control
of the UCM.
of UCM
During all normal functional activities, the Example of dissociation in ‘series’
muscles that have global stability and local stabil-
If the hamstrings lack extensibility and restrict the
ity roles co-activate in integrated patterns to
hips from normal flexion, the lumbar spine can
maintain stability. All functional activities impose
‘give’ into increased flexion to compensate during
stress and strain forces on the movement system
functional forward bending movements. This
in varying loads and in all three planes or direc-
eventually results in the back extensor stability
tions of motion. Normal functional movements
muscles losing the ability to protect the back from
rarely eliminate motion from one joint system
flexion loading stresses. A movement pattern or
while others move through range. Functional
recruitment skill of keeping the back straight and
movement rarely occurs in only one plane.
hinging forwards at the hips is a motor control
However, everybody has the ability to perform
exercise for the back extensor muscles. By using
patterns of movement that are not habitually
the back extensor stabiliser muscles to hold the
used in ‘normal function’ (e.g. pat the head and
back in a more neutral (mid-range) position and
rub the stomach). Some of these patterns of
prevent the back from flexing while independent
movement are unfamiliar and feel ‘unnatural’
isolated hip flexion is performed, the back exten-
precisely because they are not habitual patterns
sor muscles are trained to become more efficient
of recruitment.
at stabilising the spine against flexion stress and
Low threshold recruitment patterns should be
strain. This pattern of movement dissociation ini-
efficient, when stability muscles are recruited to
tially feels unfamiliar for most people and is not
control motion or to produce movement within
part of normal or natural forward bending func-
normal, non-fatiguing functional loads. Normal
tion, but it is a pattern of movement that every-
functional loading includes static holding of pos-
body has the ability to perform (or learn to
tures and dynamic movement through available
perform).
range of the unloaded limbs and trunk (even in
unfamiliar or non-habitual movements). If low
threshold recruitment is efficient then there Example of dissociation in ‘parallel’
should be a perceived low sensation of effort to If the tensor fasciae latae exhibits recruitment
perform these normal, non-fatiguing activities. dominance over posterior gluteus medius at the
55
2. hypermobile or excessive range of

Box 3.3 Key points of dissociation tests and
movement
retraining exercises
3. hypermobile or excessive translation during
• Direction control or ‘dissociation’ exercises are not primary movement
usually normal functional movements. These exercises 4. excessive initiation of compensation during
and movements are tests of ability and efficiency of primary movement
recruitment and motor control. Even though it is 5. discrepancies of range in different positions
accepted that they are not ‘normal’ functional of function.
movements, they are, however, movement skills and
motor patterns that everybody should normally be UCM presents as a lack of ability to perform these
able to perform so long as they are taught and dissociation patterns of movement (motor control
understand the movement pattern. tests) to benchmark standards. A dissociation test
• Range of movement (even hypermobile range) or a that cannot be actively controlled through appro-
compensation that can be easily controlled actively priate dissociation range (rating ✗✗), or can only
during a dissociation test is normal and does not be controlled with difficulty (e.g. high perceived
highlight UCM or stability dysfunction. However, this or actual effort) (rating ✓✗), is considered to
could be considered to be hypermobility with good demonstrate UCM and present as a significant
functional control and stability. stability dysfunction.
• UCM may be present in one or more directions (or During the assessment of the site and direction
planes) of movement at any given joint. That is, any
of UCM there are two steps that can help the clini-
particular site may have UCM in more than one
direction.
cian with the diagnosis.
• The UCM is not always proximal to the restriction. The 1. Observation of natural functional movement
restriction can be at the trunk or girdle and the to identify:
compensation or the UCM can be distal. (a) restrictions within function – note a
• Direction control tests and movements are not loss of range of motion, either
stretches or strengthening exercises. segmentally or multisegmentally,
• Direction control (dissociation) tests are low threshold during the movement
(low force and non-fatiguing) and there should be no (b) hypermobile range – note excessive
pain.
range of movement at the site that the
patient complains of symptoms
(c) compensatory movement strategies
– note abnormal initiation of
hip, instead of flexing in the path of neutral hip movement at the site that the patient
alignment, the hip will be pulled into medial complains of symptoms
rotation, for example during the descending of (d) symptoms (pain, discomfort, strain,
stairs. This eventually results in the posterior etc.) associated with the functional
gluteus medius losing the ability to protect the movement.
hip from flexion–medial rotation loading stresses. 2. Test for site and direction of UCM.
This can result in a hip impingement dysfunction. Start with the joint in a neutral or
By using the posterior gluteal muscles to hold the mid-range position and prevent movement
hip in a more neutral (mid-range) alignment or ‘uncontrolled movement’ into the test
during the swing phase hip and knee flexion direction and: (a) move the adjacent joint
movements, they can resist the uncontrolled devi- (above or below) in the same direction; or
ation into hip medial rotation. The posterior (b) move the test joint in a different
gluteal muscles are trained to become more effi- direction. Assess the person’s ability to
cient at stabilising the hip against flexion–medial actively control movement in the specified
rotation stress and strain. direction (control the UCM) and move
independently at the adjacent joint in the
Indications to test for UCM direction of the specific stability dysfunction.
That is, dissociate movement at one joint
Observe or palpate for: from movement at another. This is the
1. symptoms (pain, discomfort, strain) aspect that is rated as assessment of
associated with specific movement direction recruitment efficiency.
56
For example, during functional forward bending the benchmark standard, not because they
excessive lumbar flexion is observed as compen- do not understand or have not learnt what
sation for restricted hip flexion (hamstrings) and to do.
lumbar pain is provoked as the lumbar flexion • Test. When the therapist is confident
increases. A dissociation test would involve that the person understands the test
actively keeping the spine straight and preventing movement or action and knows what
lumbar flexion (with active recruitment of the is expected, the person is required to
lumbar extensor stabiliser muscles) while bending perform the test without visual or tactile
forwards with isolated and independent hip feedback, verbal facilitation or corrective
flexion. instruction.
• Rating. The therapist then rates the
performance of the test. A failure to
adequately perform the test movement
Movement control test identifies the site and direction of
procedure UCM.
• Relate dysfunction to symptoms to
• Start position. Position in the person’s identify clinical priorities. Look for a
neutral (mid-range) training region. link between the direction of UCM and the
• Teaching the test movement. The direction of symptom provocation:
dissociation tests are not natural movements. ■ Does the site of UCM relate to the site or
Consequently, the person needs to be taught joint that the person complains of as the
the test movement before assessing the source of symptoms?
quality of active control. The therapist ■ Does the direction of movement or load
instructs the person in the test dissociation testing relate to the direction or position
movement, the principle being to control the of provocation of symptoms? This
uncontrolled movement and move the identifies clinical priorities.
adjacent joint. Teaching skills are key here
and include visual, auditory and kinaesthetic
cues. For example:
■ visually demonstrate the test movement Using the MCRS
or action, or help the person visualise the UCM can be present, even if there is no obvious
task with the use of imagery excessive or hypermobile range, if active recruit-
■ verbally explain and describe the test ment of the muscle stability system cannot
movement or action control movement to the benchmark range.
■ manually facilitate or ‘hands on’ guide UCM may be non-symptomatic. Even if there is
the person through the test movement or obvious hypermobile range, so long as the
action. control of the benchmark range is efficient
The therapist facilitates the test action and there is no significant stability dysfunction. So
guides the elimination substitution strategies. long as the direction being tested has good
• Assessment of passive or available range. control it can achieve a ‘pass’ (✓✓) rating. (The
The therapist passively stabilises the test ability to efficiently control hypermobile range
region and assesses the passive available is evaluated during the assessment of ‘control
range of the test movement. of range’.)
• Active learning. The person actively If the ability to dissociate and control the UCM
practises the movement with the necessary throughout the available range appears to be effi-
cues; for example, visual and palpation cient but the range available is significantly
feedback, unloading (if required), therapist restricted, then to maintain normal function, sta-
support (‘hands on’ facilitation) and verbal bility is sacrificed and compensation for the
correction. Usually, 3–8 repetitions are restriction is required. Note what structure lacks
sufficient for teaching, learning and extensibility (if the restriction is obvious) so that
familiarisation with the test movement. direct intervention to regain normal mobility
If a person fails the test, it should be because can be commenced. If the restriction is structural
they cannot perform the movement skill to and therefore permanent, then there must be
57
compensation elsewhere to maintain function. If ✓✓ = the person demonstrates the correct

the compensation has poor control (UCM) this dissociation movement pattern to the benchmark
obviously has implications for ongoing risk of range and efficient low threshold recruitment
recurrence. • If all requirements for the first ✓ and all
If the available range is excessive (significantly requirements for the second ✓ are demonstrated,
more than the benchmark standard), the disso- then rate the test as ✓✓.
ciation requirements for control of direction are ✓✗ = the person demonstrates the correct
achieved if the subject can demonstrate good dissociation movement pattern to the benchmark
motor control of dissociation throughout the range, but inefficient low threshold recruitment
benchmark range only. This demonstrates effi- • If the test demonstrates all the requirements for
cient coordination of motor control strategies the first ✓ but fails any of the requirements for
related to the recruitment pattern required to the second ✓, then rate the test as ✓✗. Note the
control direction-specific stress and strain. Control reason for the ✗.
throughout the full hypermobile range is not ✗✗ = the person is unable to demonstrate the
assessed at this level. That is dealt with by the correct dissociation movement pattern to the
benchmark range
principles of ‘control of range’.
• If there is failure to achieve all of the requirements
A ✓✗ rating or ✗✗ rating labels or diagnoses the
of the first ✓, then rate the test as ✗✗. Note what
UCM or stability dysfunction. The diagnosis of proportion of benchmark range can be controlled.
UCM should label both the SITE and the DIREC-
TION of movement that is uncontrolled.
Clarification of a ‘grey’ area of interpretation. If

movement is observed in the opposite direction
Each direction is assessed separately. If during a test of and presents only through partial range, for
one specific direction, UCM into another direction is example, a small range of extension is observed
observed, then the stability dysfunction (i.e. site and while testing flexion control, the flexion control
direction) is at the site of poor control and in the
test should be rated as ✓✓. However, if move-
direction of actual UCM. For example, if during a test of
control of lumbar flexion, the lumbar spine loses control
ment in the opposite direction consistently uses
into extension, there is likely to be a problem with end-range positioning to prevent movement in
stability function for lumbar extension. The ability to the test direction, for example, if end-range exten-
control this apparent stability dysfunction should be sion is used to prevent flexion, this indicates inef-
specifically assessed with extension-related tests. If there ficient control of flexion and poor afferent
was no UCM into flexion, then flexion is not the primary feedback. This should be rated as ✓✗ for ineffi-
direction of dysfunction. cient flexion control.
The therapist should monitor the person’s
symptom responses to testing for UCM. If
symptom provocation can be noticeably reduced
by performing movement dissociation, then
For clarification purposes, the scoring or rating retraining active movement control with the
of each test can be detailed in a rating table retraining strategies suggested in this text is
(Table 3.3). likely to have a positive effect on symptom
reduction. This response, that is, actively con-
trolling or preventing movement in the provoca-
Rating interpretation tive direction and achieving symptom relief,
further supports the hypothesis that UCM is a
The first (left) column ✓ relates to correct
significant mechanism in the production of
pattern of voluntary dissociation.
tissue pathology.
The second (right) column ✓ relates to the Clinical priorities for retraining are determined
efficiency of low threshold recruitment. by identifying the link between the direction of
(Always qualify a ✗ rating with the reason for movement provocation and an inability to pass a
that ✗.) test of movement control for that direction. For
58
Table 3.3 Movement control rating system table (Comerford & Mottram 2011)
Control point:
• Prevent: [site and direction]
Movement challenge: [movement]
Benchmark range: [range]
RATING OF LOW THRESHOLD RECRUITMENT EFFICIENCY

✓ or ✗ ✓ or ✗
• Able to prevent UCM into the test ! • Looks easy, and in the opinion of the assessor, !
direction. Correct dissociation pattern of is performed with confidence
movement • Feels easy, and the subject has sufficient !
Prevent [site] of UCM into: awareness of the movement pattern that
[direction] they confidently prevent UCM into the test
and move adjacent region direction
• Dissociate movement through the ! • The pattern of dissociation is smooth during !
benchmark range of [benchmark] concentric and eccentric movement
(If there is more available range than the • Does not (consistently) use end-range !
benchmark standard, only the benchmark movement into the opposite direction to
range needs to be actively controlled) prevent the UCM
• Without holding breath (though it is ! • No extra feedback needed (tactile, visual or !
acceptable to use an alternate breathing verbal cuing)
strategy) • Without external support or unloading !
• Control during eccentric phase ! • Relaxed natural breathing (even if not ideal – so !
• Control during concentric phase ! long as natural pattern does not change)
• No fatigue !
CORRECT DISSOCIATION PATTERN RECRUITMENT EFFICIENCY
example, if lumbar symptoms are provoked by

Box 3.4 Checklist for testing UCM
bending forwards and prolonged sitting in a pos-
terior tilted or flexed back posture and if that Checklist for testing of UCM
person also lacks the ability to prevent lumbar Observe the natural or normal pattern of movement.
flexion while actively flexing the hips, then Note relative stiffness : relative flexibility issues or
retraining this movement dissociation becomes a restrictions and compensation.
clinical priority for symptom management and Teach the test movement or action using visual,
for changing recruitment patterns to manage auditory and kinaesthetic cues with feedback and
recurrence. support.
The MCRS is used to diagnose the site and Test the person’s ability to reproduce the test
direction of UCM. This will support the clinical movement or action without cuing, feedback or
reasoning framework and the development of the support.
management plan (Chapter 1). A checklist sum- Rate the performance of the test in terms of voluntary
marising the complete process from testing UCM low threshold recruitment efficiency (✓✓ = good
through to clinical analysis and rehabilitation is motor control, while ✓✗ or ✗✗ = stability dysfunction)
shown in Box 3.4. then …
The next chapter (Chapter 4) details the appli- Relate poor performance (✓✗ or ✗✗) to the
cation of key principles in the design of therap- symptomatic area (high clinical priority).
eutic exercise interventions for the retraining of Rehab is required for stability dysfunction that relates to
UCM. symptoms or pathology.
59
REFERENCES
Barr, A., Burden, A., 2009. A patterns of superficial trunk muscle proposed treatment-based
comparison of two styles of the activation during sitting in classification system for patients
football instep kick and their nonspecific chronic low back pain receiving physical therapy
relationship to lumbopelvic stability. patients: importance of interventions for neck pain. Physical
2009 3rd International Conference subclassification. Spine 31 (17), Therapy 87 (5), 513–524.
on Movement Dysfunction in 2017–2023. Fritz, J.M., Childs, J.D., Flynn, T.W.,
Edinburgh, UK, pp. S33. Dankaerts, W., O’Sullivan, P.B., Straker. 2005. Pragmatic application of a
Bhalla, S.K., Simmons, E.H., 1969. L.M., Burnett. A.F., Skouen, J.S., clinical prediction rule in primary
Normal ranges of intervertebral-joint 2006b. The inter-examiner reliability care to identify patients with low
motion of the cervical spine. of a classification method for back pain with a good prognosis
Canadian Journal of Surgery 12 (2), non-specific chronic low back pain following a brief spinal
181–187. patients with motor control manipulation intervention. BMC
Burnett, A.F., Cornelius, M.W., impairment. Manual Therapy 11 (1), Family Practice 6 (1), 29.
Dankaerts, W., O’Sullivan, P.B., 2004. 28–39. Fritz, J.M., Cleland, J.A., Childs, J.D.,
Spinal kinematics and trunk muscle DonTigny, R.L., 1997. Mechanics and 2007. Subgrouping patients with low
activity in cyclists: a comparison treatment of the SIJ joint. In: back pain: evolution of a
between healthy controls and Vleeming, A., Mooney, V., Snijders, classification approach to physical
non-specific chronic low back C.J., Dorman, T.A., Stoekart, R. therapy. Journal of Orthopaediac
pain subjects – a pilot investigation. (Eds.), Movement, stability and low and Sports Physical Therapy 37 (6),
Manual Therapy 9 (4), 211–219. back pain. Churchill Livingstone, 290–302.
Butler, D., Moseley, L., 2003. Explain Edinburgh, ch 38. Gibbons, S.G.T., 2005. Muscle function
pain. NOI, Adelaide. Dvorak, J., Dvorak, V., 1990. Manual and a critical evaluation. KC MACP,
medicine: diagnostics, 2nd edn. 2nd International Conference on
Caldwell, C., Sahrmann, S., Van, D.L.,
Thieme, Stuttgart. Movement Dysfunction, Edinburgh,
2007. Use of a movement system
Dvorak, J., Froelich, D., Penning, L., UK.
impairment diagnosis for physical
therapy in the management of a Baumgartner, H., Panjabi, M., 1988. Gibbons, S.G.T., 2007. Clinical anatomy
patient with shoulder pain. Journal Functional radiographic diagnosis of and function of psoas major and
of Orthopaedic and Sports Physical the cervical spine: flexion/extension. deep sacral gluteus maximus. In:
Therapy 37 (9), 551–563. Spine 13 (7), 748–755. Vleeming, A., Mooney, V., Stoeckart,
Edwards, B., 1999. Manual of combined R. (Eds.), Movement, stability and
Cholewicki, J., McGill, S.M., 1996.
movements: their use in the lumbopelvic pain: integration of
Mechanical stability of the in vivo
examination and treatment of research and therapy. Elsevier,
lumbar spine: implications for injury
mechanical vertebral column Edinburgh, part 1, section 1, ch 6.
and chronic low back pain. Clinical
Biomechanics 11 (1), 11. disorders. Butterworth-Heinemann, Goldspink, G., Williams, P.E., 1992.
Oxford. Muscle fibre and connective tissue
Comerford, M., Mottram, S.L., 2001a. changes associated with use and
Esola, M.A., McClure, P.W., Fitzgerald,
Movement and stability dysfunction disuse. In: Ada, L., Canning, C.
G.K., Siegler, S., 1996. Analysis of
– contemporary developments. (Eds.), Key issues in neurological
lumbar spine and hip motion during
Manual Therapy 6 (1), 15–26. physiotherapy. Butterworth
forward bending in subjects with
Comerford, M.J., Mottram, S.L., 2001b. and without a history of low back Heinemann, Oxford, ch 8, pp.
Functional stability re-training: pain. Spine 21 (1), 71–78. 197–218.
principles and strategies for Gombatto, S.P., Collins, D.R.,
Falla, D., Bilenkij, G., Jull, G., 2004b.
managing mechanical dysfunction. Sahrmann, S.A., Engsberg, J.R., Van
Patients with chronic neck pain
Manual Therapy 6 (1), 3–14. Dillen, L.R., 2007. Patterns of
demonstrate altered patterns of
Comerford, M.J., Mottram, S.L., 2011. muscle activation during lumbar region movement during
Understanding movement and performance of a functional upper trunk lateral bending in two
function – assessment and retraining limb task. Spine 29, 1436–1440. subgroups of people with low back
of uncontrolled movement. Course pain. Physical Therapy 87 (4),
Falla, D., Jull, G., Hodges, P., 2004a.
Notes, Kinetic Control, UK. 441–454.
Patients with neck pain demonstrate
Cyriax, J.H., 1980. Textbook of reduced electromyographic activity Gossman, M.R., Sahrmann, S.A., Rose,
orthopaedic medicine. Volume II. of the deep cervical flexor muscles S.J., 1982. Review of length-
Treatment by manipulation, massage during performance of the associated changes in muscle.
and injection, 10th edn. Ballière craniocervical flexion test. Spine 29, Physical Therapy 62 (12),
Tindall, London. 2108–2114. 1799–1808.
Dankaerts, W., O’Sullivan, P., Burnett, Fritz, J.M., Brennan, G.P., 2007. Hamilton, C., Richardson, C., 1998.
A., Straker, L., 2006a. Altered Preliminary examination of a Active control of the neural
60
lumbopelvic posture; a comparison Janda, V., 1986. Muscle weakness and of shoulder instability and
between back pain and non back inhibition (pseudoparesis) in low impingement. PhD thesis, University
pain subjects. In: Vleeming, A., back pain. In: Grieve, G.P. (Ed.), of London.
Mooney, V., Tilsher, H., Dorman, T., Modern manual therapy of the Morrissey, D., Morrissey, M.C., Driver,
Snijders, C. (Eds.), 3rd vertebral column. Churchill W., King, J.B., Woledge, R.C., 2008.
Interdisciplinary World Congress on Livingston, Edinburgh. Manual landmark identification and
Low Back Pain and Pelvic Pain, Jones, L.H., Kusunose, R., Goering, E., tracking during the medial rotation
Vienna, Austria. 1995. Jones strain-counterstrain. test of the shoulder: an accuracy
Harris-Hayes, M., Van Dillen, L.R., 2009. Jones Strain-CounterStrain Inc. study using three dimensional
The inter-tester reliability of physical Boise, ID. ultrasound and motion analysis
therapists classifying low back pain Jull, G.A., 2000. Deep cervical flexor measures. Manual Therapy 13 (6),
problems based on the movement muscle dysfunction in whiplash. 529–535.
system impairment classification Journal of Musculoskeletal Pain 8 Mottram, S.L., 2003. Dynamic stability
system. PM & R 1 (2), 117–126. (1/2), 143–154. of the scapula. In: Beeton, K.S. (Ed.),
Hicks, G.E., Fritz, J.M., Delitto, A., Jull, G., Kristjansson, E., Dall’Alba, P., Manual therapy masterclasses – the
McGill, S.M., 2005. Preliminary 2004. Impairment in the cervical peripheral joints. Churchill
development of a clinical prediction flexors: a comparison of whiplash Livingstone, Edinburgh, pp. 1–17.
rule for determining which patients and insidious onset neck pain Mottram, S.L., Comerford, M., 2008. A
with low back pain will respond to a patients. Manual Therapy 9, 89–94. new perspective on risk assessment.
stabilization exercise program.
Jull, G., Sterling, M., Falla, D., Treleaven, Physical Therapy in Sport 9 (1),
Archives of Physical Medicine and
J., O’Leary, S., 2008. Whiplash, 40–51.
Rehabilitation 86 (9), 1753–1762.
headache and neck pain. Elsevier, Mottram, S., Warner, M., Chappell, P.,
Hides, J.A., Richardson, C.A., Jull, G.A., Edinburgh.
1996. Multifidus muscle recovery is Morrissey, D., Stokes, M., 2009.
Jull, G., Trott, P., Potter, H., Zito, G., Impaired control of scapular rotation
not automatic after resolution of
Niere, K., Shirley, D., et al., 2002. A during a clinical dissociation test in
acute, first-episode low back pain.
randomized controlled trial of people with a history of shoulder
Spine 21 (23), 2763–2769.
exercise and manipulative therapy pain. 3rd International Conference
Hides, J., Gilmore, C., Stanton, W., for cervicogenic headache. Spine 27 on Movement Dysfunction,
Bohlscheid, E., 2008. Multifidus (17), 1835–1843. Edinburgh, UK. Manual Therapy 14
size and symmetry among chronic (1), S20.
LBP and healthy asymptomatic Kaltenborn, F.M., 2003. Orthopedic
subjects. Manual Therapy 13 (1), manual therapy for physical Mueller, M.J., Maluf, K.S., 2002. Tissue
43–49. therapists Nordic System: OMT adaptation to physical stress: a
Kaltenborn-Evjenth concept. Journal proposed ‘physical stress theory’ to
Hodges, P.W., 2001. Changes in motor
of Manual and Manipulative Therapy guide physical therapist practice,
planning of feedforward postural
1 (2), 47–51. education, and research. Physical
responses of the trunk muscles in
Luomajoki, H., Kool, J., de Bruin, E.D., Therapy 82 (4), 383–403.
low back pain. Experimental Brain
Research 141, 261–266. Airaksinen, O., 2007. Reliability of Mulligan, B.R., 2003. Manual therapy
movement control tests in the NAGS SNAGS MWMS, etc. Plane
Hodges, P.W., 2003. Core stability
lumbar spine. BMC Musculoskeletal View Services, Wellington, New
exercise in chronic low back pain.
Disorders 8, 90. Zealand.
Orthopedic Clinics of North America
34 (2), 245–254. Luomajoki, H., Kool, J., de Bruin, E.D., Norlander, S., Nordgren, B., 1998.
Hodges, P.W., Moseley, G.L., 2003. Airaksinen, O., 2008. Movement Clinical symptoms related to
Pain and motor control of the control tests of the low back: musculoskeletal neck-shoulder pain
lumbopelvic region: effect and evaluation of the difference between and mobility in the cervico-thoracic
possible mechanisms. Journal of patients with low back pain and spine. Scandinavian Journal of
Electromyography and Kinesiology healthy controls. BMC Rehabilitation Medicine 30 (4),
13 (4), 361–370. Musculoskeletal Disorders 9, 170. 243–251.
Hodges, P.W., Richardson, C.A., 1996. McKenzie, R., May, S., 2003. The lumbar O’Sullivan, P.B., 2000. Lumbar
Inefficient muscular stabilisation of spine: mechanical diagnosis and segmental instability’: clinical
the lumbar spine associated with therapy, 2nd edn. Spinal presentation and specific stabilizing
low back pain: a motor control Publications New Zealand, exercise management. Manual
evaluation of transversus abdominis. Wellington, New Zealand. Therapy 5 (1), 2–12.
Spine 21 (22), 2640–2650. Maitland, G., Hengeveld, E., Banks, K., O’Sullivan, P., 2005. Diagnosis and
Janda, V., 1985. Pain in the locomotor English, K., 2005. Maitland’s classification of chronic low back
system – a broad approach. In: vertebral manipulation, 7th edn. pain disorders: maladaptive
Glasgow, E.F. (Ed.), Aspects of Butterworth-Heinemann, Oxford. movement and motor control
manipulative therapy. Churchill Morrissey, D., 2005. Development of impairments as underlying
Livingstone, Edinburgh, pp. the kinetic medial rotation test of mechanism. Manual Therapy 10 (4),
148–151. the shoulder: a dynamic clinical test 242–255.
61
O’Sullivan, P., Dankaerts, W., Burnett, Schafer, A., Hall, T., Briffa, K., 2007. chronic low back pain. Journal of
A., Chen, D., Booth, R., Carlsen, C., Classification of low back-related Orthopaedic and Sports Physical
et al., 2006. Evaluation of the flexion leg pain – a proposed patho- Therapy 38 (6), 371–376.
relaxation phenomenon of the trunk mechanism-based approach. Manual Van Dillen, L.R., Bloom, N.J.,
muscles in sitting. Spine 31 (17), Therapy 14 (2), 222–230. Gombatto, S.P., Susco, T.M., 2008.
2009–2016. Scholtes, S.A., Gombatto, S.P., Van Hip rotation range of motion in
O’Sullivan, P.B., Grahamslaw, K.M., Dillen, L.R., 2008. Differences in people with and without low back
Kendell, M., Lapenskie, S.C., Moller, lumbopelvic motion between people pain who participate in rotation-
N.E., Richards, K.V., 2002. The effect with and people without low back related sports. Physical Therapy in
of different standing and sitting pain during two lower limb Sport 9, 72–81.
postures on trunk muscle activity in movement tests. Clinical Biomechics Van Dillen, L.R., Maluf, K.S., Sahrmann,
a pain-free population. Spine 27 24 (1), 7–12. S.A., 2009. Further examination of
(11), 1238–1244. Scholtes, S.A., Van Dillen, L.R., 2007. modifying patient-preferred
O’Sullivan, P.B., Twomey, L., Allison, G., Gender-related differences in movement and alignment strategies
1997. Evaluation of specific prevalence of lumbopelvic region in patients with low back pain
stabilising exercises in the treatment movement impairments in people during symptomatic tests. Manual
of chronic low back pain with with low back pain. Journal of Therapy 14 (1), 52–60.
radiological diagnosis of spondylosis Orthopaedic and Sports Physical Van Dillen, L.R., Sahrmann, S.A.,
or spondylolisthesis. Spine 22 (24), Therapy 37 (12), 744–753. Norton, B.J., Caldwell, C.A., Fleming,
2959–2967. Singer, K.P., Fitzgerald, D., Milne, N., D.A., McDonnell, M.K., et al., 1998.
1993. Neck retraction exercises and Reliability of physical examination
Panjabi, M.M., 1992. The stabilising
cervical disk disease. MPAA items used for classification of
system of the spine. Part II. Neutral
Conference Proceedings, Australia. patients with low back pain. Physical
zone and instability hypothesis.
Sterling, M., Jull, G., Vicenzino, B., Therapy 78 (9), 979–988.
Journal of Spinal Disorders 5 (4),
390–397. Kenardy, J., 2003. Sensory Van Dillen, L.R., Sahrmann, S.A.,
hypersensitivity occurs soon after Norton, B.J., Caldwell, C.A., Fleming,
Peng, Q., Jones, R., Shishido, K.,
whiplash injury and is associated D., McDonnell, M.K., et al., 2001.
Constantinou, C.E., 2007.
with poor recovery. Pain 104 (3), Effect of active limb movements on
Ultrasound evaluation of dynamic
509–517. symptoms in patients with low back
responses of female pelvic floor
Sterling, M., Jull, G., Vicenzino, B., pain. Journal of Orthopaedic and
muscles. Ultrasound in Medicine
Kenardy, J., 2004. Characterization Sports Physical Therapy 31 (8),
and Biology 33 (3), 342–352.
of acute whiplash-associated 402–413.
Richardson, C., Hodges, P., Hides, J., disorders. Spine (Phila Pa 1976) 29 Vibe Fersum, K., O’Sullivan, P.B., Kvåle,
2004. Therapeutic exercise for (2), 182–188. A., Skouen, J.S., 2009. Inter-examiner
lumbopelvic stabilization – a motor reliability of a classification system
Stokes, M.A., Cooper, R., Morris, G.,
control approach for the treatment for patients with non-specific low
Jayson, M.I.V., 1992. Selective
and prevention of low back pain. back pain. Manual Therapy 4 (5),
changes in multifidus dimensions in
Churchill Livingstone, Edinburgh. 555–561.
patients with chronic low back pain.
Roussel, N.A., Nijs, J., Mottram, S., van European Spine Journal 1 (1), Waddell, G., 2004. The back pain
Moorsel, A., Truijen, S., Stassijns, G., 38–42. revolution. Churchill Livingstone,
2009. Altered lumbopelvic Torstensen, T.A., Ljunggren, A.E., Meen, Edinburgh.
movement control but not H.D., Odland, E., Mowinckel, P., Watson, P., Kendall, N., 2000. Assessing
generalised joint hypermobility is Geijerstam, S., 1998. Efficiency and psychosocial yellow flags. In: Gifford,
associated with increased injury in costs of medical exercise therapy, L. (Ed.), Topical issues in pain 2.
dancers. A prospective study. Manual conventional physiotherapy, and Physiotherapy Pain Association. CNS
Therapy 14 (6), 630–635. self-exercise in patients with chronic Press, Falmouth, pp. 111–129.
Sahrmann, S.A., 1992. Posture and low back pain. A pragmatic, Whittaker, J.L., 2007. Ultrasound
muscle imbalance: faulty lumbar- randomized, single-blinded, imaging for rehabilitation of the
pelvic alignment and associated controlled trial with 1-year follow-up. lumbo-pelvic region – a clinical
musculoskeletal pain syndromes. Spine 23 (23), 2616–2624. approach. Churchill Livingstone
Orthopaedic Division Review Nov/ Trudelle-Jackson, E., Sarvaiya-Shah, S.A., Elsevier, Edinburgh.
Dec, 13–20. Wang, S.S., 2008. Interrater reliability Woolsey, N.B., Sahrmann, S.A., Dixon,
Sahrmann, S.A., 2002. Diagnosis and of a movement impairment-based L., 1988. Triaxial movement of the
treatment of movement impairment classification system for lumbar pelvis during prone knee flexion.
syndromes. Mosby, St Louis. spine syndromes in patients with Physical Therapy 68, 827.
62
Chapter 4
Retraining strategies for uncontrolled movement
Torstensen et al 1998). Consideration and man-

REHABILITATION MANAGEMENT agement of psychosocial factors is also essential
AND RETRAINING in the management of chronic low back pain
and other chronic musculoskeletal conditions.
The retraining of efficient control of uncontrolled Cognitive behavioural approaches have a signi-
movement (UCM) will depend on the pattern ficant role to play for optimal outcomes in chronic
of the dysfunction and the site and direction of low back pain (Waddell 2004). The more multi-
the UCM. From the assessment (as outlined in factorial the patient’s pain presentation is, the
Chapter 3) the translation and range of UCM and more likely a multidisciplinary approach will
restriction will have been identified. Correcting be required. The clinical reasoning framework
aberrant motor control and recruitment patterns to encompass these factors has previously been
is the priority in the rehabilitation of the local described in Chapter 1.
stability system. Correcting length and recruit-
ment dysfunction is the priority of the global
Management overview
system. Addressing the UCM and restriction is the
key to rehabilitation and this principle is covered In the integrated management of musculoskeletal
throughout this text. pain there are several factors that require consid-
As well as dealing with mechanical components eration (Figure 4.1).
of movement dysfunction the pathology must be Firstly, the mechanical components of the dys-
addressed and non-mechanical issues identified function need to be addressed. These include
and managed. Dependent upon reported signs identifying and understanding the relationships
and symptoms, local tissues should be assessed between articular and myofascial restrictions and
to identify the pain-producing or most damaged the compensations that develop to maintain
structure(s). Intervention may include treatment good function. The compensations require more
of the pain mechanisms, inflammation and detailed assessment and UCM needs to be identi-
pathology with techniques such as large ampli- fied in terms of the site and direction of UCM.
tude manual mobilisations, cryotherapy, heat, The UCM can present as uncontrolled translation
active exercise, electrophysiological modalities, which is best controlled by local muscle retrain-
neurodynamic techniques, acupuncture, trigger ing or uncontrolled range which is best control-
point release, positional release and appropriate led by global muscle retraining. These restrictions
medication. These interventions should be sup- and uncontrolled compensations make up the
plemented with fitness and exercise programs base of the ‘pyramid’ of mechanical movement
which are effective approaches for the manage- dysfunction. The top of the pyramid involves
ment of chronic low back pain (Frost et al 1998; treating the pain-sensitive tissues to optimise the

DOI: 10.1016/B978-0-7295-3907-4.00004-9 63
han
Non-mec ical pain including those with osteoarthritis of the knee
(Brosseau et al 2003; Pelland et al 2004), chronic
low back pain (Hayden et al 2005), shoulder pain
(Green et al 2003) and chronic neck pain (Kay
Pathology et al 2005). Different patients appear to need dif-
ferent therapeutic exercises to manage different
n
therapeutic goals. There are indications that

ctio
un
specifically targeted and individualised exercise

ysf
programs are more beneficial than standardised

al d
nic
programs (Stuge et al 2004; Taylor et al 2007).

cha
The development of rehabilitation strategies

Me
Translational Range
UCM UCM directed at correcting the movement faults, identi-
fied by evidence-based assessment, rather than
developing rehabilitation strategies based on
Articular Myofascial diagnosis of pathology alone, is gaining recogni-
restriction restriction tion and acceptance because patients may present
Figure 4.1 Overview of the ‘pyramid’ of mechanical
with a similar diagnosis of pathology but differ-
movement dysfunction ing kinematic mechanisms. However, there
remain many examples of exercise programs
being developed with the ‘one size fits all’ ideol-
ogy. Most of these programs become ‘protocols’
resolution of inflammatory pathology and to for ‘core stability’ training or a particular injury
promote an optimal healing environment. Finally, such as patellar malalignment, shoulder instabil-
if the dysfunction is longstanding (chronic or ity or a post-surgical protocol.
recurrent), then ‘yellow flag’ issues also need Protocol-based training regimens can be
consideration. Yellow flag issues may include designed with clear goals, performance targets
peripheral and central neurogenic sensitisation and structured timeframes and the ‘protocol’ can
and contextual factors such as behavioural or be readily disseminated to a large number of
psychosocial factors that can affect both the people. The developers of these protocols have
perception of pain and the prognosis for symptom the unenviable task of producing a program that
change. must be simple yet at the same time comprehen-
It is important to relate the site and direction sive enough to deal with a wide range of variabil-
of UCM to symptoms and pathology and to the ity in patient presentation and complications.
mechanisms of provocation of symptoms. Man- However, it is difficult for one protocol to cover
agement of the dysfunction that relates to the the timeframe from injury to return to high level
symptoms and pathology becomes the clinical function (e.g. elite sport).
priority. UCM that may be evident, but does not An inherent weakness with protocol-based
relate to symptoms, is not a priority of pathology training programs is an assumption that all
management. However, it may indicate a poten- people who use the protocol have, to a large
tial risk for the future (Mottram & Comerford extent, the same problem. Most protocols are
2008; Roussel et al 2009). The movement control designed along a linear framework. That is, there
dysfunction can be labelled and classified by the are a series of linear progressions from one skill
site and direction of UCM and is described in or stage to the next. Consequently, in the attempt
following chapters. to account for individual differences in pre-
sentation (especially if injury and pathology
are involved) many protocols are modified or
adapted, often many times over. The primary
THERAPEUTIC EXERCISE problem then with protocol-based training pro-
grams is that they are forced to become ‘recipes’.
Therapeutic exercise within clinical practice is The recipe works well for one particular goal or a
beneficial (Taylor et al 2007). There is evidence ‘textbook’ presentation of a problem. However,
that different types of therapeutic exercise are therapists and trainers who regularly work with
beneficial to many different groups of patients, injured athletes know that they rarely present
64
Retraining strategies for uncontrolled movement Chapter |4|
3. Control
segmental translation
2. Unload tissues 4. Control functional

and ↓ pain range of movement
Restoring
1. Maintain optimal 5. ↑ Strength
mobility function
8. Cognitive and
6. ↑ Speed and
behavioural
power
modification
7. ↑ Skill and
coordination
Figure 4.2 A paradigm of therapeutic exercise goals
as the ‘textbook case’. Each patient has his or 5. recondition and recover from atrophy and
her own variations, complications and differing tolerate load (increase strength and
expectations. endurance)
Thus, a paradigm shift is needed towards a 6. cope with speed (produce acceleration and
process of systematic assessment and analysis that control momentum)
can be used to guide the rehabilitation of dys- 7. train and re-enforce sport-specific skills (skill
function and retraining of performance deficits. and coordination)
Based on a comprehensive assessment of an indi- 8. influence mood and sense of wellbeing to
vidual’s deficits, the development of individual- assist in the management of behavioural/
ised and specific retraining programs to better affective issues.
manage real priorities in injury rehabilitation and Figure 4.2 incorporates these goals into a non-
performance training can be developed. The sub- linear therapeutic exercise paradigm.
sequent retraining program is designed along a In a clinical situation, a patient may be pre-
multidimensional and parallel framework, rather scribed an exercise program to achieve one or
than a linear recipe. several goals at the same time. As the condition
When a clinical reasoning process is used in the changes the exercise prescription should progress
application of exercise for a therapeutic purpose, to match the changing nature of the condition
several distinct goals can be identified. and the goals themselves will change as the
Therapeutic exercise can be used to: condition improves and resolves. Some of the
1. maintain mobility/flexibility and mobilise exercise goals may also be incorporated into
restrictions (especially after manual therapy either a short-term or a long-term maintenance
mobilisation or myofascial stretching) program. These goals should not be prescribed
2. manage pain and symptoms (unload or in rigid linear progressions; that is, start with
support pain sensitive tissues) one, then as its aims are achieved, progress to
3. control segmental translatatory motion the next one. There seems to be an assumption
(local muscle system motor control) that the skills acquired with one goal are a neces-
4. control aberrant motion – uncontrolled sary prerequisite before starting the next one.
direction or range (global muscle system This assumption does not have any real evidence
motor control) base.
65
Box 4.1 Clinical reasoning steps in therapeutic Box 4.2 Key factors to be explained with the
exercise prescription therapeutic exercise plan
• Identify general aim of an exercise process – look at • What is the reason for giving this exercise?
the process (i.e. what the exercise can make a • Is this exercise appropriate for this patient, having
difference to). considered their presenting symptoms and
• Identify key therapeutic goals that may be helped by dysfunction?
exercise (these goals will continually change and • Should the exercise be started now or later?
evolve as the patient’s condition changes). • What is the exercise dosage? (e.g. For how long? How
• Match an exercise process to the immediate many repetitions? How often?)
therapeutic goals. • When can it be progressed?
• Keep it simple – do not over-complicate the • When can it be stopped?
application.
• How do I know it is working? What changes should I
• Where appropriate, work on more than one goal at look for?
the same time – integrate and progress along parallel
• Over what timeframe should I expect to see some
paths.
change?
• Do not use recipes – ensure a clear reason for giving
• Are there any risks? Can the exercise be provocative
any particular exercise and make sure there is a clear
or increase symptoms? If so, what is acceptable and
understanding of when the exercise can be stopped or
what is not?
progressed.
It is more appropriate and more functional to re-establishing control of the site and direction of
prescribe therapeutic exercise in parallel combi- UCM including functional integration. The key to
nations based on a clinical assessment and then delivering effective treatment is to understand the
decide what rehabilitative changes are required principles behind assessment and sound clinical
and how and when those changes can be imple- reasoning.
mented. Therapeutic exercise uses movement as a The therapist’s clinical decision-making should
tool to decrease pain, increase joint range and consider the patient’s perspective and interven-
muscle extensibility, to enhance movement per- tions should be primarily aimed at those aspects
formance and to improve wellbeing. The best way of impairments that have a direct bearing on
to approach therapeutic exercise is to use a clini- disability and/or functional limitations. In the
cal reasoning approach. The steps involved in this subjective examination, patients define their
approach are outlined in Box 4.1. Box 4.2 high- perspective in terms of pain, disability and dys-
lights some key questions that the therapist function. These factors will be further influenced
should be able to answer and justify. These factors by contextual factors such as fear of pain/
should be understood by the therapist prescribing provocation, their coping ability, their work and
therapeutic exercise and can be explained and social requirements, their belief systems, etc.
supported with the therapeutic exercise plan. Therapeutic exercise needs to address real every-
Therapeutic exercise can use movement as a day functional limitations; for example, the ina-
tool to decrease pain, to increase joint range bility to bend over when tying shoelaces (due
and muscle extensibility, to enhance muscle per- to low back pain or the fear of provoking low
formance and to promote wellbeing. This and back pain), or the inability (due to shoulder
other chapters in this text detail the concept pain) to reach up to a cupboard. If a patient with
and strategy to ‘look at movement’; to be able to low back pain is unable to actively control move-
make mechanical subclassifications according ments of the low back, especially flexion control
to site and direction of UCM; relate UCM to while performing a ‘waiter’s bow’ (Luomajoki
symptoms, disability, dysfunction, recurrence, 2008), then clinicians should aim an intervention
risk and performance; make a clinical diagnosis at the neuromuscular impairment underpinning
in terms of site and direction of uncontrolled this. Likewise, if a patient with shoulder pain is
motion, complaining tissue and presenting unable to actively control the scapula during
pain mechanisms. Rehabilitation will focus on functional movements of reaching with the
66
arm (von Eisenhart-Rothe et al 2005; Tate et al moving the same segment in a different
2008), then clinicians should aim an intervention direction). For example, if the site of the
strategy at regaining this control. There is evi- UCM is the lumbar spine, position it in
dence to support the use of movement retraining a long shallow mid-range lordosis. If the
to gain an improvement in function (Jull et al direction of the UCM is uncontrolled
2009; Roussel et al 2009b). flexion, the therapist instructs the person to
Altering movement patterns via exercise can control or prevent lumbar flexion while the
influence clinical signs (Tate et al 2008). However, person flexes forwards independently at the
it is important to establish a clear diagnosis of the hips, or flexes the thoracic spine
movement faults and from this diagnosis develop independently of any lumbar movement.
an appropriate rehabilitation strategy. The thera- The person is taught to use whatever
pist requires a sound knowledge of exercise con- feedback helps to monitor and ensure that
cepts so a patient-specific retraining program the lumbar spine does not increase flexion
can be developed. This is dependent on expertise during the retraining exercise.
in the assessment of movement disorders as • The motor control retraining emphasis is
described in Chapters 1 and 3, and effective clini- focused at the joint and in the direction that
cal reasoning. movement is isometrically controlled (not
where the movement is actively performed).
That is, for the lumbar flexion UCM control
exercise described above, the lumbar
THE SITE AND DIRECTION OF UCM
extensor stabiliser muscles are actively
recruited to isometrically control lumbar
Chapter 3 has detailed the assessment of the site flexion during repetitions of the retraining
and direction of UCM. The next stage is regaining exercise. The flexion movement at the hip or
control of the UCM and integrating this new the thoracic spine creates a flexion loading
movement pattern into normal movement and challenge that the lumbar extensor stabiliser
function. muscles have to work against. Throughout
The key goal to effective retraining is to the dissociation retraining movements, local
re-establish control of the UCM and regain and global stability muscles are continually
normal mobility of motion restrictions. The dis- active to control the UCM.
sociation tests, as described in Chapter 3, are • The person is taught to move an adjacent
tests of motor control and these establish the site joint above or below in the same direction
and direction of UCM. If this UCM is related to as the UCM, or same joint (in a different
symptoms, disability, recurrence, risk of injury direction of the UCM) only as far as:
and performance, a key focus of rehabilitation is ■ movement is independent of the UCM
regaining the control of movement and changing ■ control can be maintained at the site of the
motor control patterns. The aim is to change the UCM
recruitment pattern and actively control move- ■ any joint or myofascial restriction permits.
ment at the site and in the direction of stability • A variety of feedback tools can be employed
dysfunction. This is a process of sensory-motor to teach and facilitate the required retraining
reprogramming. movement. These can involve visual feedback
(watch the movement), visualisation
Retraining in control of the site (including imagery), palpation feedback
(with the person’s own hands), kinaesthetic
and direction of UCM feedback (with adhesive tape and skin
• Firstly, position the site of UCM within its tension), verbal instruction and verbal
neutral training region (as described in correction, and motion monitoring
Chapter 3) and teach the person how to equipment (e.g. pressure biofeedback).
recruit the appropriate muscles to control a Effective cueing is essential for effective
specific direction of movement at this site, retraining.
while concurrently moving an adjacent joint • Repetitions are required to change motor
(above or below) in the same direction (or control patterns. Slow, low effort repetitions
67
are encouraged and movement takes place

through the range that the UCM can be
actively controlled. A general guide is to
perform 20–30 slow repetitions or up to 2
minutes of slow repetitions. Occasionally,
the body or limb weight has to be unloaded
(supported) so that the stability muscles can
control the UCM. As unloaded control gets
easier, the training is progressed to
controlling the normal functional load of
the unsupported limbs or trunk. For
example, if lumbar flexion is the UCM and it
is difficult to retrain, an early retraining
option could be to stand with both hands
on a chair or bench top and take partial
body weight through the hands. Then, with
the weight of the trunk partially supported
through the hands, the person is instructed
to push the hips away from the bench or
chair and try to keep the lumbar spine
straight and control lumbar flexion (Figure
4.3). When the ability to perform this
retraining exercise is well established, it can
be progressed to performing the same
strategy without any partial support of the
trunk through the hands (Figure 4.4)
• The focus is on the quality of control.
Substitution strategies or UCM must be
avoided. Again, patient awareness is
paramount. Retraining is focused on training
motor control of inefficient muscle groups Figure 4.3 Retraining lumbar flexion control with partial
support
and establishing efficiency of a corrective
movement pattern, not on strengthening the
dominant muscles. muscle systems to control movement and by
• The efficiency of control at the UCM is more restoring the appropriate use of muscle
important initially than the range of motion stiffness to control movement.
at the adjacent joint. This movement is • With retraining the person should regain
practised until it feels familiar and natural. awareness of:
Initially, when these low load exercises ‘feel’ ■ alignment and postural position
difficult or a high sensation of effort is ■ movement precision
perceived, then it is likely that slow motor ■ muscle tension and effort
unit or tonic recruitment is inefficient (see ■ the sensation of ‘easy’ low load holding
Chapter 2). However, when the same low ■ multi-joint motion differences.
load exercise starts to feel easy and less • This is also linked to improving
unnatural, then it is likely that there is better proprioceptive responses and low threshold
facilitation of slow motor unit recruitment recruitment efficiency.
and improved proprioceptive feedback is • Encourage normal breathing patterns.
becoming established. This is a good clinical People with chronic non-specific low
indicator of improving stability function and back pain may exhibit altered breathing
motor control efficiency. patterns during tests for UCM (Roussel
• The aim of this dissociation retraining is to et al 2009c).
facilitate the active and eventually automatic • The therapist needs to educate the person
recruitment of the local and global stability about the concept of movement retraining
68
• Patients with proprioceptive deficits often:

■ need more supervision and correction to
ensure retraining exercises are performed
properly
■ experience a high sensation of effort with
low load skills
■ are less aware of substitution strategies
(‘cheating’) – they need to rely heavily on
‘external’ feedback
■ progress through movement control
training more slowly
■ do not integrate into automatic
unconscious function as easily
■ have a higher incidence of recurrence
■ are more likely to require a long-term
maintenance program to stay symptom
free.
The key retraining processes and principles are
summarised in Box 4.3.
Progression of training the site and

direction of UCM
Initially training may begin in an unloaded and
supported position but progressed to normal
low functional load and unsupported positions.
Progression is often challenged by reducing
load facilitation (unloading) or by adding a
proprioceptive challenge to the stability of the
Figure 4.4 Retraining lumbar flexion control unsupported base of support. Balance boards, inflatable discs,
Pilates reformer, gym balls and other small equip-
ment can be used to train these movement control
patterns by exercising on an unstable base, thereby
and emphasise the importance of cognitive
adding a proprioceptive challenge. Retraining
input into the retraining process. This
can be further progressed into functional and
promotes a concept of ‘mindful’ movement.
task-specific situations, discussed later in this
Awareness and concentration is essential.
chapter.
The focus is on retraining the coordination
of movement patterns and not the range of
movement or the strength of muscle Management of symptoms using
activation. Dissociation exercise is one of retraining control of the UCM
many strategies that can be employed in the
The therapist should ensure that the person per-
retraining of movement. The goal is to be
forming the exercise understands the link between
mindful of movements during pain-
the UCM and symptoms/disability so they can
provoking activities.
use the control strategies to decrease symptoms
• None of the corrective exercises to improve
and improve disability. Regaining the control of
dynamic stability should produce or provoke
movement, which is dependent on a patient-
any symptoms at all.
specific exercise program, can be used as a pain
• The speed of progression and prognosis will
control strategy.
depend on many factors, including changes
in proprioceptive input, chronic pain
Retraining exercises need to be prescriptive, that is,
patterns with sensitisation and behavioural
modality-sensitive and dose-specific.
issues and pathology.
69
Retraining the motor control patterns to control UCM themselves and therefore be less dependent
the site and direction of UCM aims to unload on the therapist.
mechanical stress and strain which exceeds tissue
tolerance and subsequently has a provocative
effect on pain-sensitive structures. This can be KEY PRINCIPLES IN THE RETRAINING OF
seen to have a direct effect on symptoms. Direc-
tion control movements can also be used to MOTOR CONTROL PATTERNS
unload pathology, decrease mechanical provoca-
tion of pathology and assist in symptom manage- Motor unit recruitment
ment. Regaining control of the UCM may be very
Some of the key physiological principles
useful for early symptom control, particularly
relevant to motor control retraining were
when UCM has been established as a contribut-
described in Chapter 2. From these principles,
ing factor to the development of symptoms. The
clinical strategies to facilitate slow motor unit
aim is for the patient to take control of their
recruitment can be developed. Situations where
symptoms, to manage the pain by controlling the
slow motor unit (SMU) recruitment is preferen-
tial to fast motor unit (FMU) recruitment can be
utilised in retraining strategies. Conversely, there
Box 4.3 Key features and principles of are situations where FMU recruitment becomes
retraining control of the UCM preferential to SMU recruitment. Awareness of
these situations allows the therapist to avoid
• Position the site of the UCM within the neutral them if they are linked with aberrant movement
training region. patterns. These situations are illustrated in
• Train the person to use the stability muscles to control Table 4.1.
a specific direction of movement at this site and move Retraining strategies to facilitate more efficient
the adjacent joint (above or below), or move the same SMU recruitment may be beneficial in recovering
site in a different direction. the detrimental changes to SMU recruitment
• Use appropriate visual, auditory and kinaesthetic cues.
• Movement occurs only through the range that:
– movement is independent of the UCM
– stability can be maintained at the UCM (isometric
Table 4.1 Situations of preferential slow or fast
control)
motor unit recruitment
– any joint restriction allows.
• Quality is more important.
CONDITIONS CONTRIBUTING TO
• Slow, low effort repetitive movement.
DOMINANT SLOW MOTOR UNIT
• Perform 20–30 or up to 2 minutes of slow repetitions.
RECRUITMENT
• Unload body or limb weight as necessary to gain
control. • Performance of slow non fatiguing movement
• Low force static muscle holding
• Progress to normal functional load of the unsupported
• Maintain consistency of non fatiguing muscle
limbs or trunk.
contraction
• Practised until it feels familiar and natural.
• Manage the symptoms of pain and swelling to
• Retrain awareness of: minimise their inhibitory influence
– alignment and postural position • Stimulate afferent proprioceptors to facilitate
– movement recruitment
– muscle tension and effort
– the sensation of ‘easy’ low load holding CONDITIONS CONTRIBUTING TO
– multi-joint motion differences. DOMINANT FAST MOTOR UNIT
• Encourage normal breathing patterns. RECRUITMENT
• It is mindful movement and requires cognitive • increasing load to the point of fatigue
retraining. • fatiguing eccentric exercise
• No pain provocation. • exercising with a length tension disadvantage (e.g.
• No co-contraction rigidity, i.e. dominance of the global maximum inner or outer range)
mobility muscle. • conscious initiation of fast movements
70
slump sitting and sway back) inhibit muscle func-

Box 4.4 Additional recruitment strategies to
tion that provides spinal stabilisation.
facilitate SMU recruitment
The integration of specific recruitment retrain-
• Increasing or decreasing base of support. ing into function is discussed in the following
• Adding non-fatiguing low load or facilitatory section.
resistance to stimulate recruitment.
• Co-contraction of other stability muscles.
• Awareness of sensation of effort.
CHALLENGES IN RETRAINING
• Change position.
• Unload restriction. NEUROMUSCULOSKELETAL
• Increase proprioceptive input. DYSFUNCTION
• Passive support of the UCM.
It is frequently observed that patients with

chronic or recurrent musculoskeletal conditions
that have been demonstrated to be associated
are often labelled as having ‘non-specific’ low
with chronic and recurrent pain (see Chapter 2
back, neck or hip pain. This label is used in
for details). A number of these strategies may be
many systematic reviews and meta-analyses. The
incorporated into the retraining program as the
label ‘non-specific’ pain, is used when no single
patient progresses. Some examples for facilitating
particular patho-anatomical process can account
SMU recruitment are described in Box 4.4.
for the patient’s symptoms. These patients fre-
quently become frustrated and disillusioned
Cognitive awareness with the search for a diagnosis and complain
that ‘no one knows what’s wrong with them’.
Understanding how the site and direction of
They may have seen many different health care
UCM relates to pain provocation is the initial step
practitioners who have, between them, diag-
in gaining cognitive awareness of how movement
nosed (usually correctly) many different tissues
can influence pain. Patient education should
as a cause of their symptoms. This should not be
include information to promote awareness of
surprising if someone has UCM contributing to
their own UCM and:
their symptoms. UCM can increase compression
• develop an understanding of the retraining or impingement of tissues on one side of a joint
movement strategy and why it will help while concurrently increasing tensile strain
symptoms and recurrence within tissues on the other side of a joint. If this
• demonstrate an ability to perform the UCM is not managed and the related tissue stress
retraining movement strategy and strain is sustained or repeated beyond the
• learn to judge when they are controlling the limits of tissue tolerance, multiple tissues even-
UCM and when they lose control. tually develop pathological changes and a com-
This knowledge can lead directly into developing bination of symptoms develop. These patients
strategies for increasing proprioception and have usually already experienced that the model
awareness and retraining more appropriate move- of treating one symptom-producing tissue (of
ment patterns. the multiple involved) does not resolve the
problem.
If presented with the opportunity to take a dif-
The effect of posture on retraining
ferent approach to the model that has consist-
Clinically maintaining a position of neutral align- ently failed them in the past, patients with
ment will enhance the outcome of movement chronic pain may appear more motivated to
fault retraining (Comerford & Mottram 2011). explore the possibility of a different treatment
There has been some evaluation of this in the model. If they are educated about the link
literature. For example, Falla et al (2007) noted between UCM and their symptoms, and if they
an increase in activity of the deep cervical flexors can learn to regain control of the site and direc-
when sitting in a posture which facilitated a position of the UCM, then the tissues that have been
tion of neutral spinal orientation. O’Sullivan undergoing provocative stress and strain are now
(2002) also reported that passive postures (e.g. unloaded and are allowed a chance to heal and
71
recover. The body has a remarkable ability to heal is important to vary the task being carried out to
itself if it is given the opportunity. This model ensure cortical connections are developed – for
is a paradigm shift for many therapists – by example control of direction retraining in func-
managing the dysfunction and regaining control tional situations – as patients presenting with
of the UCM, the symptoms are affected in a posi- musculoskeletal problems may have altered corti-
tive way. cal maps and practice may be able to reverse these
Once the site and direction of UCM has been changes, reinforcing the need to take rehabilita-
identified, and is considered a significant factor tion into function (Van Vliet & Hennigan 2006).
in the presentation, then correction of the faulty Habitual movement patterns and postures have
movement strategy (site and direction of UCM) facilitatory influences on the central nervous
is the focus of rehabilitation (Roussel et al 2009). system (CNS) and re-enforcement of these pat-
This is not easy, but a clinical reasoning approach, terns of recruitment produces long-lasting neuro-
as described in Chapter 1 and earlier in this plastic changes. These patterns become so efficient
chapter, is essential if a good outcome is to be that we unconsciously use them automatically in
achieved. Box 1.4 in Chapter 1 described the normal function. Likewise the absence or the loss
analysis and clinical reasoning of movement of certain movement patterns or postures results
faults with 10 key points to understanding the in adverse neuroplastic change and the CNS
relationship between movement and pain. Figure appears to virtually ‘forget’ them so that we are
4.1 illustrates a paradigm of therapeutic exercise unable to use them efficiently in automatic or
goals and Box 4.1 outlines the clinical reasoning normal function unless we cognitively think
steps in therapeutic exercise prescription. about what we are doing.
The main focus should be on addressing the Other clinicians and researchers advocate the
four criteria of pain and dysfunction – as detailed integration of movement retraining into func-
in ‘clinical reasoning in a diagnostic framework’ tional tasks (O’Sullivan et al 1997; Jull et al 2002;
(Chapter 1). UCM may or may not be a signifi- Stuge et al 2004; O’Sullivan & Beales 2007) and
cant component. If UCM is a significant compo- have demonstrated the clinical effectiveness and
nent, then retraining control of the dysfunction/ importance of the integration of the retraining
impairment should be the key focus rather than movement control and specific stability muscle
administering a non-specific rehabilitation pro- activation into functional movements, activities
tocol. Motor control dysfunction has been identi- of daily living and even to high load activity and
fied in elite, highly trained individuals highlighting provocative positions.
the need to be able to identify this dysfunction Evidence suggests that postural habits can
(Hides et al 2008) rather than non-specific change automatic muscle activation patterns in
retraining. Chapter 3 described the assessment of unsupported sitting (Dankaerts et al 2006) and
UCM and this chapter has outlined retraining this supports the belief that movement patterns
principles and strategies (i.e. retraining control of need to be established in daily function and
the site and direction of UCM). This is often habits. This is particularly important in standing
started in a supported and non-functional posi- as sway postures have been shown to inhibit
tion. This non-functional retraining is often nec- the automatic recruitment of stability muscles
essary to establish recovery of efficient low (O’Sullivan et al 2002). Falla et al (2008) have
threshold recruitment. Once this is achieved, pro- demonstrated that retraining specific recruitment
gression into functional postures and positions is of the deep neck flexors does not automatically
essential. change muscle activity in sternocleidomastoid
(SCM) in an untrained functional task, suggesting
retraining needs to take place in functional posi-
tions with modification through retraining of
INTEGRATION INTO FUNCTIONAL TASKS functional activities.
AND ACTIVITIES The first goal should be establishing the correct
movement pattern or recruitment strategy; that
Functionally orientated exercises should be incor- is, regaining control of the UCM and then pro-
porated as early as possible to ensure both the gression by integrating the control of movement
feedforward and feedback mechanisms can be into functional activity. As a general rule, retrain-
integrated with the appropriate motor pattern. It ing should take place in functional positions
72
but if this demonstrates unwanted substitution has retrained this control), then rehabilitation
strategies then specific retraining is required can be progressed earlier and fast-tracked into
as detailed earlier in this chapter. It has been functional integration.
shown that ‘non-functional’ retraining can affect The process of stability retraining involves
dysfunction; for example, a persistent improve- elements of motor learning, movement aware-
ment in the feedforward activation of transversus ness and proprioception, skill acquisition and
abdominis can be achieved with training of neural plasticity. Figure 4.6 illustrates the pathway
isolated voluntary contraction (Tsao et al 2008). of correcting UCM with clinical assessment and
This study suggests that motor learning had retraining and finally integration into function.
occurred and changes been made within the
CNS established, which can then be accessed
during a functional task.
Retraining the site and direction of UCM
Figure 4.5 illustrates the progression of retrain-
ing the site and direction of UCM. If a patient is
unable to demonstrate efficient active control of
Control of site and
the UCM then rehabilitation needs to be directed YES
direction of UCM
towards training, highly specific, non-functional
movement patterns and strategies (such as dis-
sociation exercise) to regain control of the site
and the direction of the UCM. Training the ability
Fast track into
to demonstrate efficient active control of the site function
and the direction of the UCM ideally should be Integrate into
present before progressing into functional inte- functionally
gration. Functional movements use the strategies related exercises
and movement patterns that are currently auto-
matically used. If these current strategies and
movement patterns are already associated with
Non-functional
pain and dysfunction, then functional integra- retraining of the site
NO
tion, if emphasised too soon in a rehabilitation and direction of UCM
program, may contribute to maintaining these
aberrant patterns of movement. Alternatively, if
the patient can demonstrate efficient active Figure 4.5 Flow diagram for the integration of UCM
control of the site and direction of the UCM (or retraining into function
Process of motor control stability rehabilitation
Unconscious Conscious Conscious Unconscious

incapable incapable capable capable
Local and Functional

global retraining integration
Unaware of Aware of Learns to correct Automatically

dysfunction dysfunction dysfunction corrects dysfunction
Teach !!
test rate "!
‘Normal’ movement Unable to correct Able to correct ‘Normal’ movement

is dysfunctional dysfunction efficiently dysfunction efficiently has automatic control
Figure 4.6 The process of regaining conscious and eventual automatic control of the site and direction of uncontrolled
movement (adapted Strassl)
73
Initially, the person with chronic or recurrent into functional activities and automating recruit-
musculoskeletal pain, who has aberrant patterns ment. Of the four key criteria highlighted within
of recruitment, is unaware that they have UCM the clinical reasoning framework described in
contributing to their pain. The way they move Chapter 1, the assessment and management of
feels ‘normal’ to them, even thought it hurts. contextual factors is critical here. Because of indi-
Their ‘normal’ movement is dysfunctional. They vidual behavioural traits and psychosocial factors
lack conscious awareness of the problem and they there is no single strategy that is appropriate for
are unable to recruit a corrective strategy. On everyone. We have attempted to categorise various
clinical assessment of the UCM using the move- approaches in order to identify a processes that
ment control rating system (see Chapter 3) they can accommodate individual differences in moti-
achieve a score of ✗✗. vation and compliance.
After clinical assessment of the UCM the person Some patients benefit from a very structured
is now aware of the dysfunctional pattern of process with very clear goals and progressions.
movement, but is still often unable to correct the Other patients, however, do better with a non-
aberrant movement pattern. However, with some structured, more flexible process with an end goal
time spent retraining the aberrant movement, the but without a rigid step-by-step pathway. Some
person learns to correct the dysfunction. They are patients respond to specific motor control retrain-
now conscious of the UCM but are now able to ing where they think about, try to feel or visualise
correct the movement efficiently. They can tell the a specific muscle activating. Other patients do not
difference between good control and poor control seem to be able to do this but appear to get the
of the UCM. On clinical assessment of the UCM correct recruitment when they do not think about
using the movement control rating system they a specific muscle. Instead they seem to use non-
achieve a score of ✓✓. specific motor control strategies such as correct-
Although cognitive control of the UCM may be ing alignment or posture, controlling the site and
effective while the person is actively thinking direction of UCM, achieving a certain position or
about how to perform the corrective exercise, it moving in a certain way to get the recruitment
does not necessarily mean that this correction required.
automatically integrates into normal functional Various combinations of structured or non-
movement. For some people this integration structured approaches with specific or non-
does occur automatically, but for many people specific processes (Figure 4.7) can be used to
this integration is not automatic and requires optimise motivation and compliance in the per-
some functional integration training. The ideal formance of therapeutic exercise and movement
end result is that their normal functional move- retraining.
ment has automatic control. By this time, they do By finding the right combination of structured
not have to consciously think about correcting or non-structured and specific or non-specific
the UCM. motor control retraining strategies, the therapist
Motor control retraining can be effective in has many options available to find a combination
altering specific motor control deficits identified that will maintain motivation and achieve com-
in people with low back pain (O’Sullivan et al pliance for most patients.
1997a, 1998), cervical pain (Jull et al 2000), sac- Several applications of these options are pre-
roiliac joint pain (O’Sullivan et al 2007), head- sented below.
aches (McDonnell et al 2005; Van Ettekoven &
Lucas 2006; Amiri et al 2007), knee pain (Cowan
et al 2002), and can positively influence symp-
toms (Cowan et al 2002) and disability (Stuge Structured Non-structured
et al 2004; McDonnell et al 2005; Jull et al 2009).
Personality and behavioural traits

for motivation and compliance Specific Non-specific
One of the greatest challenges facing the therapist
is the integration of specific training regimens Figure 4.7 Strategies to enhance motor control retraining
74
Red dot functional integration Box 4.5 Alternative approaches useful in the
Rothstein (1982) has suggested that to integrate retraining of UCM
an activity or skill into normal, automatic or
unconscious function many repetitions must be Tai chi
performed under diverse functional situations. To Alexander technique
do this, some form of ‘reminder’ is needed. He Pilates
has proposed that small ‘red dots’ placed so that Yoga
they are frequently seen will ‘remind’ the subject Physio ball
to perform a specific task each time they are Feldenkrais
observed. Gyrotonic
When the red dot is sighted, the subject is
reminded to actively control the site and direc-
tion of UCM (or to perform a specific muscle
activation strategy). This process is repeated each site and direction of the UCM once the basic
time that a red dot is sighted. Place red dots in motor control recruitment has been established.
appropriate positions (e.g. wristwatch, clock, tele- Box 4.5 lists some of these approaches.
phone, coffee/tea making area, office drawer, The Pilates method was initially popularised by
bathroom mirror, red traffic light). Auditory (e.g. the dance community. It is a unique method
phone ringing), time-specific or activity-related incorporating body awareness and movement
reminders may be similarly appropriate. control and is based on established principles
(Isacowitz 2006). These are integrated with the
repertoire and recent literature has demonstrated
Low load (facilitatory) proprioceptive evidence supporting the value of many of these
stimulus principles. Table 4.2 illustrates evidence to
Providing a proprioceptive challenge can be a support some of them.
useful facilitation and progression strategy. The Therapists can develop skills in motor control
aim here is to facilitate stability muscle recruit- retraining and core stability training by under-
ment around neutral joint positions with auto- standing and applying the principles, repertoire
matic postural reflex responses and use unstable and adaptations of Pilates; for example:
bases of support. The eyes are open for initial • Language is client friendly and facilitatory;
training but as control improves the eyes can be for example, ‘tuck your chin in’ may be less
closed to rely on the muscle system for proprio- effective than the thought of ‘lengthening
ception. A balance board, the ‘Pilates reformer’ through the back of the neck’.
and the ‘physio ball’ are also appropriate and • Cues that target the auditory, kinaesthetic
useful tools. and visual learning.
• Cues can work on the somatic mind–body
integration (e.g. ‘float, soften, and lengthen’).
Integrative dissociation These cues encourage the ‘letting go’ of the
Once the basic recruitment skill to actively control global mobility muscles. In the literature
the site and direction of UCM has been estab- these muscles have been shown to be
lished, this strategy of controlling the region of dominant and overactive under low
dysfunction is incorporated with functionally threshold (functional) loading (Hungerford
orientated exercises where, so long as the problem et al 2003; Falla et al 2004; Richardson et al
region is controlled, any other movement is 2004).
appropriate. This can be built into an exercise • Eccentric control is emphasised and this is
program or just simply control the UCM while a requirement for good postural control.
performing functional tasks. • Maintaining control of the ‘centre’ is the key
for controlled movement. Joseph Pilates
called it the ‘powerhouse’ and advocated
Other approaches
bracing – this is appropriate for high loads
Many other approaches used in clinical practice but a modified activation of the abdominals
have great potential to assist the control of the is more appropriate for low load activity.
75
Table 4.2 Consistencies between Pilates principles • Joseph Pilates promoted the influence of
and neuromusculoskeletal research ‘mind, body and spirit’. ‘It’s the mind that
builds the body.’
Concentration Moseley (2004) has demonstrated a • Motor control learning is mindful exercise,
link between pain cognition and requiring the development of awareness
physical performance. through concentration and focus.
A higher sensation of effort • Its popularity may influence compliance.
(concentration) is required in subjects
The Pilates method traditionally focused on high
with proprioceptive deficits for efficient
activation of slow motor units (Grimby
load retraining, but in recent years this has been
& Hannerz 1976). modified to include low threshold motor control
training for the rehabilitation environment. Effec-
Breath O’Sullivan et al (2002) have identified tiveness of this approach has been demonstrated
altered motor control strategies and by Rydeard et al (2006).
alteration of respiratory function in
subjects with sacroiliac joint pain.
Roussel et al (2009c) have Use of training tools/equipment
demonstrated low back pain patients
exhibit altered breathing patterns The objective of training is to retrain the UCM
during performances in which trunk to effect symptoms, disability and dysfunction.
stability muscles are challenged. The use of tools and equipment to enhance the
control of movement is of great value to clinicians
Alignment O’Sullivan et al (2002) have
demonstrated that the lumbopelvic
(e.g. body blade, Pilates reformer, and gym ball).
stabilising musculature is active in However, the appropriate use of these tools is
maintaining optimally aligned erect paramount and they should only be used to
postures, and these muscle are less enhance the retraining process. Close observation
active during passive postures (slump of technique and control of movement are essen-
sitting and sway standing). tial if these tools are to be an effective adjunct to
Centre/control Van Dillen et al (2009) examined the retraining with the elimination of substitution
effect on symptoms of altering the strategies (Moreside et al 2007). One key point to
patient’s habitual movements and remember is when retraining UCM, low load (low
alignments of the lumbar spine. There threshold slow motor unit dominant recruitment)
was a significant reduction in is paramount and although it seems that the easy
symptoms when the lumbar spine is progression is to add load or resistance to the
supported in neutral during direction- exercise, this may not be an optimal progression
specific tests. initially for retraining control of the UCM. Low
load retraining is best progressed by challenging
low threshold recruitment (taking away load), not
by adding load or by cognitive activation in the
presence of a proprioceptive challenge.
• Maintaining appropriate alignment during
movement facilitates appropriate
recruitment.
Manual therapy
• A focus on breath control can help The value of integrating manual therapy tech-
encourage slow motor unit recruitment and niques into the management of movement dys-
retrain dysfunction. function must not be overlooked. Jull et al (2002)
• Flowing movements require efficient motor have demonstrated the value of manual therapy
control. in the management of headaches. There is some
• A ‘repertoire’ of linked multi-joint evidence that spinal manipulative therapy (SMT)
movements influences the whole body rather can change the functional activity of trunk
than just one segment. muscles in people with low back pain (LBP), sug-
• Concentration encourages the mind–body gesting that SMT can have an effect on motor
connection. neurone excitability (Ferreira et al 2007). The
• The mind–body connection can influence mechanism of how this may happen is unclear
pain (Moseley 2004). but could be a useful clinical tool assisting in
76
helping change motor recruitment patterns. therapist is reminded that the training period will
Indeed this research supports the need for a mul- also be influenced by interactions between the
timodal effect. patient’s health condition and contextual (envi-
Mulligan’s Mobilisations with Movement ronmental and personal) factors (Chapter 1).
(MWM) is a manual therapy treatment technique
in which a manual force, usually in the form of
a joint glide, is applied to a motion segment and Movement control retraining
sustained while a previously impaired action The movement control rating system (MCRS) is
(e.g. painful movement) is performed (Vicenzino used to diagnose the site and direction of UCM.
et al 2009). These techniques may well assist in This will support the clinical reasoning frame-
restoring normal movement patterns and have work and the development of the management
been shown to have an effect on the manage- plan (Chapter 1).
ment of musculoskeletal conditions (Vicenzino There are three key processes involved in man-
1993; Exelby 2001; Folk 2001; Vicenzino et al aging UCM (Table 4.3):
2009) but the mechanisms to date are poorly 1. retrain control of the site and direction of
understood. the UCM
Skin taping (e.g. adhesive sports tape, kinesio 2. retrain control of translation associated with
tape) can be a useful tool to facilitate recruitment the UCM
or control UCM (Constantinou & Brown 2010). 3. correct recruitment and length imbalances
associated with the UCM.
How long does training take?
The literature suggests that a training period of
8–20 weeks is necessary to change automatic CONCLUSION
‘unconscious’ motor control patterns (Stuge et al
2004; O’Sullivan & Beales 2007) and have a long- It is clear that there is a need to identify sub-
term effect on automatic or unconscious ‘normal’ groups within our patients who present with
function (Jull et al 2002; Stuge et al 2004). The pain, dysfunction, disability and contextual
Table 4.3 Three key processes for the retraining of UCM
Control of the site and direction Retrain control of the stability dysfunction in the direction of symptom-producing
of UCM movements. Use the low load integration of local and global stabiliser recruitment to
control and limit motion at the segment or region of UCM and then actively move
the adjacent restriction. Only move through as much range as the restriction allows or
as far as the UCM is dynamically controlled.
Control of translation Retrain tonic, low threshold activation of the local stability system to increase muscle
stiffness and train the functional low load integration of the local and global stabiliser
muscles to control the neutral joint position.
Retrain global stabiliser Retrain the global stability system to actively control the full available range of joint
control through range motion. These muscles are required to be able to actively shorten and control limb
load through to the full passive inner range of joint motion. They must also be able
Control of imbalance
to control any hypermobile outer range. The ability to control rotational forces is an
especially important role of global stabilisers. Eccentric control of range is more
important for stability function than concentric work. This is optimised by low effort,
sustained holds in the muscle’s shortened position with controlled eccentric lowering.
Regain extensibility and When the two-joint global mobility muscles demonstrate a lack of extensibility due to
inhibit excessive dominance overuse or adaptive shortening, compensatory overstrain or UCM occurs elsewhere in
of the global mobilisers the kinetic chain in an attempt to maintain function. It becomes necessary to
lengthen or inhibit overactivity in the global mobiliser muscles to eliminate the need
for compensation to keep function.
77
Box 4.6 Key factors to help the therapist retrain UCM in practice
• Use clinical reasoning to help you with the decision- • Use this knowledge to empower the patient to better
making process (Chapter 1). manage their own condition.
• Work on your observation skills and review again • Consider how the local and global muscle function
once you have established the site and direction contributes to the control of movement.
test results – this will help you confirm what • Consider carefully how you prioritise your management
you see. – symptoms, disability and dysfunction need to be
• Be specific with your training and exercise prescription. addressed at the same time.
• Ensure your patient understands the link between UCM • Use the same principles to address risk of injury and
and their presenting signs and symptoms. performance issues related to movement dysfunction
• Discuss the diagnostic framework with them and how (Mottram & Comerford 2008).
each component relates to their symptoms: • Remember facilitating and retraining movement is a skill
– site and direction of UCM and needs practice! … and gaining compliance is an art
– presenting pathology and symptomatic tissues as much as a science.
– pain mechanisms • Consider how you can adapt the retraining to suit the
patient with tools and other retraining approaches (e.g.
– contextual factors.
Pilates).
psychosocial factors that influence their function be used as clinical reference guides as well as for
and lifestyle. If UCM is a feature in presentation academic study and for use on movement analy-
of the symptoms, dysfunction, disability, recur- sis and training courses. To this end, there is a
rence, risk of injury and performance issues, certain amount of repetition in the description of
then an appropriate assessment and retraining is each movement test and retraining. This repeti-
appropriate. Box 4.6 highlights some key practi- tion maintains consistency and completeness
cal guidelines. while allowing the user to quickly refer to any
The following section (Chapters 5–9) details a movement test and its retraining options and
comprehensive assessment of UCM for the access all of the relevant information without
lumbar spine, cervical spine, thoracic spine shoul- having to search for background information at
der and hip. These chapters have been written to the beginning of each chapter.
REFERENCES
Amiri, M., Jull, G., Bullock-Saxton, J., Constantinou, M., Brown, M., 2010. Exelby, L., 2001. The locked lumbar
Darnell, R., Lander, C., 2007. Therapeutic taping for facet joint intervention using
Cervical musculoskeletal impairment musculoskeletal conditions. mobilisations with movement.
in frequent intermittent headache. Churchill Livingstone, Edinburgh. Manual Therapy 6 (2), 116–
Part 2: subjects with concurrent Cowan, S.M., Bennell, K.L., Crossley, 121.
headache types. Cephalalgia 27 (8), K.M., Hodges, P.W., McConnell, J., Falla, D., Bilenkij, G., Jull, G., 2004.
891–898. 2002. Physical therapy alters Patients with chronic neck pain
Brosseau, L., Macleay, L., Welch, V., recruitment of the vasti in demonstrate altered patterns of
Tugwell, P., Wells, G.A., 2003. patellofemoral pain syndrome. muscle activation during
Intensity of exercise for the Medicine and Science in Sports and performance of a functional upper
treatment of osteoarthritis. Cochrane Exercise 34 (12), 1879–1885. limb task. Spine 29 (13),
Library Issue 2, Update Software, Dankaerts, W., O’Sullivan, P., Burnett, 1436–1440.
Oxford. A., Straker, L., 2006. Differences in Falla, D., O’Leary, S., Fagan, A., Jull, G.,
Comerford, M.J., Mottram, S.L., 2010. sitting postures are associated with 2007. Recruitment of the deep
Understanding movement and nonspecific chronic low back pain cervical flexor muscles during a
function – assessment and retraining disorders when patients are postural-correction exercise
of uncontrolled movement. Course subclassified. Spine 31 (6), 698– performed in sitting. Manual
Notes, Kinetic Control, UK. 704. Therapy 12 (2), 139–143.
78
Falla, D., Jull, G., Hodges, P., 2008. the deep cervical flexor muscles in postures on trunk muscle activity in
Training the cervical muscles with people with chronic neck pain. a pain-free population. Spine 27
prescribed motor tasks does not Manual Therapy 14 (6), 696–701. (11), 1238–1244.
change muscle activation during a Kay, T.M., Gross, A., Goldsmith, C., O’Sullivan, P.B., Beales D.J., 2007.
functional activity. Manual Therapy Santaguida, P.L., Hoving, J., Bronfort, Changes in pelvic floor and
13 (6), 507–512. G., 2005. Exercises for mechanical diaphragm kinematics and
Ferreira, M.L., Ferreira, P.H., Hodges, neck disorders. Cervical Overview respiratory patterns in subjects with
P.W., 2007 Changes in postural Group. Cochrane Database sacroiliac joint pain following a
activity of the trunk muscles Systematic Review July 20 (3), motor learning intervention: a case
following spinal manipulative CD004250. series. Manual Therapy 12 (3),
therapy. Manual Therapy 12 (3), Luomajoki, H., Kool, J., de Bruin, E.D., 209–218.
240–248. Airaksinen, O., 2008. Movement Pelland, L., Brosseau, L., Wells, G.,
Folk, B., 2001. Traumatic thumb injury control tests of the low back: Maclearly, L., Lambert, J., Lamonthe,
management using mobilization evaluation of the difference between C., et al., 2004. Efficacy of
with movement. Manual Therapy 6 patients with low back pain and strengthening exercises for
(3), 178–182. healthy controls. BMC osteoarthritis (part 1) a meta-
Frost, H., 1998. Exercise for patients Musculoskeletal Disorders 9, analysis. Physical Therapy
with low back pain. Spine 23 (4), 170. Reviews 9, 77–108.
508. McDonnell, M.K., Sahrmann, S.A., Van, Richardson, C., Hodges, P., Hides, J.,
Green, S., Buchbinder, R., Hetrick, S., D.L., 2005. A specific exercise 2004. Therapeutic exercise for
2003. Physiotherapy intervention for program and modification of lumbopelvic stabilization. Churchill
shoulder pain. Cochrane Library postural alignment for treatment of Livingstone, Edinburgh.
Issue 2, Update Software, Oxford. cervicogenic headache: a case report. Rothstein, J.M.1982. Muscle biology
Grimby, L., Hannerz, J., 1976. Journal of Orthopaedic and Sports clinical considerations. Physical
Disturbances in voluntary Physical Therapy 35 (1), 3–15. Therapy 62 (12), 1823–1830.
recruitment order of low and high Moreside, J.M., Vera-Garcia, F.J., McGill, Roussel, N.A., Nijs, J., Mottram, S., Van
frequency motor units on blockades S.M., 2007. Trunk muscle activation Moorsel, A., Truijen, S., Stassijns, G.,
of proprioception afferent activity. patterns, lumbar compressive forces, 2009a. Altered lumbopelvic
Acta Physiologica Scandinavica 96, and spine stability when using the movement control but not
207–216. bodyblade. Physical Therapy 87 (2), generalised joint hypermobility is
Hayden, J.A., van Tulder, M.W., 153–163. associated with increased injury in
Tomlinson, G., 2005. Systematic Moseley, G.L., 2004. Evidence for a dancers. A prospective study. Manual
review: strategies for using exercise direct relationship between cognitive Therapy 14 (6), 630–635.
therapy to improve outcomes in and physical change during an Roussel, N.A., Daenen, L., Vissers, D.,
chronic low back pain. Annals of education intervention in people Lambeets, D., Schutt, A., Van
Internal Medicine 142 (9), 776– with chronic low back pain. Moorsel, A., et al., 2009b. Motor
785. European Journal of Pain 8 (1), control and physical fitness training
Hides, J.A., Stanton, W.R., McMahon, S., 39–45. to prevent musculoskeletal injuries
Sims Richardson, C.A., 2008. Effect Mottram, S.L., Comerford, M., 2008. A in professional dancers. 3rd
of stabilization training on new perspective on risk assessment. International Conference on
multifidus muscle cross-sectional Physical Therapy in Sport 9 (1), Movement Dysfunction, Edinburgh,
area among young elite cricketers 40–51. UK. 30 October–1 November.
with low back pain. J Orthop Sports O’Sullivan, P.B., Twomey, L., Allison, G., Manual Therapy 14, 1 pS22.
Phys Ther 38 (3), 101–108. 1997. Evaluation of specific Roussel, N., Nijs, J., Truijen, S.,
Hungerford, B., Gilleard, W., Hodges, P., stabilising exercises in the treatment Vervecken, L., Mottram, S., Stassijns,
2003. Evidence of altered of chronic low back pain with G., 2009c. Altered breathing patterns
lumbopelvic muscle recruitment in radiological diagnosis of spondylosis during lumbopelvic motor control
the presence of sacroiliac joint pain. or spondylolisthesis. Spine 22 (24), tests in chronic low back pain: a
Spine 28 (14), 1593–1600. 2959–2967. case-control study. European Spine
Isacowitz, R., 2006. Pilates. Champaign, O’Sullivan, P., Twomey, L., Allison, G., Journal 18 (7), 1066–1073.
IL: Human Kinetics, pp. 1–42. 1998. Altered abdominal muscle Rydeard, R., Leger, A., Smith, D., 2006.
Jull, G., Trott, P., Potter, H., Zito, G., recruitment in back pain patients Pilates-based therapeutic exercise:
Niere, K., Shirley, D., et al., 2002. A following specific exercise effect on subjects with nonspecific
randomized controlled trial of intervention. Journal of Orthopaedic chronic low back pain and
exercise and manipulative therapy and Sports Physical Therapy 27(2): functional disability: a randomized
for cervicogenic headache. Spine 27 114–124 controlled trial. Journal of
(17), 1835–1843. O’Sullivan, P.B., Grahamslaw, K.M., Orthopaedic and Sports Physical
Kendell, M., Lapenskie, S.C., Moller, Therapy 36 (7), 472–484.
Jull, G.A., Falla, D., Vicenzino, B.,
Hodges, P.W., 2009. The effect of N.E., Richards, K.V., 2002. The effect Stuge, B., Veierod, M.B., Laerum, E.,
therapeutic exercise on activation of of different standing and sitting Vollestad, N., 2004. The efficacy of a
79
treatment program focusing on low back pain. A pragmatic, of musculoskeletal dysfunction.

specific stabilizing exercises for randomized, single-blinded, Manual Therapy 11 (3), 208–213.
pelvic girdle pain after pregnancy: a controlled trial with 1-year follow-up. Vicenzino, B., 2003. Lateral
two-year follow-up of a randomized Spine 23 (23), 2616–2624. epicondylalgia: a musculoskeletal
clinical trial. Spine 29 (10), Tsao, H., Hodges, P.W., 2008. physiotherapy perspective. Manual
E197–E203. Persistence of improvements in Therapy 8 (2), 66–79.
Tate, A.R., McClure, P., Kareha, S., Irwin, postural strategies following motor Vicenzino, B., Smith, D., Cleland, J.,
D., 2008. Effect of the scapula control training in people with Bisset, L., 2009. Development of a
reposition test on shoulder recurrent low back pain. Journal of clinical prediction rule to identify
impingement symptoms and Electromyography and Kinesiology initial responders to mobilisation
elevation in overhead athletes. 18 (4), 559–567. with movement and exercise for
Journal of Orthopaedic and Sports Van Dillen, L.R., Maluf, K.S., Sahrmann, lateral epicondylalgia. Manual
Physical Therapy 38 (1), 4–11. S.A., 2009. Further examination of Therapy 14 (5), 550–554.
Taylor, N.F., Dodd, K.J., Shields, N., modifying patient-preferred von Eisenhart-Rothe, R., Matsen 3rd.,
Bruder, A., 2007. Therapeutic exercise movement and alignment strategies F.A., Eckstein, F., Vogl, T., Graichen,
in physiotherapy practice is in patients with low back pain H., 2005. Pathomechanics in
beneficial: a summary of systematic during symptomatic tests. Manual a-traumatic shoulder instability:
reviews 2002–2005. Australian Therapy 14 (1), 52–60. scapular positioning correlates with
Journal of Physiotherapy 53 (1), van Ettekoven, H., Lucas, C., 2006. humeral head centering. Clinical
7–16. Efficacy of physiotherapy including a Orthopaedics and Related Research
Torstensen, T.A., Ljunggren, A.E., Meen, craniocervical training programme (433), 82–89.
H.D., Odland, E., Mowinckel, P., for tension-type headache; a Waddell, G., 2004. The back pain
Geijerstam, S., 1998. Efficiency and randomized clinical trial. revolution. Churchill Livingstone,
costs of medical exercise therapy, Cephalalgia 26 (8), 983–991. Edinburgh.
conventional physiotherapy, and Van Vliet, P.M., Heneghan, N.R., 2006.
self-exercise in patients with chronic Motor control and the management
80
Section 2
81
CHAPTER 5
THE LUMBOPELVIC REGION
Flexion (posterior pelvic tilt) control

T1 Standing: trunk lean test 93
T2 4 point: backward push test 97
T3 Crook: double bent leg lift test 100
T4 Sitting: forward lean test 106
T5 Sitting: chest drop test 109
T6 Sitting: double knee extension test 113
T7 Stand to sit: ischial weight bearing test 116
Extension (anterior pelvic tilt/pelvic sway) control

T8 Standing: thoracic extension (SWAY) test 124
T9 Standing: thoracic extension (TILT) test 128
T10 Sitting: chest lift (TILT) test 132
T11 Sitting: forward lean test 137
T12 4 point: forward rocking test 140
T13 Crook: double bent leg lower test 144
T14 Prone: double knee bend test 149
T15 Prone: hip extension lift test 153
T16 Standing: hip extension toe slide test 157
Rotation/side-bend (open chain) control

T17 Supine: single heel slide test 164
T18 Supine: bent knee fall out test 169
T19 Side-lying: top leg turn out test 174
T20 Prone: single hip rotation test 178
T21 Prone: single knee flexion test 183
T22 Prone: hip extension lift test 186
T23 Sitting: single knee extension test 189
Rotation/side-bend (closed chain) control

T24 Crook lying: single leg bridge extension test 192
T25 Standing: thoracic rotation test 196
T26 Standing: double knee swing test 200
T27 Standing: trunk side-bend test 206
T28 Standing: pelvic side-shift test 210
Chapter 5
The lumbopelvic region
need for further research and clinical develop-

INTRODUCTION ments (Airaksinen et al 2006).
This chapter sets out to explore the assessment
There is rapidly growing acceptance among clini- and retraining of uncontrolled movement (UCM)
cians and researchers that the development of in the lumbopelvic region. Understanding the
movement-based diagnostic frameworks is the development of lumbopelvic UCM and the
way forwards in managing chronic and recurrent process of assessment and diagnostic classifica-
low back pain (LBP). The systems most supported tion of lumbopelvic UCM are integral steps in
by evidence are those that examine inter- retraining control of lumbopelvic pain provoca-
relationships between altered patterns of muscle tive movements and postures. Before details of
recruitment and motor control strategies and the assessment and retraining of UCM in the lum-
establish a direction-based mechanism of provo- bopelvic region are explained, a brief review of
cation or relief of symptoms (Sahrmann 2002; changes in movement and postural control in the
Dankaerts et al 2006; Luomajoki et al 2008; Van region is presented.
Dillen et al 2009; Vibe Fersum et al 2009). In the
lumbar spine, this approach is now well estab- Changes in movement and postural
lished. In the management of non-specific low
back pain, the subgrouping and classification of
control in the lumbopelvic region
patients’ symptoms based on the assessment of Different postural positions have been shown to
movement and motor control has become more alter trunk muscle activation (O’Sullivan et al
important than trying to identify a pathology- 2002a; O’Sullivan et al 2006). In particular a
based diagnosis (Sahrmann 2002; Fritz et al lumbopelvic upright posture (with a maintained
2007; Gombatto et al 2007). The influence of lumbar lordosis and some anterior pelvic tilt)
movement faults on pain has been illustrated recruits more of the internal oblique and superfi-
(Van Dillen et al 2009) and a link between cial multifidus muscles than does an upright
the direction of uncontrolled motion in low posture of thoracic extension, where there is less
threshold motor control testing and pain pro- lumbar extension and anterior pelvic tilt, less
vocative movements identified (Sahrmann 2002; superficial multifidus and internal oblique recruit-
O’Sullivan 2005; Dankaerts et al 2006; Luoma- ment and more erector spinae activation. Simi-
joki et al 2008; Vibe Fersum et al 2009). Research larly, sway standing postures and slump sitting
to date highlights the poor to moderate treatment postures decrease activity in the internal oblique
effects with current intervention strategies for and multifidus muscles and sway standing
chronic specific low back pain, highlighting the increases the activity in rectus abdominis. These

DOI: 10.1016/B978-0-7295-3907-4.00005-0 83
changes in muscle recruitment patterns have been lumbar spine in a neutral position during move-
linked to the presence of lumbopelvic pain (Sahr- ment similar to the principles discussed in Chap-
mann, 2002; O’Sullivan 2005; Dankaerts et al ters 3 and 4. The modifications resulted in a
2006; O’Sullivan et al 2002b, 2003, 2006). decrease in symptoms in the majority of patients.
Changes in the alignment of the lumbar spine This illustrates a classification system of subjects
have been noted in subjects with flexion-related with LBP based on the direction(s) of alignment
lumbar pain (O’Sullivan et al 2006). These people and movement consistently associated with a
sit with their lumbar spines closer towards the change in symptoms.
end of flexion range and with more posterior Luomajoki et al (2008) demonstrated signifi-
pelvic tilt than healthy pain-free controls. Inter- cant differences between healthy people without
estingly they also had reduced back muscle endur- back pain and back pain subjects in their ability
ance compared to the controls, suggesting a link to control movement in the lumbar spine using
between changes in muscle function and changes a battery of six movement control tests (Luoma-
in postural position. Differences in sitting pos- joki et al 2008). These six tests (all of which are
tures and control of the lumbar neutral position described later in this chapter), are based on cog-
have been identified in patients with back pain nitively controlling lumbar flexion, lumbar exten-
(Trudelle-Jackson et al 2008). sion and lumbopelvic rotation. The back pain
Segmental dysfunction has been identified in subjects failed a significantly greater proportion
low back pain subjects with uncontrolled seg- of these tests than the healthy people. The ability
mental movement noted around the neutral to perform these six movement control tests can
zone, as described by Panjabi (1992), during reveal differences between subjects with chronic
lumbar flexion (Teyhen et al 2007). The dysfunc- low back pain and subjects with acute or subacute
tional movement occurs during the early part of pain (Luomajoki et al 2008).
movement when the motion should be under
neuromuscular control and not at end of range Reliability of movement observation
where the passive osteoligamentous system con-
tributes to stability. These changes illustrate alter- The reliability of therapist observation to identify
ations in control of segmental motion. UCM and to make consistent clinical judgements
Gombatto et al (2007) have identified different based on movement observation has significant
patterns of lumbar region movement during support. Van Dillen et al (2009), Dankaerts et al
trunk lateral bending in two subgroups in people (2006), Luomajoki et al (2007), Vibe Fersum
with LBP. In people with patterns of uncontrolled et al (2009) and Roussel et al (2009) have all
extension and rotation, the lumbar region dem- demonstrated good intra-tester and inter-tester
onstrated asymmetry in movement and contrib- reliability for observational assessment of a
uted more to trunk lateral bend particularly in the patient’s ability to perform cognitively learned
early stages of lateral bending on one side. They movement patterns or motor control tests of
suggest that this lumbar region movement will movement control. Van Dillen et al (2009) and
unilaterally load one or more lumbar segments Morrissey et al (2008) have further demonstrated
and repeated stress on the tissues during func- that therapist observation correlates closely with
tional movements which involve side-bend, will 3D motion analysis.
cause cumulative stress of the lumbar region and
eventually result in pain. Efficacy of treatment to retrain
Van Dillen et al (2009) demonstrated that
control of lumbopelvic UCM
movement tests can provoke symptoms in people
with LBP. These researchers explored the effect of The efficacy of retraining the activation of muscles
modifying, or ‘correcting’, symptomatic align- that contribute to lumbopelvic stability is well
ment or movement in people with LBP. This was supported (Hides et al 2001; Hodges 2003;
done by correcting the spinal alignment or move- O’Sullivan 2005; Tsao & Hodges 2008; Luoma-
ment that occurred when symptoms were pro- joki et al 2010). More recently there is evidence
voked. The modifications involved: i) restricting from randomised clinical trials (RCTs) that
movement of the lumbar spine while encourag- retraining programs which focus on motor control
ing movement elsewhere (e.g. thoracic spine or are beneficial (Macedo et al 2009). Stabilising
hip); and ii) positioning and maintaining the exercises have been shown to have an effect on
84
The lumbopelvic region Chapter |5|
pain and disability (O’Sullivan et al 1997; can identify subgroups within the non-specific
Moseley 2002; Stuge et al 2004) and can effec- musculoskeletal pain population. These UCM
tively reduce recurrence of back pain at long term can be retrained and correction of these aberrant
follow-up (Hides et al 2001). Specific recruitment movement patterns has been advocated as an
of these deep stability muscles seems to be an effective treatment intervention. This chapter
important part of retraining (Hall et al 2007). details the assessment of UCM at the lumbo-
Motor control impairment during functional pelvic region and describes relevant retraining
movement tasks can change following a motor strategies.
learning intervention (Dankaerts et al 2007;
O’Sullivan & Beales 2007a). Once the site and
direction of UCM have been identified specific DIAGNOSIS OF THE SITE AND
muscle retraining can be used to retrain control
of the dysfunction. For example, ‘drawing in’ the DIRECTION OF UCM IN THE
abdominal wall, to activate the deep abdominal LUMBAR SPINE
muscles, has been shown to decrease erector
spinae activity and increase gluteus maximus The diagnosis of the site and direction of UCM in
activity in prone hip extension lift test (Oh et al the lumbar spine can be identified in terms of the
2007). site (being lumbar) and the direction of flexion,
In subjects with spondylosis and spondylo- extension and rotation/side-bend (asymmetry)
listhesis, lumbopelvic stability training has (Table 5.1). As with all UCM, the motor control
resulted in decreased pain intensity and pain deficit can present as uncontrolled translational
descriptor scores and improvements in functional movement (e.g. spondylolisthesis at L5–S1) or
disability levels (O’Sullivan et al 1997). Exercise uncontrolled range of functional movement (e.g.
interventions have been described based on the lumbar flexion) (Sahrmann 2002; O’Sullivan
evaluation of spinal alignment with postures and 2005).
during active movements of both the spine and A diagnosis of UCM requires evaluation of its
the extremities (Maluf et al 2000; Van Dillen et al clinical priority. This is based on the relationship
2009). Their treatment approach is to teach the between the UCM and the presenting symptoms.
patient specific strategies to reduce the symptoms The therapist should look for a link between the
associated with movements to enable them to direction of UCM (‘give’) and the direction of
perform activities they would otherwise avoid. symptom provocation: a) Does the site of UCM
Aberrant motor control strategies have also relate to the site or joint that the patient com-
been identified in people with sacroiliac joint plains of as the source of symptoms? b) Does the
(SIJ) and pelvic girdle pain. O’Sullivan et al direction of movement or load testing relate to
(2002b) observed abnormal kinematics of the the direction or position of provocation of symp-
diaphragm and pelvic floor during an active toms? This identifies the clinical priorities.
straight leg raise test in subjects with SIJ pain, and The site and direction of UCM at the lumbar
noted that these aberrant motor control strategies spine can be linked with different clinical presen-
could be eliminated with manual compression tations, postures and activities aggravating symp-
during the test. In addition these people demon- toms. The typical assessment findings in the
strated bracing strategies in the abdominal wall lumbar spine are identified in Table 5.2.
not seen in the non-pain group. Transversus
abdominis recruitment has been shown to
increase sacroiliac joint stiffness to a significantly
greater degree than the general abdominal exer-
cise pattern illustrating the stability role that this Table 5.1 Site and direction of UCM in the lumbar
muscle has on the SIJ (Richardson et al 2002). spine
People with musculoskeletal pain demonstrate
consistent changes in muscle recruitment pat- SITE DIRECTION
terns during the performance of functional move-
Lumbar • Flexion
ments and postural control tasks. There is evidence
• Extension
to support that assessment and classification of • Rotation/side-bend
these aberrant uncontrolled movement patterns
85
Table 5.2 The link between the site and direction of UCM and different clinical presentations
SITE AND DIRECTION OF SYMPTOM PRESENTATION PROVOCATIVE MOVEMENTS,

UCM POSTURES AND ACTIVITIES
LUMBAR FLEXION UCM • Presents with symptoms in the lumbar Symptoms provoked by flexion
Can present as: spine movements and postures (especially
• segmental flexion hinge (usually • May present with a segmental if repetitive or sustained)
at L5–S1, occasionally at L4–5 or localised pain pattern For example, sustained sitting,
L3–4) • ±Radicular pain from myofascial and bending forwards, driving, lifting,
• multisegmental hyperflexion articular structures sleeping supine on a soft bed
(involving all lumbar levels) • ±Referral from neural tissue
LUMBAR EXTENSION UCM • Presents with symptoms in lumbar Symptoms provoked by extension
Can present as: spine movements and postures (especially
• segmental extension hinge • May present with a segmental if repetitive or sustained)
(usually at L5–S1, occasionally at localised pain pattern For example, walking (especially
L4–5 or L3–4) • ±Radicular pain from myofascial and downhill), looking up, reaching
• multisegmental hyperextension articular structures overhead, sustained standing, lying
(involving all lumbar levels) • ±Referral from neural tissue prone
LUMBOPELVIC ROTATION/ • Presents with unilateral symptoms ± Unilateral symptoms provoked by
SIDE-BEND UCM unilateral radicular symptoms movements or sustained postures
(asymmetry superimposed on any • Coupled with any of the above flexion away from the midline
of the above flexion or extension or extension uncontrolled movements For example, rotation or side-bend
UCM) • Symptoms can be localised to either a with symptoms usually worse in one
Can present as: single segment or generalised across direction more than another
• uncontrolled rotation or the whole multisegmental lumbar Unilateral symptoms provoked by
side-bend in the lumbar spine. region either flexion or extension activities
The rotation or side-bend UCM or sustained postures linked to the
is usually unilateral (i.e. more above UCM
pronounced to either the right
or left side)
• can present bilaterally
Segmental UCM
IDENTIFYING SITE AND DIRECTION
A single segment UCM may appear to ‘hinge’ into
OF UCM AT THE LUMBAR SPINE
excessive translatory displacement associated
with the flexion (segmental ‘flexion hinge’) or
The key principles for assessment and classifica- extension (segmental ‘extension hinge’). This is
tion of UCM have previously been described in observed as either a ‘hinge’ or ‘pivot point’ or
Chapter 3. All dissociation tests are performed excessive translational shear during motion
with the lumbar spine in the neutral training testing. Identification of segmental UCM phe-
region. nomena is described below.
A segmental flexion hinge (which opens poster-
Segmental and multi-segmental iorly and translates backwards) can be identified
in motion testing in the following ways:
uncontrolled motion in the sagittal
1. Place a short piece of adhesive strapping tape
plane
across the primary hinging segment. The skin
When direction-specific, uncontrolled sagittal is tensioned from the adjacent segment
motion (flexion or extension) is observed in the below to the adjacent segment above. If the
spine, it can present in two ways. The uncon- subject cannot prevent flexion across this
trolled motion can present as either a segmental segment, the tape pulls off the skin when
UCM or a multisegmental UCM. uncontrolled flexion is produced.
86
2. Place one finger tip on the spinous process reversal of the lordosis curve when instructed
of the primary hinging segment and another to prevent flexion.
finger tip on the spinous process of each 2. Place a long piece of adhesive strapping tape
adjacent segment (above and below). If the across the entire group of spinal segments
subject is unable to prevent flexion at this (e.g. whole lumbar lordosis L1–S1). The skin
segment the therapist palpates uncontrolled is tensioned from the lowermost segment
opening (spinous processes moving apart). (below) to the uppermost segment. If the
A segmental extension hinge (which closes subject cannot prevent flexion across this
poster-iorly and translates forwards) can be iden- multisegmental group, the tape pulls off the
tified in motion testing in the following ways: skin when uncontrolled flexion motion is
1. Place one finger tip on the spinous process
produced.
of the primary hinging segment. During A multisegmental hyperextension can be identi-
normal extension the spinous process can be fied in motion testing in the following ways:
palpated moving slightly forwards (as the 1. Observe or palpate the multisegmental group
articular surfaces close and compress), then of spinal segments (e.g. whole lumbar
the spinous process is palpated moving lordosis L1–S1). The therapist relies on
backwards and down as the articular surface visual observation or manual palpation to
of the upper segment glides backwards on identify if the subject cannot maintain a
the lower segment. If the subject is unable to neutral lordosis and prevent extension
prevent extension or translation shear at this during the test movement. The subject
segment the therapist palpates uncontrolled demonstrates an increase in the depth or
and excessive forward displacement of the exaggeration of the lordosis curve when
spinous process during active extension instructed to prevent extension.
(spinous process moving forwards too far) 2. Place a long piece of adhesive strapping tape
and a lack of sufficient backward glide. across the anterior abdomen (e.g. from the
2. Place one finger tip on the spinous process ASIS (anterior superior iliac spine) to the
of the primary hinging segment and another lower anterolateral ribcage or along the
finger tip on the spinous process of each rectus abdominis muscle). The skin is
adjacent segment (above and below). If the tensioned from the lowermost attachment
subject is unable to prevent extension at this (below) to the uppermost attachment. If the
segment the therapist palpates uncontrolled subject cannot prevent spinal extension or
closing (spinous processes moving together) anterior pelvic tilt across this multisegmental
during lumbar spine extension. group, the tape pulls off the skin when
uncontrolled extension motion is produced.
Occasionally, both single segment and multi-
Multisegmental UCM segmental dysfunctions can present together.
A multisegmental UCM demonstrates hypermo-
bile motion into flexion (multisegmental ‘hyper-
flexion’) or into extension (multisegmental CLINICAL EXAMPLES
‘hyperextension’) across a group of adjacent ver-
tebral levels. This is observed as either an exag-
Lumbar extension UCM
geration of the spinal curve or hypermobile range.
A multisegmental hyperflexion can be identified The patient complains of extension-related symp-
in motion testing in the following ways: toms in the lumbar spine. The lumbar spine dem-
1. Observe or palpate the multisegmental group onstrates UCM into extension relative to the hips
of spinal segments (e.g. whole lumbar or thoracic spine under extension load. During a
lordosis L1–S1). The therapist relies on motor control test of active hip or thoracic exten-
visual observation or manual palpation to sion where the instruction is to prevent lumbar
identify if the subject cannot maintain a extension (dissociation), the lumbopelvic region
neutral lordosis and prevent flexion during demonstrates UCM into either:
the test movement. The subject demonstrates • segmental extension hinge – uncontrolled
a decrease in the depth or flattening or segmental extension and translational shear
87
at a pivot point (primarily at L5–S1, but between the sacrum and the innominates. Reports
potentially also at L3–4–5) vary, but it is generally accepted that there are
or approximately 2–6° of rotation and 2 mm of
translation (Sturesson et al 1989; Bogduk 1997;
• multisegmental hyperextension –
Lee 2004). These small ranges of motion are only
uncontrolled lumbar hyperextension and
able to be measured with specialised radiographic
exaggerated anterior tilt.
techniques (Sturesson et al 1989). Consequently,
During the attempt to dissociate the lumbar spine it is not possible to visually measure this range of
from independent hip or thoracic extension, the motion and therefore not reliable to evaluate the
subject either cannot control the lumbar exten- site and direction of sacroiliac motion visually.
sion UCM or has to concentrate and try too hard. However, the muscles that provide movement
control and functional stability for the lumbar
Lumbar flexion UCM spine and the hip also appear to be effective in
controlling movement and stability of the SIJ and
The patient complains of flexion related symp- pelvis. Aberrant motor control strategies involv-
toms in the lumbar spine. The lumbar spine dem- ing these muscles also have the potential to con-
onstrates UCM into flexion relative to the hips or tribute to pelvic girdle pain and dysfunction,
thoracic spine under flexion load. During a motor hence strategies to promote movement control
control test of active hip or thoracic flexion where and functional stability in the lumbar spine may
the instruction is to prevent lumbar flexion (dis- have a positive effect on reducing sacroiliac and
sociation), the lumbopelvic region demonstrates pelvic girdle pain.
UCM into either:
• segmental flexion hinge – uncontrolled Identifying UCM at the SIJ
segmental flexion and translational shear at
and pelvis
a pivot point (primarily at L5–S1)
or Aberrant motor control strategies have been iden-
tified in people with SIJ and pelvic pain. O’Sullivan
• multisegmental hyperflexion – uncontrolled
et al (2002b) observed abnormal kinematics of
lumbar hyperflexion and exaggerated
the diaphragm and pelvic floor during an active
posterior tilt.
straight leg raise test in subjects with SIJ pain, and
During the attempt to dissociate the lumbar spine noted that these aberrant motor control strategies
from independent hip or thoracic flexion, the could be eliminated with manual compression
subject either cannot control the lumbar flexion during the test. In addition, these people demon-
UCM or has to concentrate and try too hard. strated bracing strategies in the abdominal wall
not seen in the non-pain group. Transversus
abdominis recruitment has been shown to
MOVEMENT AND POSTURAL increase SIJ stiffness to a significantly greater
degree than the general abdominal exercise
CONTROL AT THE SACROILIAC pattern, illustrating the stability role that this
JOINT (SIJ) AND PELVIS muscle has on the SIJ (Richardson et al 2002).
Evaluation of the presence of SIJ dysfunction
The relationship between SIJ or pelvic girdle pain has historically been difficult to evaluate (Riddle
and insufficiencies in the stability of the lum- & Freburger 2002). Laslett et al (2005) have dem-
bopelvic region is currently an active area of onstrated that composites of provocation tests are
research (Hungerford et al 2003; Stuge et al 2004; of value in clinical diagnosis of the symptomatic
O’Sullivan & Beales 2007b). The classification of SIJ but do not evaluate movement faults or guide
UCM in terms of site and direction at the SIJ and diagnosis. Some authors have reconsidered the
pelvis is gaining recognition and reports of label- influence on force closure but not detailed spe-
ling movement and positional faults can be seen cific assessment of movement faults (Pool-
in the literature (Cibulka 2002). Goudzwaard 1998). O’Sullivan & Beales (2007a)
The range of motion that is available to the SIJ have recognised that movement faults can be a
is very small in terms of translation and rotation part of SIJ dysfunction but do not detail the site
88
and direction of UCM. Altered motor control Table 5.3 Potential site and direction of UCM in the
strategies and alteration of respiratory function pelvic girdle
have been identified in subjects with sacroiliac
pain (O’Sullivan & Beales 2007a). Hungerford SITE DIRECTION
et al (2003) have indentified delayed onset of
internal oblique, multifidus and gluteus maximus Forward torsion
on the supporting leg during hip flexion in sub- Sacrum Backward torsion
jects with SIJ changes, which they consider evi- Nutated and side-bent (unilateral flexion)
dence of altered lumbopelvic control. Muscle Counternutated and side-bent (unilateral
recruitment dysfunction has been shown to be extension)
Anterior rotation
reversible: an individualised specific exercise
training program has been shown to be more Innominate Posterior rotation
effective than physical therapy for women with Superior shear (upslip)
pelvic girdle pain after pregnancy (Stuge et al Inferior shear (downslip)
Inflare
2004). Outflare
Although research has demonstrated the pres- Superior shear
ence of movement faults in subjects with SIJ or
pelvic girdle pain (Mens et al 2002; Hungerford Pubis Inferior shear
Anterior shear
et al 2004) reliability and validity of clinical tests Posterior shear
are lacking. However, Hungerford et al (2007)
have shown that physical therapists can reliably
palpate and recognise altered patterns of intra-
pelvic motion with a weight shift from bilateral
stance to unilateral hip flexion.
The range of movement within the SIJ is so adaptive compensatory motion of the pelvis.
small that it is not possible to observe normal The site and direction of adaptive compensatory
movement at the articulation between the sacrum motion appears to be related to the site and direc-
and innominate. Consequently, we are unable to tion of UCM. The process of positional diagnosis
diagnose either the site or direction of UCM of currently labels three separate sites of pelvic girdle
the SIJ using movement observation. It may be adaptation: i) the sacrum; ii) the innominate; and
possible to palpate motion between the sacrum iii) the pubis. These three sites also demonstrate
and innominate during functional movement specific directions of adaptive compensation or
testing. However, there are almost no studies that UCM (Table 5.3).
demonstrate good intra-tester or inter-tester reli- If the process of manual palpation to determine
ability for palpation of SIJ movement. the positional adaptation of segmental motion
The osteopathic process of positional diagnosis, within the SIJ eventually becomes validated, then
as advocated by Mitchell et al (1979) and clinicians will have an indirect method of diag-
Greenman (2003), uses manual palpation of the nosing the site and direction of uncontrolled
pelvis during functional movement testing to motion in the sacroiliac complex. When these
determine motion restriction of the SIJ. There is diagnoses are made using manual palpation
a lack of consensus among the clinicians who use assessment, restrictions can be mobilised by
this approach as to which motion tests identify movement of the segment in the opposite direc-
restriction in function and as to precisely where tion to compensation. Likewise, the UCM can be
to palpate the pelvis to interpret the positional stabilised by training myofascial recruitment
change of adaptation. Once the restriction is strategies to prevent or resist movement in the
determined as being related to abnormal motion direction of adaptation at those sites (sacrum,
of the sacrum, the right innominate or the left innominate or pubis).
innominate, palpation of pelvic landmarks is In the absence of being able to easily observe
then used to determine the position of adaptive the site and direction of UCM within the sacro-
change. iliac complex, this process of positional diagnosis
This process of positional diagnosis attempts using manual palpation is potentially an alterna-
to identify and label the site and direction of tive method of identifying site and direction of
89
sacroiliac uncontrolled motion. Primary SIJ UCM Each direction is assessed separately! If during a test of
usually demonstrates good lumbar flexion control one specific direction (e.g. flexion), a movement into
even though the patient usually complains of another direction (e.g. extension) is observed, it is
flexion-related symptoms. Movement control possible to score a ✓✓ rating for the test. For example,
dysfunctions of the SIJ and pelvic girdle are con- if during a test of control of lumbar flexion control, the
sistently unilateral in nature and always demon- lumbar spine moves into extension, there is a possibility
strate significant open chain or closed chain of a problem with lumbar extension control. The ability
rotation UCMs. to control this potential UCM should be specifically
A suggestion for early management of primary assessed with extension related tests. However, if there
was no UCM into flexion, then flexion is not the direction
sacroiliac and pelvic girdle pain is to assess for
of UCM and the flexion control test should be rated as
and retrain uncontrolled rotation as a primary ✓✓.
intervention. Secondly, if a positional diagnosis Exception: if the movement in another direction
of the site and direction of pelvic girdle UCM can consistently reaches end range the control of the primary
be made then specific movement correction can test direction is deemed to be inefficient. For example, if,
be implemented. However, because of the lack of during a test of control of lumbar flexion control, the
reliability and validity for using palpation to lumbar spine consistently uses full end-range extension to
determine motion restriction or the positional prevent flexion, then the efficiency of flexion control is
change of adaptation, specific diagnosis of the inadequate, and the flexion control test should be rated
site and direction of UCM of the SIJ is not specifi- as ✓✗.
cally covered in this text.
The UCM is always qualified by a diagnostic label

TESTING FOR UCM – REVIEW of its site and direction.
OF PRINCIPLES A ✓✗ rating or ✗✗ rating labels or diagnoses the
stability dysfunction. The diagnosis should label
both the SITE and the DIRECTION of give that
Identifying the site and the direction of UCM uses is uncontrolled.
a cognitive motor control test demonstrating the The following section will demonstrate the spe-
efficiency of learning and performing a move- cific procedures for testing for UCM in the lumbar
ment skill of dissociated movement. That is, to spine.
actively prevent a particular movement at one
site (the provocative movement direction at the
painful joint system while actively moving in the
same direction at an adjacent joint). When
the therapist is confident that the person under- LUMBOPELVIC TESTS FOR
stands the test movement and knows what is UNCONTROLLED MOVEMENT
expected of the test, the person is required to
perform the test without visual or tactile feed-
back, verbal facilitation, or corrective instruction. Lumbar flexion control
The therapist then rates the performance of the
test as:
FLEXION CONTROL TESTS AND FLEXION
• ✓✓ (good control of site and direction) CONTROL REHABILITATION
• ✓✗ (inefficient control of site and direction)
• ✗✗ (uncontrolled site and direction).
These flexion control tests assess the extent of
To achieve a ✓✓ rating, the person must demon- flexion UCM in the lumbar spine and assess the
strate good control to the benchmark standard ability of the dynamic stability system to ade-
and the test movement must look and feel easy quately control flexion load or strain. It is a prior-
and does not require any specific movement ity to assess for flexion UCM if the patient
retraining. An assessment rating of ✓✗ or ✗✗ for complains of or demonstrates flexion-related
any particular test identifies the presence of UCM. symptoms or disability.
90
Movement faults associated with

OBSERVATION AND ANALYSIS OF
lumbar flexion
LUMBAR FLEXION AND FORWARD
BENDING Relative stiffness (restrictions)
• Hamstrings restriction of hip flexion – the hips
Description of ideal pattern lack 70° of normal range in standing
forward bending. The lumbar spine
The subject is instructed to stand with the feet in frequently increases flexion to compensate
a natural stance and bend forwards in a normal for the lack of hip mobility. Hamstring
relaxed pattern. Ideally, there should be even extensibility can be tested passively and
flexion throughout the lumbar and thoracic dynamically with manual muscle
regions with the hips flexing to approximately extensibility examination.
70°. The spinal flexion and hip flexion should • Thoracic restriction of flexion – mid and upper
occur concurrently. The finger tips should reach thoracic flexion restriction may also
the floor without the need to bend the knees contribute to compensatory increases in
(Figure 5.1). There should be good symmetry of lumbar flexion range. This is confirmed with
movement without any lateral deviation, tilt or manual segmental assessment (e.g. Maitland
rotation of the trunk or pelvis. The pelvis and hips passive physiological intervertebral
should lead the return to standing with the spine movements or passive accessory
unrolling on the way back to the upright posture. intervertebral movements) (Maitland et al
2005).
Relative flexibility (potential UCM)

• Lumbar flexion – the lumbar spine may
initiate the movement into flexion and
contribute more to producing forward
bending while the hips and thoracic
contributions start later and contribute less.
At the limit of forward bending, excessive or
hypermobile range of lumbar flexion may be
observed. During the return to neutral the
lumbar flexion and posterior pelvic tilt
persists and unrolls late.
During the assessment of flexion control, the
uncontrolled movement can be identified as
either a segmental or a multisegmental UCM.
• Segmental flexion hinge. If only one spinous
process is observed as prominent and
protruding ‘out of line’ compared to the
other vertebrae then the UCM is interpreted
as a segmental flexion hinge. The specific
hinging segment should be noted and
recorded. This commonly occurs at the
L5–S1 segment. Ideally, when lumbar flexion
control is assessed, the positional alignment
between the low lumbar spine and the pelvis
should be maintained during hip flexion or
thoracic flexion challenges. If lumbopelvic
stability and control is inadequate, L5
alignment with the sacrum cannot be
Figure 5.1 Ideal pattern of lumbar flexion (forward bending) maintained and during flexion control tests
91
the L5 and S1 segments appear to ‘open’ (the challenges, uncontrolled lumbar flexion and
spinous processes move apart) as the pelvis posterior pelvic tilt are observed.
posteriorly tilts instead of moving forwards
with the spinal position. The upper lumbar
lordosis can be maintained well and the Indications to test for lumbar
failure of control is demonstrated only at the flexion UCM
lumbopelvic junction.
Observe or palpate for:
• Multisegmental hyperflexion. If, on the other
hand, excessive or hypermobile lumbar 1. hypermobile lumbar flexion range
flexion is observed, but no one particular 2. excessive initiation of forward bending with
spinous process is prominent from the lumbar flexion
adjacent vertebrae then the UCM is 3. symptoms (pain, discomfort, strain)
interpreted as a multisegmental hyperflexion. associated with flexion.
This is commonly observed as excessive The person complains of flexion-related symp-
reversal of the lumbar lordosis and toms in the lumbar spine. Under flexion load, the
hypermobile flexion of the whole lumbar lumbar spine has greater give into flexion relative
region. Instead of maintaining positional to the hips or relative to the thoracic spine. The
control of the lumbar lordosis and the pelvis dysfunction is confirmed with motor control tests
during hip flexion or thoracic flexion of flexion dissociation.
92
The therapist monitors the lumbosacral neutral

Tests of lumbar flexion control position by palpating the spinous process of L2,
L5, and S2 with their finger tips (Figure 5.3).
During testing, if the palpating fingers do not
T1 STANDING: TRUNK LEAN TEST
move, the lumbosacral region is able to maintain
(tests for lumbar flexion UCM) neutral (Figure 5.4). If the palpating fingers move
This dissociation test assesses the ability to actively

dissociate and control lumbar flexion and poste-
rior pelvic tilt then lean forwards by moving the
hips through flexion while standing.
Test procedure
The person should have the ability to actively lean
forwards by flexing at the hips while controlling
the lumbar spine and pelvis. The person stands
tall with legs straight and the lumbar spine and
pelvis positioned in neutral (Figure 5.2). Lum-
bopelvic motion is monitored by the therapist.
Figure 5.3 Palpation of lumbosacral alignment
Figure 5.4 Palpation of lumbosacral alignment during

Figure 5.2 Start position for trunk lean test movement
93
spine starts to flex before achieving 50° forward

lean. During the attempt to dissociate the lumbar
spine from independent hip flexion the person
either cannot control the UCM or has to concen-
trate and try hard.
• If only one spinous process is observed as prominent

and protruding ‘out of line’ compared to the other
vertebrae then the UCM is interpreted as a segmental
flexion hinge. The specific hinging segment should be
noted and recorded.
• If excessive lumbopelvic flexion is observed, but no
one particular spinous process is prominent from the
adjacent vertebrae, then the UCM is interpreted as a
multisegmental hyperflexion.
Clinical assessment note for direction-specific

motor control testing
If some other movement (e.g. a small amount of

extension or rotation) is observed during a motor control
(dissociation) test of flexion control, do not score this as
uncontrolled flexion. The extension and rotation motor
control tests will identify if the observed movement is
uncontrolled. A test for lumbar flexion UCM is only
positive if uncontrolled lumbar flexion is demonstrated.
Figure 5.5 Benchmark for trunk lean test Rating and diagnosis of lumbar
flexion UCM
(T1.1 and T1.2)
further apart, uncontrolled segmental lumbar
flexion is identified. Correction
The person is instructed to stand tall and to The person stands tall with legs straight and the
‘bow’ or lean the trunk forwards from the hips, lumbar spine and pelvis positioned in the neutral.
keeping the back straight (neutral spine). Ideally, They monitor the lumbosacral neutral position
the subject should have the ability to dissociate by palpating the spinous process of L2, L5, and
the lumbar spine from hip flexion as evidenced S2 with their fingers (Figure 5.6). The person is
by 50° forward lean while preventing lumbar instructed to stand tall and to ‘bow’ or lean the
flexion or posterior pelvic tilt (Figure 5.5). This trunk forwards from the hips, keeping the back
test should be performed without any feedback straight (neutral spine). If the palpating fingers do
(self-palpation, vision, tape, etc.) or cueing for not move further apart, lumbar flexion is being
correction. controlled (Figure 5.7).
The person should self-monitor the lumbopel-
vic alignment and control with a variety of feed-
Lumbar flexion UCM
back options (T1.3). In some cases it may be useful
The person complains of flexion-related symp- to tension a strip of adhesive sports strapping tape
toms in the lumbar spine. The lumbar spine has to the skin across the uncontrolled segments. This
UCM into flexion relative to the hips under will provide sensory feedback and some degree of
flexion load. During active hip flexion, the lumbar mechanical support to the control of flexion.
94
T1.1 Assessment and rating of low threshold recruitment efficiency of the Trunk Lean Test
T1.2 Diagnosis of the site and direction of UCM T1.3 Feedback tools to monitor retraining
from the Trunk Lean Test
FEEDBACK TOOL PROCESS
TRUNK LEAN TEST – STANDING
Self-palpation Palpation monitoring of joint
Site Direction Segmental/ ✗✗ or ✓✗ position
multisegmental
Visual observation Observe in a mirror or directly
Lumbar Flexion Segmental flexion hinge ! watch the movement
(indicate level)
Adhesive tape Skin tension for tactile feedback
Multisegmental !
Cueing and verbal Listen to feedback from another
hyperflexion
correction observer
95
Figure 5.6 Self-palpation of lumbosacral alignment
Figure 5.8 Retraining lumbar flexion control with partial

support
symptoms under flexion load, within the range

that the flexion UCM can be controlled.
If control is poor, the pattern of forward leaning
with a straight back and independent hip flexion
should be performed only as far as lumbar flexion
and posterior pelvic tilt can be actively controlled
or prevented. Also, the upper body and trunk
weight can be supported by weight bearing
through the arms to decrease the load that must
be controlled by the local and global stabiliser
Figure 5.7 Self-palpation of lumbosacral alignment during muscles (Figure 5.8). As the ability to control the
correction UCM gets easier and the pattern of dissociation
feels less unnatural, the exercise can be progressed
to the unsupported position. This exercise can
Visual feedback (e.g. observation in a mirror) is also be performed with the knees bent to decrease
also a useful retraining tool. Ideally, the subject the influence of the hamstrings and to encourage
should have the ability to dissociate the lumbar the gluteal muscles to eccentrically control the
spine from hip flexion as evidenced by 50° forward hip. Once the pattern of dissociation is efficient
lean while preventing lumbar flexion or posterior and feels familiar it should be integrated into
pelvic tilt. There should be no provocation of any various functional postures and positions.
96
Ideally, the person should have the ability to

T2 4 POINT: BACKWARD PUSH TEST dissociate the lumbar spine and pelvis from hip
(tests for lumbar flexion UCM) flexion as evidenced by 120° of hip flexion during
the backward push while preventing lumbar
This dissociation test assesses the ability to actively flexion or posterior pelvic tilt (Figure 5.11). After
dissociate and control lumbar flexion/posterior 120° hip flexion the pelvis should start to tilt
pelvic tilt and push the body backwards with the posteriorly and the spine should start to flex as
hands by moving the hips backwards through the pelvis moves towards the heels. The lumbar
flexion while in 4 point kneeling (hands and spine and pelvis should return to a neutral posi-
knees) position. tion as the subject rocks forwards, back to the
starting position. The pelvis should have good
symmetry. That is, no lateral tilt or rotation. This
Test procedure test should be performed without any feedback
The person should have the ability to actively (self-palpation, vision, tape, etc.) or cueing for
push the body away with the hands while leaning correction.
forwards by flexing at the hips and controlling the
lumbar spine and pelvis. The person positions
themselves in 4 point kneeling (hands and knees)
with the lumbar spine and pelvis in neutral align-
ment (Figure 5.9). Lumbopelvic motion is moni-
tored by the therapist. The therapist monitors the
lumbosacral neutral position by palpating the
spinous process of L2, L5, and S2 with their fin-
gertips (Figure 5.10).
neutral. If the palpating fingers move further
apart, uncontrolled segmental lumbar flexion is
identified.
The person is instructed to push with the hands
to rock backwards from the hips towards their
heels, keeping the back straight (neutral spine).
Ideally, the neutral lumbar lordosis should be
maintained until about 120° of hip flexion as the
pelvis moves backwards (half way back towards
the heels).
Figure 5.10 Palpation of lumbosacral alignment
Figure 5.9 Start position for backward push test Figure 5.11 Benchmark for backward push test
97
Lumbar flexion UCM

The person complains of flexion-related symp-
toms in the lumbar spine. The lumbar spine has
UCM into flexion relative to the hips under
flexion load. During a backward push from the
hands, in a hands and knees position that pro-
duces hip flexion, the lumbar spine starts to flex
before achieving 120° of hip flexion. During the
attempt to dissociate the lumbar spine and pelvis
from independent hip flexion, the person either
cannot control the UCM or has to concentrate
and try hard.
Figure 5.12 Retraining lumbar flexion control

noted and recorded. pushing with the hands. The goal is to push the
• If excessive lumbopelvic flexion is observed, but no pelvis backwards with independent hip flexion,
one particular spinous process is prominent from the but only as far as the neutral lumbopelvic posi-
adjacent vertebrae then the UCM is interpreted as a tion can be maintained. Ideally, the person
multisegmental hyperflexion. should have the ability to dissociate the lum-
bopelvic region from hip flexion as evidenced by
120° of hip flexion as the pelvis moves backwards
Clinical assessment note for direction-specific (half way back towards the heels) (Figure 5.12)
motor control testing while preventing lumbar flexion or posterior
pelvic tilt.
If some other movement (e.g. a small amount of The person should self-monitor the lumbopel-
extension or rotation) is observed during a motor control vic alignment and control with a variety of feed-
(dissociation) test of flexion control, do not score this as back options (T2.3). It is very useful to tension
uncontrolled flexion. The extension and rotation motor a strip of adhesive sports strapping tape to the
control tests will identify if the observed movement is skin across the uncontrolled segments. This will
uncontrolled. A test for lumbar flexion UCM is only provide sensory feedback and some degree of
positive if uncontrolled lumbar flexion is demonstrated. mechanical support to the control of flexion.
Visual feedback (e.g. observation in a mirror) is
also a useful retraining tool.
If control is poor, the pattern of pushing the
pelvis backwards from the hands with a straight
Rating and diagnosis of lumbar back and independent hip flexion should be per-
flexion UCM formed only as far as lumbar flexion and posterior
(T2.1 and T2.2) pelvic tilt can be actively controlled or prevented.
There should be no provocation of any symp-
toms, so long as the flexion give can be control-
Correction led. Progress until good control through half
The person positions themselves in 4 point kneel- range (120° hip flexion) is easy, but not beyond
ing (hands and knees) with the lumbar spine and this range. Once the pattern of dissociation is
pelvis in neutral alignment. The person rocks efficient and feels familiar it should be integrated
backwards from the pelvis towards their heels by into various functional postures and positions.
98
T2.1 Assessment and rating of low threshold recruitment efficiency of the Backward Push Test
from the Backward Push Test
BACKWARD PUSH TEST – 4 POINT
KNEELING position
Site Direction Segmental/ ✗✗ or ✓✗
multisegmental
watch the movement
Lumbar Flexion Segmental flexion hinge !
(indicate level)
Cueing and verbal Listen to feedback from
Multisegmental !
correction another observer
hyperflexion
99
starting position a decrease in pressure is regis-

T3 CROOK: DOUBLE BENT LEG LIFT TEST tered by the PBU.
(tests for lumbar flexion UCM) The person is instructed to slowly lift both feet
off the floor (both at the same time) until both hips
This dissociation test assesses the ability to actively are flexed to 90°. They are instructed to keep the
dissociate and control lumbar flexion and poste- knees bent and the lumbar spine neutral (no
rior pelvic tilt when lifting both feet off the floor pressure change) while they flex the hips to 90°
by actively flexing the hips in a crook lying by lifting the feet from the floor. They are required
position. to hold this position (Figure 5.17) and keep the
back stable (no pressure change) for at least 5
seconds. Ideally, the person should have the
Test procedure ability to dissociate the lumbar spine and pelvis
The person should have the ability to lift both feet from hip flexion as evidenced by 90° of bilateral
off the floor (in crook lying) by flexing at the hips hip flexion during the double leg lift while pre-
and controlling the lumbar spine and pelvis. The venting lumbar flexion or posterior pelvic tilt.
person lies on the back in crook lying (hips and The person is permitted to watch the PBU to
knees bent and feet resting on the floor) with the monitor the accuracy of their ability to control
lumbar spine and pelvis relaxed in neutral align-
ment (Figure 5.13). Lumbopelvic motion is mon-
itored by the placement of a Pressure Biofeedback
Unit (PBU) (Stabilizer – Chattanooga) under the
back, centred at L3 in the middle of the lumbar
lordosis (Figures 5.14 and 5.15). During limb
load tests and exercises the PBU can objectively
monitor the functional stability of the trunk
(Richardson et al 1992, Jull et al 1993). In crook
lying the PBU is inflated to a base pressure of
40 mmHg (Figure 5.16). This pressure is used to
position and support the lumbar spine in neutral
alignment. Under functional limb load or move-
ment, no pressure change = no loss of neutral
position = good control. If the lumbar spine
flexes beyond the neutral starting position an
increase in pressure is registered by the PBU. If Figure 5.14 Therapist positioning the PBU in the lumbar
the lumbar spine extends beyond the neutral lordosis
Figure 5.13 Start position for double bent leg lift test Figure 5.15 Self-positioning the PBU in the lumbar lordosis
100
Figure 5.17 Benchmark for double bent leg lift test
flexion load. During a double leg lift from crook

lying that produces hip flexion, the lumbar spine
starts to flex before achieving 90° of hip flexion.
Figure 5.16 Inflating the PBU to a base pressure of During the attempt to dissociate the lumbar spine
40 mmHg and pelvis from independent hip flexion, the
person either cannot control the UCM or has to
concentrate and try hard.
In the process of trying to keep the back neutral,
the lumbar spine and prevent lumbar flexion. The the pelvis must not tilt posteriorly and flex the
PBU is initially inflated to a base pressure of lumbar spine. The anterior abdominal wall
40 mmHg while the lumbar spine is relaxed and should stay hollow or flat. Excessive recruitment
supported in a neutral resting position. During (dominance) of rectus abdominis causes the
the double leg lift some small movement of the anterior abdominal wall to ‘bulge’ out or ‘crunch’,
pelvis is normal. This is accounted for in the test flexing the trunk and increasing the flattening
by allowing a small tolerance of pressure change pressure. A pressure increase of more than
during the leg movement phase. Therefore, a pres- 10 mmHg (increase to more than 50 mmHg)
sure increase or decrease of 10 mmHg either side indicates gross posterior tilt and a loss of stability
of the base pressure of 40 mmHg is acceptable. into spinal flexion due to overactivation of rectus
However, when the hips are flexed to 90° the abdominis or a lack of posterior counterbalance
lumbar spine should be maintained in the origi- from the back extensor stabilisers (e.g. superficial
nal resting neutral position with the pressure held lumbar multifidus).
constantly at 40 mmHg for at least 5 seconds. As soon as any pressure increase (beyond
If no PBU is available the therapist should place 50 mmHg) is registered, the leg movement
a hand under the lumbar lordosis instead of must stop and the feet lower back to the start
inserting the PBU. It has been anecdotally claimed position. If control is poor, a series of graduated
that the hand is sensitive to a pressure change progressions using relatively less load and spe-
roughly equivalent to a pressure change of cific facilitation of the oblique abdominals can
40 mmHg. So if no pressure increase is detected be used.
by the hand, the control would seem to be within
the limits as determined by the PBU.
• If excessive lumbopelvic flexion occurs, a significant

Lumbar flexion UCM increase in pressure is registered by the PBU (pressure
The person complains of flexion-related symp- increase by more than 10 mmHg to >50 mmHg), then
the UCM is interpreted as a multisegmental
hyperflexion.
101


Rating and diagnosis of lumbar

Figure 5.18 Adjusting lumbopelvic position for multifidus
flexion UCM facilitation
(T3.1 and T3.2)
Correction
The person lies in crook lying with the lumbar
spine and pelvis relaxed in neutral alignment. The
person is permitted to watch the PBU to monitor
the accuracy of their ability to control the lumbar
spine and prevent lumbar flexion. During all
retraining of uncontrolled lumbar flexion a pres-
sure increase of 10 mmHg is acceptable during
unsupported leg movements. That is, if the start
pressure is 40 mmHg, a pressure increase of
10 mmHg (up to 50 mmHg) is acceptable during
leg movement. Likewise, if the start pressure is
35 mmHg (with multifidus facilitation), a pres-
sure increase of 10 mmHg (up to 45 mmHg) is
acceptable during leg movement. However, when
leg movement stops the pressure must be main- Figure 5.19 Facilitation with opposite knee to hand push
tained at the original start pressure.
Multifidus facilitation
If uncontrolled lumbar flexion is identified, facili-
Static diagonal: isometric opposite knee to
tation of superficial lumbar multifidus is encour-
aged. Take a relaxed breath in and breathe out hand push
and consciously hold the sternum and ribcage First facilitate superficial lumbar multifidus (PBU
down towards the bed. Try to visualise pulling the held at 30–35 mmHg or other hand to monitor
sacrum horizontally up along the bed towards the that no pressure change = spinal control), slowly
shoulders. The lumbar lordosis should increase lift one knee towards the opposite hand and push
slightly and the pressure should decrease. Do not them isometrically against each other on a diago-
use thoracic extension to decrease the pressure nal line (Figure 5.19). Push for 10 seconds and
(no lifting of the chest). Ideally, with efficient repeat 10 times so long as stability is maintained
superficial lumbar multifidus activation, the pres- (no pressure change). As soon as any pressure
sure should decrease by 5–10 mmHg (from increase or decrease is registered the movement
40 mmHg to approximately 35–30 mmHg) must stop and return to the start position. Do not
(Figure 5.18). This pressure decrease should be stabilise with the opposite foot or allow substitu-
able to be consistently maintained. tion or fatigue.
102
Static diagonal heel lift: isometric knee to Alternate single leg heel touch: (Sahrmann
hand push + 2nd heel lift level 1)
First facilitate superficial lumbar multifidus First facilitate superficial lumbar multifidus (PBU
(PBU held at 30–35 mmHg or other hand to held at 30–35 mmHg or other hand to monitor
monitor that no pressure change = spinal stabil- that no pressure change = spinal control), slowly
ity), slowly lift one knee towards the opposite lift one foot off the floor (Figure 5.21) and then
hand and push them isometrically against each lift the second foot off the floor and bring it up
other on a diagonal line. While keeping this pres- beside the first leg (Figure 5.22). Crook lying with
sure slowly lift the second heel off the floor and hips flexed to 90° and both feet off the floor is the
bring it up beside the first leg (Figure 5.20). Hold starting position.
this position for 10 seconds and repeat 10 times Hold this position and keeping the back stable
so long as stability is maintained (no pressure (no pressure change) slowly lower one heel to the
change). As soon as any pressure increase or floor (Figure 5.23) and lift it back to the start
decrease is registered the movement must stop position. Repeat this movement, slowly alternat-
and return to the start position. The point of ing legs, for 10 seconds so long as stability is
greatest risk of losing stability is when the second maintained (no pressure change), and then return
heel leaves the floor. Do not allow substitution both feet to the floor. Repeat the whole process
or fatigue. 10 times.
Figure 5.20 Facilitation with second leg lift Figure 5.22 Progression: second leg lift
Figure 5.21 Progression: first leg lift Figure 5.23 Progression: first leg lower
103
As soon as any pressure increase (or decrease) flexion. Visual feedback (e.g. observation in a
is registered the movement must stop and return mirror) is also a useful retraining tool.
to the start position. The point of greatest risk of If control is poor, the leg lift with a controlled
losing stability is when the heel is lowering to the back and independent hip flexion should be per-
floor. Do not allow substitution or fatigue. formed only as far as lumbar flexion and posterior
The person should self-monitor the lumbopel- pelvic tilt can be actively controlled or prevented.
vic alignment and control with a variety of feed- There should be no provocation of any symp-
back options (T3.3). It is very useful to use a PBU toms, so long as the lumbar flexion can be con-
for precise monitoring of lumbar position. Taping trolled. Once the pattern of dissociation is efficient
will also provide sensory feedback and some and feels familiar it should be integrated into
degree of mechanical support to the control of various functional postures and positions.
104
T3.1 Assessment and rating of low threshold recruitment efficiency of the Double Bent Leg Lift Test
from the Double Bent Leg Lift Test
DOUBLE BENT LEG LIFT TEST – CROOK
LYING position
multisegmental
watch the movement
Lumbar Flexion Multisegmental !
hyperflexion
Pressure biofeedback Visual confirmation of the
control of position
correction observer
105
of L2, L5, and S2 with their finger tips (Figure

T4 SITTING: FORWARD LEAN TEST 5.25).
(tests for lumbar flexion UCM) During testing, if the palpating fingers do not
This dissociation test assesses the ability to actively neutral. If the palpating fingers move further
dissociate and control lumbar flexion and poste- apart, uncontrolled lumbar flexion is identified.
rior pelvic tilt then lean forwards by moving the The person is instructed to sit tall and to lean
hips through flexion while sitting. the trunk forwards from the hips, keeping the
back straight (neutral spine). Ideally, the subject
should have the ability to dissociate the lumbar
Test procedure spine from hip flexion as evidenced by 30°
The person should have the ability to actively lean forward lean (Hamilton & Richardson 1998)
forwards by flexing at the hips while controlling while preventing lumbar flexion or posterior
the lumbar spine and pelvis. The person sits tall pelvic tilt (Figure 5.26). This test should be per-
with the feet on the floor and with the lumbar formed without any feedback (self-palpation,
spine and pelvis positioned in neutral (Figure vision, tape, etc.) or cueing for correction.
5.24). Lumbopelvic motion is monitored by the
therapist. The therapist monitors the lumbosacral Lumbar flexion UCM
neutral position by palpating the spinous process
flexion load. During active hip flexion in sitting,
the lumbar spine starts to flex before achieving
30° forward lean. During the attempt to dissoci-
ate the lumbar spine from independent hip
flexion the person either cannot control the UCM
or has to concentrate and try hard.
Figure 5.24 Start position for forward lean test Figure 5.25 Palpation of lumbosacral alignment
106

flexion UCM
(T4.1 and T4.2)
Correction
The person sits tall with the feet on the floor and
with the lumbar spine and pelvis positioned in
the neutral. The person should monitor the
lumbar alignment and control with a variety of
feedback options (T4.3). They monitor the lum-
bosacral neutral position by palpating the spinous
process of L2, L5 and S2 with their fingers. The
person is instructed to sit tall and to lean the
trunk forwards from the hips, keeping the back
straight (neutral spine). If the palpating fingers do
not move further apart, lumbar flexion is being
controlled.
In some cases it may be useful to tension a strip
of adhesive sports strapping tape to the skin
across the uncontrolled segments. This will
provide sensory feedback and some degree of
mechanical support to the control of flexion.
also a useful retraining tool. Ideally, the subject
should have the ability to dissociate the lumbar
spine from hip flexion as evidenced by 30°
forward lean while preventing lumbar flexion
or posterior pelvic tilt. There should be no pro-
Figure 5.26 Benchmark for forward lean test vocation of any symptoms under flexion load,
within the range that the flexion UCM can be
controlled.
• If only one spinous process is observed as prominent If control is poor, the pattern of forward leaning
and protruding ‘out of line’ compared to the other with a straight back and independent hip flexion
vertebrae then the UCM is interpreted as a segmental should be performed only as far as lumbar flexion
flexion hinge. The specific hinging segment should be and posterior pelvic tilt can be actively controlled
noted and recorded. or prevented. Also, the upper body and trunk
• If excessive lumbopelvic flexion is observed, but no weight can be supported by weight bearing
one particular spinous process is prominent from the through the arms to decrease the load that must
adjacent vertebrae then the UCM is interpreted as a be controlled by the local and global stabiliser
muscles. As the ability to control the UCM gets
easier and the pattern of dissociation feels less
unnatural the exercise can be progressed to the
Clinical assessment note for direction-specific unsupported position. Once the pattern of dis-
motor control testing sociation is efficient and feels familiar it should
be integrated into various functional postures
and positions.
107
T4.1 Assessment and rating of low threshold recruitment efficiency of the Forward Lean Test
from the Forward Lean Test
FORWARD LEAN TEST – SITTING
multisegmental
(indicate level)
Multisegmental !
hyperflexion
correction observer
108
backwards. Position the head directly over the

T5 SITTING: CHEST DROP TEST shoulders without chin poke. Monitor thoraco-
(tests for lumbar flexion UCM) lumbar motion by placing one hand on the
sternum. Monitor lumbopelvic motion by placing
This dissociation test assesses the ability to actively the other hand on the sacrum (Figure 5.27) (alter-
dissociate and control lumbar flexion and poste- native lumbopelvic monitoring: place one finger
rior pelvic tilt then actively flex the thoracic spine on the pubic bone). Without letting the lum-
while sitting. bopelvic region move (pelvis and sacral hand
does not move), allow the sternum to lower
(drop) towards the stationary pelvis. This is inde-
Test procedure pendent thoracic flexion.
The person should have the ability to actively Ideally, the person should have the ability to
lower the sternum towards the pelvis by flexing keep the lumbopelvic region neutral while inde-
the thoracic spine while controlling the lumbar pendently flexing the thoracic region from a posi-
spine and pelvis. The person sits tall with the feet tion of extension through to full thoracic flexion,
off the floor and with the lumbar spine and pelvis without any movement of the pelvis (Figure
positioned in the neutral. Make the spine as tall 5.28). This test should be performed without any
or as long as possible to position the normal feedback (self-palpation, vision, tape, etc.) or
curves in an elongated ‘S’ without leaning cueing for correction.
Figure 5.27 Start position for chest drop test Figure 5.28 Benchmark for chest drop test
109
Lumbar flexion UCM neutral position by palpating the spinous process

of L2, L5 and S2 with their fingers. If the palpating
The person complains of flexion-related symp- fingers do not move further apart and the pelvis
toms in the lumbar spine. The lumbar spine has does not roll back into posterior tilt, lumbar
UCM into flexion relative to the thorax under flexion is being controlled.
flexion load. The lumbar spine starts to flex before In some cases it may be useful to tension a strip
full thoracic flexion is achieved. The person either of adhesive sports strapping tape to the skin
cannot control the UCM or has to concentrate across the uncontrolled segments. This will
and try hard to dissociate the lumbar spine from provide sensory feedback and some degree of
independent thoracic flexion. mechanical support to the control of flexion.
• If only one spinous process is observed as prominent also a useful retraining tool.
and protruding ‘out of line’ compared to the other Ideally, the subject should have the ability to
vertebrae then the UCM is interpreted as a segmental dissociate the lumbar spine from thoracic flexion
flexion hinge. The specific hinging segment should be as evidenced by the ability to keep the lumbopel-
noted and recorded. vic region neutral while independently flexing the
• If excessive lumbopelvic flexion is observed, but no thoracic region from a position of extension
one particular spinous process is prominent from the through flexion. Move the thoracic spine into
adjacent vertebrae then the UCM is interpreted as a flexion, but only as far as the neutral lumbopelvic
multisegmental hyperflexion. position can be maintained. There must be no
When rectus abdominis (global mobiliser) is the dominant loss of neutral or UCM into lumbar flexion or
trunk flexor, it produces concurrent thoracolumbar flexion posterior pelvic tilt. There should be no provoca-
and lumbopelvic flexion. If the lumbopelvic region can
tion of any symptoms under flexion load, so long
actively resist flexion (with segmental extensor stabiliser
activation) while the thoracolumbar region actively flexes
as the flexion give can be controlled.
the thorax, the rectus abdominis must be inhibited to As the ability to independently control move-
some extent. The oblique abdominals (global stabilisers) ment of the thoracic spine and lumbopelvic
will probably contribute more to the thoracolumbar region gets easier and the pattern of dissociation
flexion component because they are less directly inhibited feels less unnatural, the exercise can be progressed
by the thoracic flexion. to performing concurrent thoracic flexion with
lumbopelvic extension.
If control is poor, the upper body and trunk
Clinical assessment note for direction-specific weight can be supported on hands and knees.
motor control testing Position the pelvis over the knees and the shoul-
ders over the hands with the knees and hands
comfortably apart. Rock the pelvis backwards and
forwards from the sacrum (posterior and anterior
uncontrolled flexion. The extension and rotation motor tilt) until the lumbar spine is in a long shallow
control tests will identify if the observed movement is lordosis. Then, push the body gently away from
uncontrolled. A test for lumbar flexion UCM is only the hands without flexing the thoracic spine or
positive if uncontrolled lumbar flexion is demonstrated. lowering the head. Then lift the head (without
chin poke) so that the back of the head touches
an imaginary line connecting the sacrum and
Rating and diagnosis of lumbar mid-thoracic spine. Use minimal effort to main-
flexion UCM tain this neutral spine position (Figure 5.29).
(T5.1 and T5.2) When control is poor, rather than specific dis-
sociation, for some patients, it is easier to use a
recruitment reversal exercise to start with:
Correction
The person sits tall with the feet on the floor and • Actively flex the thoracic spine and then
with the lumbar spine and pelvis positioned in extend the lumbar spine and anterior tilt the
neutral. The person should monitor the lumbar pelvis (Figure 5.30).
alignment and control with a variety of feedback • The reverse order of this same pattern may
options (T5.3). They monitor the lumbosacral also be used. That is, actively extend the
110
T5.1 Assessment and rating of low threshold recruitment efficiency of the Chest Drop Test
from the Chest Drop Test
CHEST DROP TEST – SITTING
multisegmental
(indicate level)
Multisegmental !
hyperflexion
correction observer
111
Figure 5.29 Correction (neutral start position) Figure 5.31 Correction (lumbar extension followed by
thoracic flexion)
Figure 5.30 Correction (thoracic flexion followed by lumbar

extension)
lumbar spine and anterior tilt the pelvis and

then flex the thoracic spine (Figure 5.31).
When the pattern of this recruitment reversal
feels easy, then progress back to the sitting
dissociation.
As the ability to independently control move-
ment of the thoracic spine and lumbopelvic
region gets easier and the pattern of dissociation
to standing. Stand upright with the knees and
hips slightly flexed (unlocked) to prevent hip
flexor tightness influencing the pelvis). Without
letting the lumbopelvic region move (pelvis and
sacrum do not move) lower the sternum (thoracic
flexion) towards the stationary pelvis (Figure
5.32). Figure 5.32 Progression: standing thoracic flexion
Once the pattern of dissociation is efficient and
feels familiar it should be integrated into various
functional postures and positions.
112
move they should then straighten both knees

T6 SITTING: DOUBLE KNEE EXTENSION simultaneously to within 10–15° of full exten-
TEST sion, keeping the back straight (neutral spine)
(tests for lumbar flexion UCM) and without leaning back or allowing the pelvis
to posteriorly tilt (Figure 5.34). Ideally, the person
This dissociation test assesses the ability to actively should have the ability to keep the lumbopelvic
dissociate and control lumbar flexion and poste- region neutral and prevent the hamstrings pulling
rior pelvic tilt while sitting, then actively extend the pelvis into posterior tilt and lumbar flexion.
both knees to engage the point where hamstring This test should be performed without any feed-
tension starts to pull the pelvis into posterior tilt. back (self-palpation, vision, tape, etc.) or cueing
for correction.
Test procedure
Lumbar flexion UCM
The person sits tall with both feet off the floor
and with the lumbar spine and pelvis positioned The person complains of flexion-related symp-
in neutral. Make the spine as tall or as long as toms in the lumbar spine. The lumbar spine has
possible to position the normal curves in an elon- UCM into flexion relative to the pelvis under
gated ‘S’ with the acromions vertical over hamstrings tension and posterior tilt load. The
the ischiums (do not lean backwards) (Figure pelvis posteriorly tilts or the lumbar spine starts
5.33). Without letting the lumbopelvic region to flex before the knees reach 10–15° from full
Figure 5.33 Start position for double knee extension test Figure 5.34 Benchmark for the double knee extension test
113
extension. The subject either cannot control the lumbar alignment and control with a variety of
UCM or has to concentrate and try hard to dis- feedback options (T6.3). They monitor the lum-
sociate the lumbar spine from independent ham- bosacral neutral position by palpating the spinous
strings tension. process of L2, L5 and S2 with their fingers. The
person is instructed to slowly straighten both
knees simultaneously to within 10–15° of full
• If only one spinous process is observed as prominent extension, keeping the back straight (neutral
spine) and without leaning back or allowing the
pelvis to posteriorly tilt. If the palpating fingers
noted and recorded. do not move further apart, lumbar flexion and
• If excessive lumbopelvic flexion is observed, but no posterior tilt are being controlled.
one particular spinous process is prominent from the In some cases it may be useful to tension a strip
adjacent vertebrae then the UCM is interpreted as a of adhesive sports strapping tape to the skin
multisegmental hyperflexion. across the uncontrolled segments. This will
provide sensory feedback and some degree of
mechanical support to the control of flexion.
also a useful retraining tool. There should be no
provocation of any symptoms under flexion load,
so long as the flexion give can be controlled. Only
extension or rotation) is observed during a motor control straighten the knees as far as the neutral lum-
(dissociation) test of flexion control, do not score this as bopelvic position (monitored with feedback) can
uncontrolled flexion. The extension and rotation motor be maintained. There must be no loss of neutral
control tests will identify if the observed movement is or UCM into flexion or posterior tilt.
uncontrolled. A test for lumbar flexion UCM is only If control is poor it is acceptable to start with
positive if uncontrolled lumbar flexion is demonstrated. unilateral (then progress to bilateral) knee exten-
sion with a straight back, but only as far as the
neutral lumbopelvic position can be maintained.
There must be no loss of neutral or give into
Rating and diagnosis of lumbar flexion. There should be no provocation of any
flexion UCM symptoms under flexion load, so long as the
(T6.1 and T6.2) flexion give can be controlled. Beware neurody-
namic symptoms associated with positive slump
responses. Unload the neural system with ankle
Correction plantarflexion or cervical extension. Once the
The person sits tall with the feet on the floor and pattern of dissociation is efficient and feels famil-
with the lumbar spine and pelvis positioned in iar it should be integrated into various functional
the neutral. The person should monitor the postures and positions.
114
T6.1 Assessment and rating of low threshold recruitment efficiency of the Double Knee Extension Test
from the Double Knee Extension Test
DOUBLE KNEE EXTENSION TEST – SITTING
multisegmental
(indicate level)
Multisegmental !
hyperflexion
correction observer
115
and bending at the hips and knees, and not using

T7 STAND TO SIT: ISCHIAL WEIGHT the hands for support. Keeping the spine straight,
BEARING TEST the person should flex forwards at the hips as the
(tests for lumbar flexion UCM) pelvis is lowered onto the chair. The heels do not
have to stay on the floor. The critical control point
This dissociation test assesses the ability to actively occurs when the ischiums contact the chair and
dissociate and control lumbar flexion and poste- weight bearing load is transferred to the ischiums
rior pelvic tilt while moving from standing to (Figure 5.36).
sitting. Ideally, the person should have the ability to
maintain lumbopelvic neutral and prevent
lumbar flexion or posterior pelvic tilt as the hips
Test procedure flex and the pelvis lowers to the chair and weight
The chair seat height should be adjusted so that is transferred to the ischiums. This test should be
when seated the hips are slightly higher (about performed without any feedback (self-palpation,
10°) than the knees. The feet should be posi- vision, tape, etc.) or cueing for correction.
tioned where they feel natural to stand up from
sitting (Figure 5.35). The person is instructed to
Lumbar flexion UCM
stand tall with the lumbar spine and pelvis posi-
tioned in neutral and to keep the lumbopelvic The person complains of flexion-related symp-
region neutral as they sit down on a chair. Then, toms in the lumbar spine. The lumbar spine has
slowly sit down on the chair by leaning forwards UCM into flexion relative to the hips. The pelvis
Figure 5.35 Start position for ischial weight bearing test Figure 5.36 Benchmark for ischial weight bearing test
116
posteriorly tilts and the lumbar spine starts to flex from the feet to the pelvis), then immediately
as weight bearing load is transferred to the ischi- return to standing.
ums. The subject either cannot control the UCM There must be no loss of neutral or UCM into
or has to concentrate and try hard to dissociate flexion or posterior tilt. There should be no prov-
the lumbar spine from independent thoracic ocation of any symptoms under flexion load, so
flexion. long as the flexion UCM can be controlled. In
some cases it may be useful to tension a strip of
adhesive sports strapping tape to the skin across
the uncontrolled segments. This will provide
and protruding ‘out of line’ compared to the other sensory feedback and some degree of mechanical
vertebrae then the UCM is interpreted as a segmental support to the control of flexion. Visual feedback
flexion hinge. The specific hinging segment should be (e.g. observation in a mirror) is also a useful
noted and recorded. retraining tool.
• If excessive lumbopelvic flexion is observed, but no If control is poor it is acceptable to start by
one particular spinous process is prominent from the increasing the chair seat height (or use a stool or
adjacent vertebrae then the UCM is interpreted as a table) so that less hip flexion is required before
multisegmental hyperflexion. ischial weight bearing is loaded (Figure 5.37).
There must be no loss of neutral or UCM into
flexion. As control improves, lower the chair


flexion UCM
(T7.1 and T7.2)
Correction
The person stands with the feet positioned where
they feel natural to stand up from sitting. They
are instructed to slowly begin to sit down on the
chair by leaning forwards and bending at the hips
and knees, not using the hands for support. The
person should monitor the lumbar alignment
and control with a variety of feedback options
(T7.3). Keeping the spine straight, the person
should flex forwards at the hips as the pelvis is
lowered onto the chair. The heels do not have to
stay on the floor. Only move backwards towards
sitting as far as the neutral lumbopelvic position
(monitored with feedback) can be maintained.
Initially, it may be easier to just touch the chair
with the ischiums (and not transfer any weight Figure 5.37 Correction through less range
117
T7.1 Assessment and rating of low threshold recruitment efficiency of the Ischial Weight Bearing Test
from the Ischial Weight Bearing Test
ISCHIAL WEIGHT BEARING TEST –
STANDING TO SITTING position
multisegmental
watch the movement
Lumbar Flexion Segmental flexion hinge !
(indicate level)
Multisegmental !
correction observer
hyperflexion
118
Table 5.4 Summary and rating of lumbar flexion tests
UCM DIAGNOSIS AND TESTING

SITE: DIRECTION: CLINICAL PRIORITY
LUMBAR FLEXION !
TEST RATING (✓✓ or ✓✗ or ✗✗) and rationale
Standing: trunk lean
4 point: backward push
Crook: double bent leg lift
Sitting: forward lean
Sitting: chest drop
Sitting: double knee extension
Stand to sit: ischial weight bearing
height slightly and first practise moving forwards familiar it should be integrated into various func-
from sitting to standing while monitoring the tional postures and positions.
control of lumbar flexion and posterior pelvic tilt.
Progress until control is efficient on a chair with
the height adjusted so that the hips are slightly
Lumbar flexion UCM summary
higher (about 10°) than the knees. Once the
pattern of dissociation is efficient and feels (Table 5.4)
119
Tests of lumbar extension control
EXTENSION CONTROL TESTS AND

EXTENSION CONTROL REHABILITATION
These extension control tests assess the extent of

extension UCM in the lumbar spine and assess
the ability of the dynamic stability system to ade-
quately control extension load or strain. It is a
priority to assess for extension UCM if the patient
complains of or demonstrates extension-related
symptoms or disability.

LUMBAR EXTENSION AND BACKWARD
ARCHING
Description of ideal pattern

The subject is instructed to extend and arch back-
wards as they normally would. Ideally, there
should be even extension throughout the spine as
the patient actively extends, with the pelvis con-
tributing slight to moderate concurrent anterior
tilt and finishing with the hips in 10–15° of
extension. The whole lumbar and lower thoracic
spine should contribute to the spinal extension. Figure 5.38 Ideal pattern of lumbar extension (backward
The pelvis should not sway forwards any further arching)
than approximately 10 cm and there should be
good symmetry of movement without any
deviation, tilt or rotation of the trunk or pelvis
(Figure 5.38).
kyphotic) has an extension restriction that
may also contribute to compensatory
Movement faults associated with increases in lumbar extension range. This is
lumbar extension confirmed with manual segmental
Relative stiffness (restrictions) assessment (e.g. Maitland PPIVMs or
PAIVMs).
• Hip flexor muscles (tensor fasciae latae and
iliotibial band) restriction of hip extension – the
hips lack 10–15° of normal range in Relative flexibility (potential UCM)
standing backward arching. The lumbar • Lumbar extension. There are two dominant
spine frequently increases extension to mechanisms of uncontrolled extension.
compensate for the lack of hip mobility. The first involves extension being initiated
tensor fasciae latae-iliotibial band with excessive forward pelvic sway and
extensibility can be tested passively and uncontrolled extension occurring
dynamically with manual muscle segmentally at the lumbosacral junction with
extensibility examination. the upper lumbar and lower thoracic spine
• Thoracic restriction of extension – the middle contributing relatively less. The second
and lower thoracic spine (posturally involves extension being initiated by
120
excessive anterior pelvic tilt and lumbar • Multisegmental hyperextension. If, on the other
hyperextension so that uncontrolled hand, excessive or hypermobile lumbar
extension occurs across the whole of the extension and anterior pelvic tilt are
lumbar region. The lumbar spine may observed, but no one particular vertebral
initiate the movement into extension, level is dominant from the adjacent vertebrae
contribute more to producing backward then the UCM is interpreted as a
arching, while the hips and thoracic multisegmental hyperextension. This is
contributions start later and contribute less. commonly observed as an excessive (deep)
At the limit of backward arching, excessive or lumbar lordosis and hypermobile extension
hypermobile range of lumbar extension may of the whole lumbar region. This excessive
be observed. During the return to neutral the hyperlordosis is commonly initiated with
lumbar extension and anterior pelvic tilt exaggerated anterior pelvic tilt or
persists and recovers later. occasionally it may be initiated with
excessive thoracolumbar extension. Instead
In the assessment of extension movement, the
of maintaining positional control of the
UCM can be identified as either segmental or
lumbar lordosis and the pelvis during hip
multisegmental.
extension or thoracic extension challenges,
• Segmental extension hinge. If forward pelvic uncontrolled lumbar extension and anterior
sway (with hip extension) initiates backward pelvic tilt are observed.
arching, the anterior pelvic tilt required for
ideal extension is inadequate. The concurrent Indications to test for lumbar
upper lumbar and lower thoracic extension
contribution is late or absent. Consequently, extension UCM
instead of at least nine vertebral levels Observe or palpate for:
(T9–L1) contributing to (and sharing the 1. hypermobile lumbar extension range
load stresses) of spinal extension, only three 2. excessive initiation of backward arching with
segments appear to contribute significantly forward pelvic sway and a lumbosacral hinge
(L3–5). Of these, the segment at the pelvic 3. excessive initiation of backward arching with
junction (L5–S1) appears to translate hyperlordosis
forwards excessively, producing a skin crease 4. symptoms (pain, discomfort, strain)
as it hinges backwards into extension against associated with extension.
the posteriorly tilted pelvis. If this segment is
observed as hinging into translation ‘out of The person complains of extension-related symp-
line’ compared to the other vertebrae then toms in the lumbar spine. Under extension load,
the UCM is interpreted as a segmental the lumbar spine has UCM into extension relative
extension hinge. The specific hinging segment to the hips or relative to the thoracic spine. The
should be noted and recorded. This dysfunction is confirmed with motor control tests
commonly occurs at the L5–S1 segment. of extension dissociation.
Ideally, when lumbar extension control is
assessed, the positional alignment between
the low lumbar spine and the pelvis should
be maintained during hip extension or EXTENSION LOAD TESTING
thoracic extension challenges. If lumbopelvic PREREQUISITES
stability and control is inadequate, L5
alignment with the sacrum cannot be These are not tests of extension stability function,
maintained and during extension control but are considered a basic prerequisite for such
tests the L5 and S1 segments appear to tests. Back flattening on the wall is especially rel-
‘hinge’ (observe a deep skin crease) as the evant for extension control between the thoracic
pelvis sways forwards instead of anteriorly and lumbar regions. It is important to be able to
tilting and matching the alignment with the move the lumbar spine out of extension to at least
spinal movement. The upper lumbar and the flat back position. Lateral abdominal–gluteal
lower thoracic vertebral contribution is either co-activation is especially relevant for extension
late or absent. control between the lumbar–pelvic region and
121
the hips. It is important to be able to co-activate Dysfunction

the major stability muscle groups that can control
excessive lumbopelvic extension strain. Recruitment dysfunction
There is a lack of abdominal and gluteal
co-activation. The flattening action is performed
BACK FLATTENING ON WALL – only with the abdominals and the gluteals do not
participate or the flattening action is performed
STANDING (PREREQUISITE)
only with the gluteals and the abdominals do not
participate.
Ideal
The person is instructed to stand with the feet
Mobility dysfunction
5–10 cm from the wall, with the feet wide apart
(at least shoulder width apart) and with the knees The lumbar spine cannot flatten the lordosis
slightly bent. This is to take the hip flexors off sufficiently to get out of extension. This is not
tension. Ideally, with the hip flexors off load and particularly common, but may occur with the
with the sacrum and thoracic spine on the wall, longstanding lordotic posture where the back
the person should be able to contract the abdom- extensors have lost extensibility.
inal and gluteal muscles to flatten the lumbar
spine onto the wall and hold it there (Figure
5.39). Correction
With the hip flexors unloaded and the sacrum
and thoracic spine on the wall, actively flatten the
low back towards the wall. Do not allow the tho-
racic spine to move or force so hard that thoracic
pain is provoked. Hold this position for 10
seconds and repeat 10 times. Progression is
achieved by increasing the holding time until it
feels easy to get a confident low effort co-activation
while maintaining the back flat against the wall
continually for 2–3 minutes.
CO-ACTIVATION OF LATERAL
ABDOMINALS AND GLUTEALS –
PRONE (PREREQUISITE)
Ideal
The subject is instructed to actively ‘hollow’ or
pull in the abdominal wall by activating and
holding a contraction of the lateral abdominal
muscles (transversus and the oblique abdomi-
nals). While this contraction is being held the
subject is instructed to also contract the gluteal
muscles. Ideally, the gluteals should confidently
and strongly switch on with good symmetry
and maintain this contraction without losing
the abdominal contraction (Figure 5.40). These
muscle groups are the muscles which can control
Figure 5.39 Extension control prerequisite: back flattening extension strain at the lumbopelvic region under
on wall hip extension load.
122
Correction
Activate the abdominals (hollowing contraction)
and, while maintaining this contraction, con-
sciously contract the gluteals. Hold this
co-activation for 10 seconds and repeat 10 times.
Progression is achieved by increasing the holding
time until it feels easy to get a confident low effort
co-activation while maintaining the co-activation
continually for 2–3 minutes.
Figure 5.40 Extension control prerequisite: abdominal

gluteal co-activation Note: if the person fails any of these extension
prerequisites tests, care should be taken during the
subsequent extension control tests. Monitor for any
increase in symptoms while performing the extension
Dysfunction control tests. If the person cannot adequately co-activate
the stability muscles to control extension or cannot move
Recruitment dysfunction out of extension sufficiently then the attempt to control
The gluteal muscles have difficulty co-activating extension may result in a substitution overload. If the
with the abdominal muscles. They either cannot extension control test cannot be performed without
provocation of symptoms, start with the prerequisites as
activate or can only activate in a sluggish or asym-
the entry level retraining option.
metrical way (similar to a quadriceps lag).
123
Tests of lumbar extension control
T8 STANDING: THORACIC EXTENSION

(SWAY) TEST
(tests for lumbar extension UCM)

control pelvic forward sway and lumbar segmen-
tal hinging into extension translation while
actively lifting the sternum up and forwards into
thoracic extension in standing.
Test procedure
The person initially stands tall with the upper
thighs against the edge of a plinth, bench or table
and with the feet as far under the table as balance
can be maintained. Position the head directly
over the shoulders without chin poke. Demon-
strate or manually assist the movement of tho-
racic extension. The sternum, clavicles and
acromions should all move up and forwards
(Figure 5.41). There should be no forward sway
of the pelvis (the table/bench provides feedback
and support). The normal anterior pelvic should
be present (with slight concurrent hip flexion)
and all of the lumbar spine and the lower thoracic
vertebrae should contribute to the spinal exten-
sion initiated from the thoracic region. There Figure 5.41 Teaching and training thoracic extension with
sway control
should be no segmental skin crease at the lum-
bosacral junction. There should be no scapular
retraction (acromions moving backwards). The
thoracic extension should be performed by spinal position of relaxed flexion through to full exten-
muscles, not the rhomboids. Allow the person to sion (Figure 5.43). The available range of dissoci-
practise the test movement using feedback and ated thoracolumbar extension is small. This test
support and with verbal and manual correction. should be performed without any feedback
For testing, feedback and the support of the (self-palpation, vision, tape, etc.) or cueing for
table are taken away. The person stands tall and correction.
unsupported with legs straight and the lumbar
spine and pelvis positioned in the neutral. The
head is positioned directly over the shoulders
without chin poke (Figure 5.42). Without letting The person complains of extension-related symp-
the lumbopelvic region move into forward toms in the lumbar spine. The lumbar spine has
sway, the person should have the ability to actively UCM into forward pelvic sway and lumbar seg-
lift the sternum and chest up and forwards through mental extension translational shear relative to
the full available range of extension of the tho- the thoracic spine under extension load. During
racic spine. active thoracic extension, the pelvis starts to sway
Ideally, the person should have the ability forwards or the upper body sways backwards and
to prevent segmental hinging of the lumbar the low lumbar spine hinges into segmental
spine and forward sway of the pelvis while inde- extension before achieving end-range thoracic
pendently extending the thoracic region from a extension. A significant skin crease is observed at
124
Figure 5.42 Start position for thoracic extension – sway test Figure 5.43 Benchmark for thoracic extension – sway test
the ‘pivot point’ of uncontrolled extension trans-

lation. The hinge occurs primarily at L5–S1, but
can potentially also occur at L3–4 or L4–5. The
upper lumbar spine and thoracic spine may only If some other movement (e.g. a small amount of flexion
contribute (if at all) to extension at the comple- or rotation) is observed during a motor control
tion of pelvic ‘sway’. The pelvis essentially stays in (dissociation) test of extension control, do not score this
relative posterior tilt. During the attempt to dis- as uncontrolled extension. The flexion and rotation motor
sociate the pelvic sway and segmental lumbar control tests will identify if the observed movement is
hinge from independent thoracic extension uncontrolled. A test for lumbar extension UCM is only
(while allowing normal slight anterior pelvic tilt) positive if uncontrolled lumbar extension is demonstrated.
the person either cannot control the UCM or has
to concentrate and try hard. Rating and diagnosis of lumbar
extension UCM
• Note if one vertebral level appears to translate forwards
excessively, producing a skin crease as it hinges (T8.1 and T8.2)
backwards into extension. If this segment is observed
as hinging into translation ‘out of line’ compared to the Correction
other vertebrae then the UCM is interpreted as a The person stands tall and unsupported with legs
segmental extension hinge. The specific hinging
straight and the lumbar spine and pelvis posi-
segment should be noted and recorded.
tioned in the neutral. Without letting the
125
lumbopelvic region move into forward sway, the

person actively lifts the sternum and chest up and
forwards only as far as the forward sway of the
pelvis can be actively controlled or prevented and
without swaying the upper body or shoulders
backwards. The normal anterior pelvic should be
present (with slight concurrent hip flexion) and
all of the lumbar spine and the lower thoracic
vertebrae should contribute to the spinal exten-
sion initiated from the thoracic region.
The person should monitor the lumbopelvic
alignment and control with a variety of feedback
options (T8.3). It may be especially useful to
palpate the spinous process of the primary
hinging segment for uncontrolled and excessive
forward displacement of the spinous process
during active extension. This will provide sensory
feedback for the control of the segmental exten-
sion hinge. Visual feedback (e.g. observation in a
mirror) is also a useful retraining tool. There
should be no provocation of any symptoms under
extension load, within the range that the exten-
sion UCM can be controlled.
If control is poor, start retraining with addi-
tional feedback. The person stands with the upper
thighs against the edge of a bench or table and
with the feet as far under the table as balance can
be maintained. With the table preventing forward
sway of the pelvis, the sternum, clavicles and
acromions should all move up and forwards. Also,
the upper body and trunk weight can be sup- Figure 5.44 Retraining control of thoracic extension – sway
with thighs against table for feedback and support
ported by weight bearing through the arms to
decrease the load that must be controlled (Figure
5.44). Train by moving into thoracic extension
only as far as the forward sway of the pelvis can
be prevented and without swaying the upper
body or shoulders backwards. As the ability to
control the UCM gets easier, and the pattern of
dissociation feels less unnatural, the exercise can
be progressed to the unsupported position
without a bench or table and then it should be
integrated into various functional postures and
positions.
126
T8.1 Assessment and rating of low threshold recruitment efficiency of the Thoracic Extension – Sway Test
from the Thoracic Extension – Sway Test
THORACIC EXTENSION (SWAY) TEST
– STANDING position
multisegmental
watch the movement
Lumbar Extension Segmental extension !
hinge (indicate level)
correction observer
127
Demonstrate or manually assist the movement of

T9 STANDING: THORACIC EXTENSION thoracic extension. The sternum, clavicles and
(TILT) TEST acromions should all move up and forwards.
(tests for lumbar extension UCM) Allow the person to practise the test movement
using feedback and support and with verbal and
manual correction.
For testing, feedback and the support of the
control pelvic anterior tilt and lumbar extension
table are taken away. Without letting the pelvis
while actively lifting the sternum up and forwards
anteriorly tilt or the lower lumbar lordosis
into thoracic extension in standing.
increase, the person should have the ability to
actively lift the sternum and chest up and forwards
through the full available range of extension of
Test procedure
the thoracic spine (Figure 5.46). The gluteals
To teach the person the test movement, the person should activate to prevent anterior pelvic tilt. The
stands tall and unsupported with legs straight and available range of dissociated thoracolumbar
the lumbar spine and pelvis positioned in the extension is small. This test should be performed
neutral. The head is positioned directly over the without any feedback (self-palpation, vision,
shoulders without chin poke (Figure 5.45). tape, etc.) or cueing for correction.
Figure 5.45 Start position for thoracic extension – tilt test Figure 5.46 Benchmark for thoracic extension – tilt test
128

The person complains of extension-related symp-
UCM into anterior pelvic tilt and lumbar multi-
segmental hyperextension relative to the thoracic
spine under extension load. During active tho-
racic extension, the pelvis starts to anteriorly tilt
and the lumbar spine increases extension
(increased lordosis) before achieving end-range
thoracic extension. During the attempt to dissoci-
ate the pelvic tilt and lumbar extension from
independent thoracic extension, the person either
and try hard.
• If increased extension (increased lumbar lordosis) of

the whole lumbar region and increased anterior pelvic
tilt are observed, but no one particular vertebral level
is dominant from the adjacent vertebrae, then the
UCM is interpreted as a multisegmental
hyperextension.

If some other movement (e.g. a small amount of flexion

or rotation) is observed during a motor control Figure 5.47 Correction: posterior tilt onto wall
(dissociation) test of extension control, do not score this
as uncontrolled extension. The flexion and rotation motor
uncontrolled. A test for lumbar extension UCM is only
positive if uncontrolled lumbar extension is demonstrated.
The person should monitor the lumbopelvic
alignment and control with a variety of feedback
options (T9.3). It may be especially useful to
palpate the pelvis for uncontrolled and anterior
Rating and diagnosis of lumbar tilt or palpate the lumbar lordosis for any increase
extension UCM in lumbar extension during active thoracic exten-
(T9.1 and T9.2) sion. This will provide sensory feedback for the
control of the lumbar extension tilt. Visual feed-
back (e.g. observation in a mirror) is also a useful
Correction retraining tool. There should be no provocation
The person stands tall and unsupported with legs of any symptoms under extension load, within
straight and the lumbar spine and pelvis posi- the range that the extension UCM can be
tioned in the neutral. Without letting the lumbar controlled.
spine extend or the pelvis anteriorly tilt, the If control is poor, start standing against a wall
person actively lifts the sternum and chest up and with the feet apart, the knees unlocked and the
forwards only as far as the lumbar extension and thoracic spine slumped forwards into flexion so
anterior tilt can be actively controlled or that the lumbar spine is flattened onto the wall
prevented. (Figure 5.47). Monitor the pelvic tilt and slowly
129
T9.1 Assessment and rating of low threshold recruitment efficiency of the Thoracic Extension – Tilt Test
from the Thoracic Extension – Tilt Test
THORACIC EXTENSION (TILT) TEST
multisegmental
watch the movement
Lumbar Extension Multisegmental !
hyperextension
correction observer
130
Figure 5.48 Progression: unroll thoracic spine into extension
‘unroll’ the thoracic spine up the wall. Only tilt across this multisegmental group, the tape
unroll the thoracic spine into extension as far as pulls the skin to provide sensory feedback about
the lumbar spine can be stabilised on the wall the UCM. Also, the upper body and trunk weight
(Figure 5.48). Using the wall for feedback and can be supported by weight bearing through the
support, do not allow the lumbar spine to extend arms to decrease the load that must be controlled.
off the wall at all. Train by controlling lumbar extension and pelvic
Retraining with additional feedback is also a tilt while moving into thoracic extension only as
good option. Tension a piece of adhesive strap- far as the UCM can be prevented. As the ability
ping tape across the anterior abdomen (e.g. from to control the UCM gets easier and the pattern
the ASIS to the lower anterolateral ribcage or of dissociation feels less unnatural it should be
along the rectus abdominis muscle). If the person integrated into various functional postures and
cannot prevent spinal extension or anterior pelvic positions.
131
movement of thoracic extension. Monitor thora-

T10 SITTING: CHEST LIFT (TILT) TEST columbar motion by placing one hand on the
(tests for lumbar extension UCM) sternum. Monitor lumbopelvic motion by placing
the other hand on the sacrum (alternative lum-
This dissociation test assesses the ability to actively bopelvic monitoring: place one finger on the
control pelvic anterior tilt and lumbar extension pubic bone). Without letting the lumbopelvic
while actively lifting the sternum up into thoracic region move (pelvis and sacral hand does not
extension in sitting. move) lift the sternum up. This is independent
thoracic extension. The sternum, clavicles and
acromions should all move up (Figure 5.50).
Allow the person to practise the test movement
Test procedure
using feedback and support and with verbal and
To teach the person the test movement, the person manual correction.
sits tall with the feet off the floor and with the For testing, feedback and the support of the
lumbar spine and pelvis positioned in the neutral. table are taken away. Ideally, the person should
Make the spine as tall or as long as possible to have the ability to keep the lumbopelvic region
position the normal curves in an elongated ‘S’ neutral while independently extending the tho-
without leaning backwards. Position the head racic region (chest lift) from a position of flexion
directly over the shoulders without chin poke through to full thoracic extension, without any
(Figure 5.49). Demonstrate or manually assist the movement of the pelvis. This test should be
Figure 5.49 Start position for chest lift – tilt test Figure 5.50 Benchmark for chest lift – tilt test
132
performed without any feedback (self-palpation, Rating and diagnosis of lumbar

vision, tape, etc.) or cueing for correction. extension UCM
(T10.1 and T10.2)
toms in the lumbar spine. The lumbar spine has Correction
UCM into anterior pelvic tilt and lumbar multi- The person sits tall with the feet on the floor and
segmental hyperextension relative to the thoracic with the lumbar spine and pelvis positioned in
spine under extension load. During active tho- the neutral. Monitor thoracolumbar motion by
racic extension, the pelvis starts to anteriorly placing one hand on the sternum. Monitor lum-
tilt and the lumbar spine increases extension bopelvic motion by placing the other hand on the
(increased lordosis) before achieving end-range sacrum. Without letting the lumbopelvic region
thoracic extension. During the attempt to dissoci- move (pelvis and sacral hand does not move)
ate the pelvic tilt and lumbar extension from lift the sternum up into independent thoracic
independent thoracic extension, the person either extension.
cannot control the UCM or has to concentrate In some cases it may be useful to tension a strip
and try hard. of adhesive strapping tape across the anterior
When iliocostalis (global mobiliser) is the abdomen (e.g. from the ASIS to the lower antero-
dominant trunk extensor, it produces concurrent lateral ribcage or along the rectus abdominis
thoracolumbar extension and lumbopelvic exten- muscle). If the person cannot prevent spinal
sion. If the lumbopelvic flexor stabiliser muscles extension or anterior pelvic tilt across this multi-
can actively resist lumbopelvic extension (with segmental group, the tape pulls the skin to provide
internal oblique abdominal stabiliser activation) sensory feedback about the UCM. Visual feedback
while the segmental thoracolumbar spinal stabi- (e.g. observation in a mirror) is also a useful
liser muscles actively extend the thorax, then ilio- retraining tool.
costalis must be inhibited to some extent. The Ideally, the subject should have the ability to
internal oblique abdominals (global stabilisers) dissociate the lumbar spine from thoracic exten-
will probably contribute more to the control of sion as evidenced by the ability to keep the lum-
lumbopelvic extension because they are less bopelvic region neutral while independently
directly inhibited by the thoracic extension chest extending the thoracic region from a position of
lift. flexion through extension. Lift the chest into the
thoracic extension, but only as far as the neutral
lumbopelvic position can be maintained (Figure
5.51). There must be no loss of neutral or UCM
into lumbar extension or anterior pelvic tilt.
tilt are observed, but no one particular vertebral level
There should be no provocation of any symptoms
is dominant from the adjacent vertebrae, then the under flexion load, so long as the flexion give can
UCM is interpreted as a multisegmental be controlled.
hyperextension. The person should monitor the lumbar align-
ment and control with a variety of feedback
options (T10.3). As the ability to independently
control movement of the thoracic spine and lum-
Clinical assessment note for direction-specific bopelvic region gets easier and the pattern of dis-
motor control testing sociation feels less unnatural, the exercise can be
progressed to performing concurrent thoracic
If some other movement (e.g. a small amount of flexion flexion with lumbopelvic extension.
or rotation) is observed during a motor control If control is poor, the upper body and trunk
(dissociation) test of extension control, do not score this weight can be supported on hands and knees.
as uncontrolled extension. The flexion and rotation motor Position the pelvis over the knees and the shoul-
control tests will identify if the observed movement is ders over the hands with the knees and hands
comfortably apart. Rock the pelvis backwards and
forwards from the sacrum (posterior and anterior
133
T10.1 Assessment and rating of low threshold recruitment efficiency of the Chest Lift – Tilt Test
from the Chest Lift – Tilt Test
CHEST LIFT (TILT) TEST – SITTING
multisegmental
Lumbar Extension Multisegmental ! watch the movement
hyperextension
correction observer
Flexicurve positional Visual and sensory feedback of
marker positional alignment
134
Figure 5.52 Correction (neutral start position)
Figure 5.51 Ideal control of lumbopelvic extension
Figure 5.53 Correction (thoracic extension followed by

lumbar flexion)
tilt) until the lumbar spine is in a long shallow

lordosis. Then, push the body gently away from
the hands without flexing the thoracic spine or
lowering the head. Then lift the head (without
chin poke) so that the back of the head touches
an imaginary line connecting the sacrum and
mid-thoracic spine. Use minimal effort to main-
tain this neutral spine position (Figure 5.52).
When control is poor, rather than specific dis-
sociation, for some patients it is easier to use a
recruitment reversal exercise to start with:
• Actively extend the thoracic spine and then
flex the lumbar spine and posteriorly tilt the
pelvis. (Figure 5.53).
• The reverse order of this same pattern may
also be used. That is, actively flex the lumbar
spine and posteriorly tilt the pelvis and then Figure 5.54 Correction (lumbar flexion followed by thoracic
extend the thoracic spine (Figure 5.54). extension)
135
When the pattern of this recruitment reversal hips slightly flexed (unlocked) to prevent hip
feels easy, then progress back to the sitting flexor tightness influencing the pelvis. Without
dissociation. letting the lumbopelvic region move (pelvis and
As the ability to independently control move- sacrum do not move), lift the sternum and chest
ment of the thoracic spine and lumbopelvic (thoracic extension). Once the pattern of disso-
region gets easier and the pattern of dissociation ciation is efficient and feels familiar it should be
feels less unnatural, the exercise can be progressed integrated into various functional postures and
to standing. Stand upright with the knees and positions.
136
therapist. The therapist monitors the lumbosacral

T11 SITTING: FORWARD LEAN TEST neutral position by palpating the spinous process
(tests for lumbar extension UCM) of L2, L5 and S2 with their finger tips. During
testing, if the palpating fingers do not move, the
This dissociation test assesses the ability to actively lumbosacral region is able to maintain neutral. If
dissociate and control lumbar extension and the palpating fingers move closer together, uncon-
anterior pelvic tilt then lean the trunk forwards trolled lumbar extension is identified.
(activates the back extensors to support the trunk The person is instructed to sit tall and to lean
load) while sitting. the trunk forwards from the hips, keeping the
back straight (neutral spine). Ideally, the subject
should have the ability to maintain a neutral
Test procedure
lumbar spine and prevent uncontrolled lumbar
The person should have the ability to actively lean extension when the back extensors activate to
forwards by flexing at the hips while controlling support the trunk through 30°of forward leaning
the lumbar spine and pelvis. The person sits tall (Hamilton et al 1998) (Figure 5.56). This test
with the feet on the floor and with the lumbar should be performed without any feedback
spine and pelvis positioned in the neutral (Figure (self-palpation, vision, tape, etc.) or cueing for
5.55). Lumbopelvic motion is monitored by the correction.
Figure 5.55 Start position for forward lean test Figure 5.56 Benchmark for forward lean test
137
Lumbar extension UCM Correction

The person complains of extension-related symp- The person sits tall with the feet on the floor and
toms in the lumbar spine. The lumbar spine has with the lumbar spine and pelvis positioned in
UCM into extension relative to the hips under the neutral. The person should monitor the
extension load. During active hip flexion and lumbar alignment and control with a variety of
forward lean of the trunk in sitting, the lumbar feedback options (T11.3). They monitor the lum-
spine starts to extend before achieving 30° bosacral neutral position by palpating the spinous
forward lean. During the attempt to maintain a process of L2, L5 and S2 with their fingers. The
neutral lumbar spine and prevent uncontrolled person is instructed to sit tall and to lean the
lumbar extension when the back extensors trunk forwards from the hips, keeping the back
activate to support the trunk, the person either straight (neutral spine). If the palpating fingers do
cannot control the UCM or has to concentrate not move closer together, lumbar extension is
and try hard. being controlled.
Palpation feedback and visual feedback (e.g.
observation in a mirror) are the most useful
• If increased extension (increased lumbar lordosis) of retraining tools. Ideally, the subject should have
the whole lumbar region and increased anterior pelvic the ability to dissociate the lumbar spine from
tilt is observed, but no one particular vertebral level is hip flexion, as evidenced by 30° forward lean
dominant from the adjacent vertebrae, then the UCM
while preventing lumbar extension. There should
is interpreted as a multisegmental hyperextension.
be no provocation of any symptoms under exten-
sion load, within the range that the flexion UCM
can be controlled.
Clinical assessment note for direction-specific If control is poor, the pattern of forward leaning
motor control testing with a straight back and independent hip flexion
should be performed only as far as lumbar exten-
If some other movement (e.g. a small amount of flexion sion can be actively controlled or prevented. Also,
or rotation) is observed during a motor control the upper body and trunk weight can be sup-
ported by weight bearing through the arms to
decrease the load that must be controlled by the
uncontrolled. A test for lumbar extension UCM is only local and global stabiliser muscles. As the ability
positive if uncontrolled lumbar extension is demonstrated. to control the UCM gets easier and the pattern of
dissociation feels less unnatural, the exercise can
be progressed to the unsupported position. Once
Rating and diagnosis of lumbar the pattern of dissociation is efficient and feels
familiar it should be integrated into various func-
extension UCM tional postures and positions.
(T11.1 and T11.2)
138
T11.1 Assessment and rating of low threshold recruitment efficiency of the Forward Lean Test
from the Forward Lean Test
FORWARD LEAN TEST – SITTING
multisegmental
Lumbar Extension Multisegmental ! watch the movement
hyperextension
correction observer
139
with the thighs (about 0° of hip extension)

T12 4 POINT: FORWARD ROCKING TEST (Figure 5.59).
(tests for lumbar extension UCM) Ideally, the person should have the ability to
dissociate the lumbar spine and pelvis from hip
This dissociation test assesses the ability to actively extension, as evidenced by 0° of hip flexion
dissociate and control lumbar extension/anterior during forward rocking while preventing lumbar
pelvic tilt and rock the body forwards, shifting extension or anterior pelvic tilt. The lumbar spine
weight onto the hands by moving the hips for- and pelvis should return to a neutral position as
wards into extension while in 4 point kneeling the subject rocks backwards to the starting posi-
(hands and knees). tion. The pelvis should have good symmetry; that
is, no lateral tilt or rotation. This test should be
Test procedure
The person should have the ability to actively
rock the body weight forwards over the hands by
extending the hips and controlling the lumbar
spine and pelvis. The person positions themselves
in 4 point kneeling (hands and knees) with the
lumbar spine and pelvis in neutral alignment
(Figure 5.57). Lumbopelvic motion is monitored
by the therapist. The therapist monitors the lum-
bosacral neutral position by palpating the spinous
process of L2, L5 and S2 with their finger tips
(Figure 5.58).
neutral. If the palpating fingers move closer
together, uncontrolled segmental lumbar exten-
sion hinge is identified.
The person is instructed to rock forwards from
the hips and shift their body weight forwards over
their hands, keeping the back straight (neutral
spine). Ideally, the neutral lumbar lordosis should
be maintained until the trunk is in a straight line Figure 5.58 Palpation of lumbosacral alignment during test
Figure 5.57 Start position for forward rocking test Figure 5.59 Benchmark for forward rocking test
140
performed without any feedback (self-palpation,

vision, tape, etc.) or cueing for correction.

UCM into extension relative to the hips under
extension load. During rocking forwards over the
hands, while the hips are extending, the lumbar
spine starts to extend before achieving 0° of hip
extension. During the attempt to dissociate the
lumbar spine and pelvis from independent hip
extension, the person either cannot control the
Figure 5.60 Correction with prone start position
UCM or has to concentrate and try hard.

vertebrae, then the UCM is interpreted as a segmental
extension hinge. The specific hinging segment should
be noted and recorded.
• If excessive lumbopelvic extension is observed, but no
one particular spinous process is hinging from the
multisegmental hyperextension.
Clinical assessment note for direction-specific Figure 5.61 Correction with ideal control in rocking forward

or rotation) is observed during a motor control keeping the trunk, pelvis and hips from moving,
(dissociation) test of extension control, do not score this and with the knees staying on the floor, slowly
as uncontrolled extension. The flexion and rotation motor push through the hands to lift the trunk away
from the floor. This ‘push up from the knees’
action does not require any active hip extension.
Instead, the hip starts in extension and just has
to prevent any further extension (Figure 5.61)
during the push up from the knees.
As control improves, the person positions
Rating and diagnosis of lumbar themselves in 4 point kneeling (hands and knees)
extension UCM with the lumbar spine and pelvis in neutral align-
(T12.1 and T12.2) ment. The person then rocks forwards shifting
partial weight towards their hands, but only as
far as lumbar extension and anterior pelvic tilt
Correction can be actively controlled or prevented (Figure
If control is poor, start with the person lying flat 5.62). There should be no provocation of any
in a prone position, with the hands positioned as symptoms, so long as the extension UCM can be
if to perform a ‘push up’ (Figure 5.60). Then, controlled. Progress until good control through
141
0° hip extension is easy, but not beyond this

range.
The person should self-monitor the lumbo-
pelvic alignment and control with a variety of
feedback options (T12.3). Visual feedback (e.g.
observation in a mirror) is also a useful retraining
tool.
Once the pattern of dissociation is efficient and
feels familiar, it should be integrated into various
functional postures and positions.
Figure 5.62 Correction with partial rocking forward from

hands and knees position
142
T12.1 Assessment and rating of low threshold recruitment efficiency of the Forward Rocking Test
from the Forward Rocking Test
FORWARD ROCKING TEST – 4 POINT
KNEELING position
multisegmental
watch the movement
hinge
(indicate level) Cueing and verbal Listen to feedback from another
correction observer
Multisegmental !
hyperextension
143
the lumbar spine and prevent lumbar extension.

T13 CROOK: DOUBLE BENT LEG LOWER The PBU is initially inflated to a base pressure of
TEST 40 mmHg while the lumbar spine is relaxed and
(tests for lumbar extension UCM) supported in a neutral resting position. During
the leg movement phase, some small movement
of the pelvis is normal. This is accounted for in
the test by allowing a small tolerance of pressure
dissociate and control lumbar extension and
change during the leg movement phase. There-
anterior pelvic tilt then lower both feet to the
fore, a pressure increase or decrease of 10 mmHg
floor by actively extending the hips (from flexion)
either side of the base pressure of 40 mmHg is
in a crook lying position.
acceptable.
The therapist then passively lifts both feet off
Test procedure
the floor until the hips are flexed to 90° (Figure
The person should have the ability to lower both 5.64). Normally a pressure increase is noted at
feet to the floor (in crook lying) by extending the this point as the back flexes slightly onto the PBU.
hips from 90° flexion to 45° flexion, while con- Keeping the thighs vertical with the hips at 90°
currently controlling the lumbar spine and pelvis. (supported passively by the therapist), the person
The person lies on the back in crook lying (hips is instructed to actively reposition the pelvic tilt
and knees bent and feet resting on the floor), with to return the back to neutral and the base pressure
the lumbar spine and pelvis relaxed in neutral to 40 mmHg keeping the hips at 90° (Figure
alignment (Figure 5.63). Lumbopelvic motion is 5.65). The person is then required to actively take
monitored by the placement of a Pressure Bio- the weight of their legs and hold this position and
feedback Unit (PBU) (Stabilizer – Chattanooga) keep the PBU pressure at 40 mmHg for at least 5
under the back, centred at L3 in the middle of the seconds without therapist support. If the person
lumbar lordosis (Figures 5.14 and 5.15). During cannot maintain the unsupported leg position at
limb load tests and exercises the PBU can objec- 90° of hip flexion and the pressure at 40 mmHg,
tively monitor the functional stability of the the test is discontinued. So long as the person can
trunk. In crook lying the PBU is inflated to a base maintain the pressure at 40 mmHg they are then
pressure of 40 mmHg (Figure 5.16). This pressure instructed to slowly lower both heels (simultane-
is used to position and support the lumbar spine ously) to the floor while keeping the back stable
in neutral alignment. Under functional limb load (no pressure change).
or movement, no pressure change = no loss of Ideally, the person should be able to slowly
neutral position = good control. If the lumbar lower both feet towards the floor and maintain
spine extends beyond the neutral starting position the pressure at 40 mmHg (±10 mmHg while the
a decrease in pressure is registered by the PBU. legs are moving). The person should hold the legs
The person is permitted to watch the PBU to steady just a few millimetres off the floor (45°
monitor the accuracy of their ability to control hip flexion) while keeping the pressure constant
Figure 5.64 Passive support to 90° of hip flexion and

Figure 5.63 Start position for double bent leg lower test reposition lumbar spine to achieve 40 mmHg
144
Figure 5.65 Unsupported leg load Figure 5.66 Benchmark for double bent leg lower test
at 40 mmHg (Figure 5.66). As soon as any pres- relatively less load and specific facilitation of the
sure decrease (towards 30 mmHg) is registered oblique abdominals can be used.
the movement must stop and the feet be returned
(one at a time) back to the start position.
• If increased extension (increased lumbar lordosis) of the
If no PBU is available the therapist should place whole lumbar region and increased anterior pelvic tilt
their hand under the lumbar lordosis instead of are observed, but no one particular vertebral level is
the PBU. It has been anecdotally claimed that the dominant from the adjacent vertebrae, then the UCM
hand is sensitive to a pressure change roughly is interpreted as a multisegmental hyperextension.
equivalent to 40 mmHg. So, if no pressure
decrease is detected by the hand, the control
would seem to be within the limits as determined Clinical assessment note for direction-specific
by the PBU. motor control testing
Lumbar extension UCM If some other movement (e.g. a small amount of flexion
or rotation) is observed during a motor control
The person complains of extension-related symp- (dissociation) test of extension control, do not score this
toms in the lumbar spine. The lumbar spine has as uncontrolled extension. The flexion and rotation motor
UCM into extension relative to the hips under control tests will identify if the observed movement is
extension load. During a double leg lower in uncontrolled. A test for lumbar extension UCM is only
crook lying, the lumbar spine starts to extend positive if uncontrolled lumbar extension is demonstrated.
before the feet reach the floor. During the attempt
to control lumbar extension and anterior pelvic
tilt from independent hip extension, the person
either cannot control the UCM or has to concen- extension UCM
trate and try hard. (T13.1 and T13.2)
In the process of trying to keep the back neutral,
the pelvis must not tilt anteriorly and extend the
lumbar spine. A pressure decrease of more than Correction
10 mmHg (decrease to more than 30 mmHg) The person lies in crook lying with the lumbar
indicates excessive uncontrolled anterior tilt and spine and pelvis relaxed in neutral alignment.
a loss of stability into spinal extension. As soon Lumbopelvic position is monitored by the place-
as any pressure increase (beyond 50 mmHg) is ment of a PBU under the back, centred at L3 in
registered the leg movement must stop and the the middle of the lumbar lordosis. Inflate the
feet lower back to the start position. If control is PBU to a base pressure of 40 mmHg. The PBU
poor, a series of graduated progressions using maintains the neutral spine.
145
The person is permitted to watch the PBU to

monitor the accuracy of their ability to control
the lumbar spine and prevent lumbar extension.
During all retraining of uncontrolled lumbar
extension a pressure increase of 10 mmHg is
acceptable during unsupported leg movements.
That is, if the start pressure is 40 mmHg a pres-
sure increase of 10 mmHg (up to 50 mmHg) is
acceptable during leg movement. Likewise, if the
start pressure is 45 mmHg (with oblique abdomi-
nal facilitation) a pressure increase of 10 mmHg
(up to 55 mmHg) is acceptable during leg move-
ment. However, when leg movement stops the
pressure must be maintained at the original start
Figure 5.67 Facilitation with opposite knee to hand push
pressure.
Oblique abdominal facilitation

If uncontrolled lumbar extension is identified,
facilitation of the oblique abdominals is encour-
aged. Take a relaxed breath in and breathe out.
Do not breathe as the low lateral abdominal wall
is hollowed (drawn up and in) in an attempt to
flatten the lumbar lordosis and increase pressure
on the pad. Specific external oblique abdominal
facilitation is achieved by cueing active lower
ribcage depression. Ensure that no pelvic tilt
occurs. The pad maintains the neutral spine. Hold
this contraction and breathe gently.
Ideally, with efficient oblique abdominal
recruitment, the pressure should increase by
8–10 mmHg (from 40 mmHg to approximately Figure 5.68 Facilitation with second leg lift
48–50 mmHg). The pressure increase should be
able to be consistently maintained.
A pressure increase of 15–20 mmHg (55–
60 mmHg) indicates posterior tilt and reversal of increase or decrease is registered the movement
the lumbar lordosis to the flat position. This pres- must stop and return to the start position. Do not
sure change is associated with bracing strategies. stabilise with the opposite foot or allow substitu-
(A bracing strategy is acceptable under double leg tion or fatigue.
load when strength training is the aim, rather
than motor control training.)
Static diagonal heel lift: isometric knee to
hand push + 2nd heel lift
Static diagonal: isometric opposite
First facilitate the oblique abdominals (PBU held
knee to hand push at 48–50 mmHg or other hand to monitor that
First facilitate the oblique abdominals (PBU held no pressure change = spinal control), slowly lift
at 48–50 mmHg or other hand to monitor that one knee towards the opposite hand and push
no pressure change = spinal control), slowly lift them isometrically against each other on a diago-
one knee towards the opposite hand and push nal line. While keeping this pressure, slowly lift
them isometrically against each other on a diago- the second heel off the floor and bring it up
nal line (Figure 5.67). Push for 10 seconds and beside the first leg. (Figure 5.68) Hold this posi-
repeat 10 times so long as stability is maintained tion for 10 seconds and repeat 10 times so long
(no pressure change). As soon as any pressure as stability is maintained (no pressure change).
146
Figure 5.69 Progression: first leg lift Figure 5.71 Progression: first leg lower
hips flexed to 90° and both feet off the floor is the
starting position.
Hold this position and, keeping the back stable
(no pressure change), slowly lower one heel to
the floor (Figure 5.71) and lift it back to the start
position. Repeat this movement, slowly alternat-
ing legs, for 10 seconds so long as stability is
maintained (no pressure change), and then return
both feet to the floor. Repeat the whole process
10 times.
As soon as any pressure decrease (or increase)
is registered the movement must stop and return
to the start position. The point of greatest risk of
losing stability is when the heel is lowering to the
Figure 5.70 Progression: second leg lift
floor. Do not allow substitution or fatigue.
As soon as any pressure increase or decrease is back options (T13.3). It is very useful to use a
registered the movement must stop and return to PBU for precise monitoring of lumbar position.
the start position. The point of greatest risk of Taping will also provide sensory feedback and
losing stability is when the second heel leaves the some degree of mechanical support to the control
floor. Do not allow substitution or fatigue. of extension. Visual feedback (e.g. observation in
a mirror) is also a useful retraining tool.
If control is poor, the leg lift with a controlled
Alternate single leg heel touch:
back and independent hip flexion should be per-
(Sahrmann level 1) formed only as far as lumbar extension and ante-
First facilitate the oblique abdominals (PBU held rior pelvic tilt can be actively controlled or
at 48–50 mmHg or other hand to monitor that prevented. There should be no provocation of any
no pressure change = spinal stability), slowly lift symptoms, so long as the lumbar extension can
one foot off the floor (Figure 5.69) and then lift be controlled. Once the pattern of dissociation is
the second foot off the floor and bring it up efficient and feels familiar, it should be integrated
beside the first leg (Figure 5.70). Crook lying with into various functional postures and positions.
147
T13.1 Assessment and rating of low threshold recruitment efficiency of the Double Bent Leg Lower Test
from the Double Bent Leg Lower Test
DOUBLE BENT LEG LOWER TEST – CROOK
LYING position
multisegmental
watch the movement
Lumbar Extension Multisegmental !
hyperextension
control of position
correction observer
148
maintenance of lumbar spine in a neutral posi-

T14 PRONE: DOUBLE KNEE BEND TEST tion during active knee flexion to 120°. Normally,
(tests for lumbar extension UCM) there will be paraspinal muscle activation but
there should be no increase in multisegmental
This dissociation test assesses the ability to actively lumbar extension or segmental shear into an
dissociate and control lumbar extension and extension hinge (marked skin crease) in the low
anterior pelvic tilt, then actively flex both knees lumbar spine. This test should be performed
to engage the point where rectus femoris tension without any feedback (self-palpation, vision,
starts to pull the pelvis into anterior tilt while tape, etc.) or cueing for correction.
lying prone.
Test procedure The person complains of extension-related symp-
In prone lying the lumbar spine is positioned in UCM into extension relative to rectus femoris
neutral alignment (long shallow lordosis) by tension and anterior tilt loading under extension
actively anteriorly or posteriorly tilting the pelvis load. The pelvis anteriorly tilts or the lumbar
from the sacrum (Figure 5.72). Monitor lum- spine starts to extend before the knees reach 120°
bopelvic motion by placing the one hand (oppo- flexion. During the attempt to maintain a neutral
site to the knee flexion) with fingers spread across lumbar spine and prevent uncontrolled lumbar
the low lumbar vertebrae and across the sacrum extension when rectus femoris tension pulls on
(alternative lumbopelvic monitoring: place hands the pelvis, the person either cannot control the
on lateral iliac crest). The person is instructed to UCM or has to concentrate and try hard.
bend both knees simultaneously. The lumbopel-
vic region should maintain a neutral position and • Note if one vertebral level appears to translate
not move into anterior tilt or increase in the forwards excessively, producing a skin crease as it
depth of the lordosis (monitor lumbar spine and hinges backwards into extension. If this segment is
sacrum) as the knees actively flex to approxi- observed as hinging into translation ‘out of line’
mately 120° (Figure 5.73). As soon as any ante- compared to the other vertebrae, then the UCM is
rior tilt or increase of lumbar lordosis is observed interpreted as a segmental extension hinge. The
(indicating a loss of neutral into extension), the specific hinging segment should be noted and
knee flexion must stop and return back to the recorded.
start position. • If increased extension (increased lumbar lordosis) of
Ideally, the person should have the ability to the whole lumbar region and increased anterior pelvic
tilt is observed, but no one particular vertebral level is
dissociate the lumbar spine from the rectus
femoris tension pulling the pelvis into anterior is interpreted as a multisegmental hyperextension.
tilt and lumbar extension, as evidenced by
Figure 5.72 Start position for double knee bend test Figure 5.73 Benchmark for double knee bend test
149


or rotation) is observed during a motor control

extension UCM Figure 5.74 Correction with PBU positioned under the
abdominal wall
(T14.1 and T14.2)
Correction
In prone lying position the lumbar spine is in
neutral alignment (long shallow lordosis).
Monitor the lumbar spine and sacrum position.
The person is instructed to bend both knees
simultaneously. The lumbopelvic region should
maintain a neutral position and not move into
anterior tilt or increase in the depth of the lordo-
sis as the knees actively flex. As soon as any
an-terior tilt or increase of lumbar lordosis is
observed (indicating a loss of neutral into exten-
sion), the knee flexion must stop and return back
to the start position.
femoris tension pulling the pelvis into anterior
tilt and lumbar extension, as evidenced by main-
tenance of lumbar spine in a neutral position
during active knee flexion to 120°. Normally,
there will be paraspinal muscle activation but
there should be no increase in multisegmental
lumbar extension or segmental shear into an Figure 5.75 Inflating the PBU to a base pressure of
extension hinge (marked skin crease) in the low 70 mmHg
lumbar spine. Only bend the knees as far as the
neutral lumbopelvic position (monitored with
feedback) can be maintained. The person should lumbopelvic position can be maintained. There
self-monitor the lumbopelvic alignment and must be no loss of neutral or give into extension.
control with a variety of feedback options (T14.3). As control of extension improves, the training can
Palpation feedback is the most useful retraining progress to bilateral knee flexion.
tool. There should be no provocation of any In some cases it may be useful to use a PBU to
symptoms within the range that the extension monitor control of the UCM. In prone lying the
UCM can be controlled. There must be no loss of lumbar spine is positioned in neutral alignment.
neutral or UCM into extension or anterior tilt. Place the PBU under the abdomen (centred about
If control is poor, start retraining with unilateral the umbilicus) (Figure 5.74). Inflate the pad to a
knee flexion, but only as far as the neutral base pressure of 70 mmHg (Figure 5.75). Take a
150
T14.1 Assessment and rating of low threshold recruitment efficiency of the Double Knee Bend Test
from the Double Knee Bend Test
DOUBLE KNEE BEND TEST – PRONE
multisegmental
Lumbar Extension Segmental extension ! watch the movement
hinge
(indicate level)
Multisegmental !
correction observer
hyperextension
151
Figure 5.77 Correction with abdominal pre-activation and

flexion of one knee
Figure 5.76 Correct abdominal pre-activation decreases PBU

pressure to 60 mmHg
relaxed breath in and breathe out. Do not breathe

as the low lateral abdominal wall is hollowed Figure 5.78 Progression: abdominal pre-activation and
(drawn up and in) in an attempt to flatten the flexion of both knees
lumbar lordosis and decrease pressure on the
pad. Ensure that no obvious pelvic tilt occurs.
Hold this abdominal contraction. Ideally, the neutral position (no pressure change) as the knee
pressure should decrease by 8–10 mmHg (from actively flexes (approximately 120°) As soon as
70 mmHg to approximately 60–62 mmHg) any pressure increase is registered (from 60 mmHg
(Figure 5.76). The pressure decrease should be towards 70 mmHg) indicating a loss of control
able to be consistently maintained. No pressure into extension, the movement must stop and
change indicates an efficient co-activation of the return back to the start position.
global and local stability muscles. A pressure If no PBU is available, the subject may place
increase indicates ineffective hollowing and sub- their opposite hand across the lumbopelvic junc-
stitution with a bracing action. tion to monitor for any loss of neutral position.
Keeping the pre-activation of the abdominal The knees may bend only as far as the neutral
muscles (extension control), the person is lumbopelvic position can be maintained without
instructed to fully bend one knee (Figure 5.77). straining or trying too hard. At this point the feet
Progress to bilateral knee flexion (Figure 5.78). are slowly eccentrically lowered back towards the
The lumbopelvic region should maintain a floor while also maintaining lumbopelvic neutral.
152
the movement must stop and return back to the

T15 PRONE (TABLE): HIP EXTENSION LIFT start position.
TEST Ideally, the lumbopelvic region should main-
(tests for lumbar extension UCM) tain a neutral position as the hip actively extends
as far as neutral (i.e. approximately horizontal).
Hip extension should be initiated and main-
tained by gluteus maximus. The hamstrings will
dissociate and control lumbar extension and
participate in the movement but should not dom-
anterior pelvic tilt, then actively extend one hip
inate. There will be paraspinal muscle activation
while lying prone with hips over the edge of a
(asymmetrically biased) but there should be no
table.
increase in multisegmental lumbar extension or
segmental shear into an extension hinge (marked
Test procedure skin crease) in the low lumbar spine. The hip
The person supports their trunk on a table, plinth extension must be independent of any lumbopel-
or bed, with the pelvis at the edge of the table and vic motion. Assess both sides. Note any excessive
both feet supported on the floor (the knees lumbar extension under hip extension load. This
slightly flexed) (Figure 5.79). The lumbar spine is test should be performed without any feedback
positioned in neutral alignment (long shallow (self-palpation, vision, tape, etc.) or cueing for
lordosis) by actively anteriorly or posteriorly correction.
tilting the pelvis from the sacrum. Monitor lum-
bopelvic motion by placing the one hand (oppo-
site to the leg extension) with fingers spread
across the low lumbar vertebrae and across the The person complains of extension-related symp-
sacrum (alternative lumbopelvic monitoring: toms in the lumbar spine. The lumbar spine has
place hands on lateral iliac crest). The person is UCM into extension relative to the hips under
instructed to slowly extend one knee and then to extension load. The pelvis anteriorly tilts or the
slowly lift the straight leg off the floor into hip lumbar spine starts to extend before the hip
extension to reach the horizontal position (0° reaches 0° extension. The hamstrings may appear
hip ‘neutral’). The lumbopelvic region should to be relatively more active than gluteus maximus
maintain a neutral position with no anterior during hip extension or overactivation of the
pelvic tilt or increase in the depth of the lordosis back extensor muscles and lumbar extension
(monitor lumbar spine and sacrum) as the hip may even initiate hip extension. During the
actively extends to approximately thigh horizon- attempt to maintain a neutral lumbar spine and
tal (Figure 5.80). As soon as any movement indi- prevent uncontrolled lumbar extension during
cating a loss of neutral into extension is observed, active hip extension, the person either cannot
Figure 5.79 Start position for hip extension lift test Figure 5.80 Benchmark for hip extension lift test
153
control the UCM or has to concentrate and

try hard.
• Note if one vertebral level appears to translate

forwards excessively, producing a skin crease as it
hinges backwards into extension. If this segment is
observed as hinging into translation ‘out of line’
compared to the other vertebrae, then the UCM is
interpreted as a segmental extension hinge. The
specific hinging segment should be noted and
recorded.
dominant from the adjacent vertebrae, then the UCM Figure 5.81 Correction with PBU positioned under the
is interpreted as a multisegmental hyperextension. abdominal wall
Clinical assessment note for direction-specific feedback) can be maintained. The person should
motor control testing self-monitor the lumbopelvic alignment and
control with a variety of feedback options (T15.3).
If some other movement (e.g. a small amount of flexion Palpation feedback is the most useful retraining
or rotation) is observed during a motor control tool. There should be no provocation of any
(dissociation) test of extension control, do not score this symptoms within the range that the extension
UCM can be controlled. There must be no loss of
neutral or UCM into extension or anterior tilt.
positive if uncontrolled lumbar extension is demonstrated. If control is poor it may be useful to use a PBU
to monitor control of the UCM. In prone lying
over the edge of the table, the lumbar spine is
positioned in neutral alignment. Place the PBU
unit under the abdomen (centred about the
Rating and diagnosis of lumbar umbilicus) (Figure 5.81). Inflate the pad to a
extension UCM base pressure of 70 mmHg (Figure 5.82). Take a
(T15.1 and T15.2) relaxed breath in and breathe out. Do not breathe
as the low lateral abdominal wall is hollowed
(drawn up and in) in an attempt to flatten the
Correction lumbar lordosis and decrease pressure on the
The person supports their trunk on a table, with pad. Ensure that no pelvic tilt occurs. Hold this
both feet supported on the floor and the lumbar abdominal contraction. Ideally, the pressure
spine positioned in neutral alignment (long should decrease by 8–10 mmHg (from 70 mmHg
shallow lordosis). Monitor lumbopelvic motion. to approximately 60–62 mmHg) (Figure 5.83).
The person is instructed to slowly extend one The pressure decrease should be able to be con-
knee and then to slowly lift the straight leg off the sistently maintained. No pressure change indi-
floor into hip extension. cates inefficient co-activation of the global and
Ideally, the person should have the ability to local stability muscles. A pressure increase indi-
dissociate the lumbar spine and pelvis as evi- cates ineffective hollowing and substitution with
denced by maintenance of the lumbar spine in a a bracing action.
neutral position during active hip extension to 0° Keeping the pre-activation of the abdominal
or thigh horizontal. The abdominal and gluteal muscles (extension control), the person is
muscles are co-activated to control the neutral instructed to fully extend one knee and then lift
spine and to prevent excessive lumbar extension. the straight leg into hip extension (Figure 5.84).
Only lift the hip into extension as far as the The lumbopelvic region should maintain a
neutral lumbopelvic position (monitored with neutral position (no pressure change) as the hip
154
T15.1 Assessment and rating of low threshold recruitment efficiency of the Hip Extension Lift Test
from the Hip Extension Lift Test
HIP EXTENSION LIFT TEST – PRONE
(TABLE) position
multisegmental
watch the movement
hinge
correction observer
Multisegmental !
hyperextension
155
Figure 5.84 Correction with abdominal pre-activation and

lifting one leg
actively extends (thigh horizontal – approxi-

mately 0°).
Figure 5.82 Inflating the PBU to a base pressure of If no PBU is available, the subject may place
70 mmHg their opposite hand across the lumbopelvic junc-
tion to monitor for any loss of neutral position.
Only lift the hip into extension as far as the
neutral lumbopelvic position (monitored with
the PBU) can be maintained without straining or
trying too hard. As soon as any pressure increase
is registered (from 60 mmHg towards 70 mmHg),
indicating a loss of control into extension, the
movement must stop and return back to the start
position. At this point the leg is slowly eccentri-
cally lowered back towards the floor while also
maintaining lumbopelvic neutral.
If control is particularly poor, the person may
only be able to dissociate the lumbar spine
(neutral) from hip extension to within 40° from
horizontal. As the ability to control lumbopelvic
extension gets easier and the pattern of dissocia-
tion feels less unnatural, the exercise can be pro-
gressed to hip extension level with the horizontal
(0°) and eventually into the full range of hip
extension (10–15° of extension above the
horizontal).
Figure 5.83 Correct abdominal pre-activation decreases PBU

pressure to 60 mmHg
156
to extend the hip 10–15° past the midline. The

T16 STANDING: HIP EXTENSION lumbar spine is positioned in neutral alignment
TOE SLIDE TEST (long shallow lordosis) by actively anteriorly or
(tests for lumbar extension UCM) posteriorly tilting the pelvis from the sacrum.
Monitor lumbopelvic motion by placing the one
hand (opposite to the leg extension) with fingers
spread across the low lumbar vertebrae and across
dissociate and control pelvic forward sway and
the sacrum (alternat ive lumbopelvic monitoring:
lumbar extension, then actively extend one hip
place hands on lateral iliac crest).
while standing.
The person is instructed to slowly bend one
knee, allowing the heel to lift, and keep the toes
in contact with the floor. The hip should now be
Test procedure
resting in 15–20° of flexion (Figure 5.86). From
The person stands tall and unsupported with legs this starting position, slowly slide the toes back-
straight and the lumbar spine and pelvis posi- wards along the floor so that the hip extends.
tioned in the neutral. The head is positioned Slide the toes back far enough to ensure that the
directly over the shoulders without chin poke hip extends past the midline to approximately
(Figure 5.85). Without letting the lumbopelvic 10–15° of extension (Figure 5.87). The lum-
region move into forward sway, or the pelvis bopelvic region should maintain a neutral posi-
move into anterior tilt and increased lumbar tion with no anterior pelvic tilt or increase in the
extension, the person should have the ability depth of the lordosis (monitor lumbar spine and
Figure 5.85 Neutral standing Figure 5.86 Start position for hip extension toe slide test
157

UCM into extension relative to the hips under
extension load. The pelvis anteriorly tilts or the
lumbar spine starts to extend before the hip
reaches 10–15° extension. During the attempt to
maintain a neutral lumbar spine and prevent
uncontrolled lumbar extension during active hip
extension, the person either cannot control the
UCM or has to concentrate and try hard.
• Note if one vertebral level appears to translate

forwards, excessively, producing a skin crease as it
hinges backwards into extension. If this segment is
observed as hinging into translation ‘out of line’
compared to the other vertebrae, then the UCM is
interpreted as a segmental extension hinge. The
specific hinging segment should be noted and
recorded.
is interpreted as a multisegmental hyperextension.
Figure 5.87 Benchmark for hip extension toe slide test Clinical assessment note for direction-specific

sacrum) and no forward sway of the pelvis or rotation) is observed during a motor control
(monitor the pelvis) as the hip actively extends (dissociation) test of extension control, do not score this
past the midline. As soon as any movement indi- as uncontrolled extension. The flexion and rotation motor
cating a loss of neutral into extension is observed, control tests will identify if the observed movement is
the movement must stop and return back to the uncontrolled. A test for lumbar extension UCM is only
start position. positive if uncontrolled lumbar extension is demonstrated.
Ideally, the lumbopelvic region should main-
tain a neutral position as the hip actively extends
10–15° past neutral. There will be paraspinal
muscle activation (asymmetrically biased) but
there should be no increase in multisegmental extension UCM
lumbar extension (increased lordosis) or sway (T16.1 and T16.2)
into a segmental extension hinge (marked skin
crease) in the low lumbar spine. The hip exten-
sion must be independent of any lumbopelvic Correction
motion. Assess both sides. Note any uncontrolled The person stands tall with their thighs right up
lumbar extension under hip extension load. This against a bench or table to limit any pelvic sway
test should be performed without any feedback or rotation (Figure 5.88). The abdominal and
(self-palpation, vision, tape, etc.) or cueing for gluteal muscles are co-activated to control the
correction. neutral spine and to prevent excessive lumbar
158
Figure 5.88 Correction with support Figure 5.89 Correction using wall fixation
extension and anterior tilt. Monitor lumbopelvic unnatural, the exercise can be progressed to the
motion with the hands if required. Bend one unsupported position without a bench or table.
knee, allowing the heel to lift with the toes in If control is very poor, start standing in a
contact with the floor. The hip should now be doorway or at a wall corner. Position the feet so
resting in 15–20° of flexion. From this starting that one foot can slide backwards (hip extension)
position, the hip is independently extended, by behind the body while the back is supported by
sliding the unweighted foot backwards (toes the doorway or wall. Activate the abdominals and
slide), but only as far as the neutral lumbopelvic gluteals to flatten the back towards the wall.
position (monitored with feedback) can be main- Maintain pressure against the wall as the
tained and without swaying the upper body or unweighted hip extends (toe slides backwards
shoulders backwards. behind the body). The hip is independently
The person should self-monitor the lumbopel- extended (Figure 5.89) by sliding the unweighted
vic alignment and control with a variety of feed- foot backwards, but only as far as the neutral
back options (T16.3). There should be no lumbopelvic position can be maintained and the
provocation of any symptoms within the range back does increase extension or the pelvis sway
that the extension UCM can be controlled. There off the wall.
must be no loss of lumbar neutral or UCM into
lumbar extension or pelvic sway. As the ability to
Lumbar extension UCM summary
control lumbar extension or pelvic sway gets
easier and the pattern of dissociation feels less (Table 5.5)
159
T16.1 Assessment and rating of low threshold recruitment efficiency of the Hip Extension Toe Slide Test
from the Hip Extension Toe Slide Test
HIP EXTENSION TOE SLIDE TEST
multisegmental
watch the movement
hinge
correction observer
Multisegmental !
hyperextension
160
Table 5.5 Summary and rating of lumbar extension tests

LUMBAR EXTENSION !
Standing: thoracic extension (sway)
Standing: thoracic extension (tilt)
Sitting: chest lift (tilt)
Sitting: forward lean
4 point: forward rocking
Crook: double bent leg lower
Prone: double knee bend
Prone (table): hip extension lift
Standing: hip extension toe slide
161
always demonstrate either open chain or closed

Tests of lumbopelvic rotation chain uncontrolled rotation.
control
LUMBOPELVIC ROTATION LUMBOPELVIC ROTATION ± SIDE-BEND
(ASYMMETRICAL/UNILATERAL)
CONTROL TESTS AND ROTATION Description of ideal pattern
CONTROL REHABILITATION
The subject is instructed to twist fully to the left
and right as they normally would. Ideally, there
These asymmetrical and unilateral load tests should be even rotation throughout the spine as
assess the extent of rotation, side-bend or side- the patient actively rotates, with both the spine
shift UCM in the lumbar spine and pelvic regions and legs concurrently contributing to the rota-
and assess the ability of the dynamic stability tion. The upper body (monitored by the line
system to adequately control rotation or lateral across the acromions) should turn approximately
load and strain. It is a priority to assess for rota- 90°. The legs (monitored by the relative position
tion UCM if the person complains of or demon- of the pelvis) should contribute approximately
strates unilaterally biased symptoms or disability 45°, while the spine should also contribute to the
or asymmetry of alignment. other 45° (position of upper body relative to the
Rotation or lateral stability dysfunctions are pelvis). Of the 45° of spinal rotation, approxi-
usually superimposed on top of a flexion or mately 10–15° should come from the lumbar
extension dysfunction. It is important to identify spine while the thoracic spine should provide the
the direction of rotational or shift UCM. There are majority of spinal rotation (30–35°). The pelvis
many tests that identify rotational stability should not sway forwards during rotation and
dysfunction. There is no particular progression there should be good symmetry of movement
implied by the order that they are presented. without any weight shift of the trunk or pelvis
They all use different co-activation synergies and (Figures 5.90 and 5.91).
different loads. It is a priority to assess for exten-
sion UCM if the patient complains of or demon- Movement faults associated with
strates extension-related symptoms or disability.
The tests that identify dysfunction can also lumbopelvic rotation
be used to guide and direct rehabilitation Relative stiffness (restrictions)
strategies.
• Hip rotation restriction – either hip may lack
Unlike flexion and extension control problems,
35–40° of normal range of rotation in
lumbopelvic rotation control does not have
standing twisting or turning movements. The
obvious direct links to functional movements.
lumbar spine or pelvis frequently increases
Rotation control faults are usually combined with
rotation to compensate for the lack of hip
lumbar flexion or extension UCMs which do have
mobility. Hip rotation range can be tested
functional links. The uncontrolled rotation con-
passively and dynamically with manual
tributes to asymmetry of alignment and unilateral
examination.
symptoms within lumbar flexion and extension
• Thoracic rotation restriction – the middle and
UCM. It is very uncommon for a primary lumbar
lower thoracic spine has a rotation restriction
dysfunction to present solely with uncontrolled
that may also contribute to compensatory
rotation while demonstrating good flexion and
increases in lumbopelvic range. This is
extension control. If a patient presents with lum-
confirmed with manual segmental
bopelvic pain and demonstrates good flexion and
assessment.
extension control, while concurrently demon-
strating poor control of rotation, this would
suggest that the primary problem of UCM is Relative flexibility (potential UCM)
related to the sacroiliac joints (SIJs), rather than • Lumbopelvic rotation. The lumbar spine and
the lumbar spine. UCM of the SIJ and pelvic pelvis may initiate functional movements
girdle are consistently unilateral in nature and into rotation and contribute more during
162
Figure 5.90 Ideal pattern of lumbopelvic rotation (side view) Figure 5.91 Ideal pattern of lumbopelvic rotation (front
view)
turning or twisting while the hips and 3. symptoms (pain, discomfort, strain)
thoracic contributions start later and associated with lumbopelvic rotation
contribute less. At the limit of turning or 4. asymmetrical or unilateral symptoms
twisting, excessive or hypermobile range of associated with flexion or extension
lumbopelvic rotation may be observed. movements
During the return to neutral the lumbopelvic 5. asymmetrical posture or alignment, in the
rotation persists and recovers later. lumbopelvic region.
In the assessment of lumbopelvic rotation move- The person complains of asymmetrical or
ment, the UCM can be identified as either open unilateral-related symptoms in the lumbar spine.
chain or closed chain. Under rotation or unilateral load, the lumbar
spine has UCM into rotation relative to the hips or
Indications to test for lumbopelvic relative to the thoracic spine. The dysfunction is
confirmed with rotation dissociation tests.
rotation UCM
1. hypermobile lumbopelvic rotation range
2. excessive initiation of rotation with
lumbopelvic rotation
163
Tests of open chain rotation

control
T17 SUPINE: SINGLE HEEL SLIDE TEST

(tests for lumbopelvic rotation UCM)

dissociate and control lumbopelvic rotation and
slide one heel along the floor (heel beside the
straight knee) by moving one hip through flexion
while in supine lying. During any unilateral or
asymmetrical limb load or movement, a rota-
tional force is transmitted to the lumbopelvic
region.
Test procedure
In supine lying, place two PBUs, clipped together,
under the lumbar lordosis (centred about L3 with
the join along the spine) (Figure 5.92). Alterna-
tively, place one PBU on one side of the spine and
a folded towel on the other side (Figure 5.93).
While lying relaxed with the legs straight, inflate
the pad(s) to a base pressure of 40 mmHg. The
PBU at this pressure maintains the neutral lordo-
sis. A loss of control into rotation causes a pres-
sure change on the pad(s). An increase in pressure
on a pad indicates rotation of the lumbopelvic
Figure 5.92 Self-positioning of two PBUs in the lumbar
region towards that side. A decrease in pressure lordosis
on a pad indicates rotation of the lumbopelvic
region away from that side. No pressure change =
no loss of neutral position = good control.
5.94). If no PBUs are available the control of
lumbopelvic position should be monitored with
When using two PBUs, if lumbopelvic rotation occurs, palpation and visual feedback. Using the PBU
one pad will increase pressure while the other pad will with the greatest pressure change to monitor the
decrease pressure. The change in pressure indicates the precision of lumbopelvic rotation control, the
direction of lumbopelvic rotation (e.g. if the pressure in person is instructed to keep the pelvis as level as
the right pad increases while the left decreases, then the possible (no pressure change) and to slide one
pelvis is rotating to the right). Usually, one PBU heel up along the floor to stop beside the other
demonstrates a greater pressure change than the other.
(straight) knee (Figure 5.95). The hip should be
For testing and retraining it is best that the person only
has to monitor one PBU. They should monitor
flexed to approximately 45°. Hold this position
lumbopelvic rotation control only with the PBU that has for about 5 seconds and then slowly straighten
the greatest change. the leg and slide the leg out to the start
position.
Ideally, the pelvis should not rotate and the
ASIS positions should remain symmetrical as the
With the person lying supine and with legs hip flexes up and returns. There should be no
extended and the feet together, both ASIS are significant pressure change in the pressure of both
checked for symmetry in the anteroposterior PBUs. A small change in pressure of less than
plane and both PBUs are set at 40 mmHg (Figure 5 mmHg (2 graduations) is acceptable while the
164
Figure 5.94 Start position for single heel slide test
Figure 5.93 Self-positioning of one PBU and a towel

Figure 5.95 Benchmark for single heel slide test
leg is moving, so long as both pads can be stabi- transmitted to the lumbopelvic region. The trunk
lised at 40 mmHg when the leg is stationary. rotation stabilisers are not able to effectively
The unilateral hip flexion must be independent control this rotation force. The lumbar spine has
of any lumbopelvic rotation. Assess both sides. UCM into lumbopelvic rotation relative to the
Note any excessive lumbopelvic rotation under hips under unilateral hip flexion load. During a
hip rotation load. The therapist should not rely single leg heel slide in supine that produces uni-
solely on the PBU. They should also use palpa- lateral hip flexion, the lumbopelvic region starts
tion of the pelvis and visual observation to deter- to rotate towards that side before the heel reaches
mine whether the control of rotation is adequate. the straight knee.
This test should be performed without any feed- Uncontrolled rotation is identified by an exces-
back (self-palpation, vision, tape, etc.) or cueing sive pressure increase in the PBU on that side as
for correction. The person is allowed to watch the the low back and pelvis rotates onto the pad (ipsi-
PBU, however, because it is required for the preci- lateral ASIS moves posteriorly). Uncontrolled
sion of the testing range. rotation can also be identified by an excessive
pressure decrease in the PBU on the other side
(straight leg side) as the low back and pelvis
Lumbopelvic rotation UCM rotates away from the pad (contralateral ASIS
The person complains of unilateral symptoms moves anteriorly). A change in pressure of
in the lumbar spine. During any unilateral or 5 mmHg (2 graduations) or more is not accept-
asymmetrical limb load a rotational force is able while the leg is moving. This indicates
165
uncontrolled lumbopelvic rotation. Uncontrolled

lumbopelvic rotation is also identified if both
pads cannot be symmetrically stabilised on
40 mmHg when the heel slide leg is stationary.
During the attempt to dissociate the lumbopel-
vic rotation from independent unilateral hip
flexion, the person either cannot control the UCM
or has to concentrate and try hard to dissociate
the lumbopelvic rotation from independent hip
movement. The movement must be assessed on
both sides. Note the direction that the rotation
cannot be controlled (i.e. is there uncontrolled
lumbopelvic rotation to the left or the right). It
may be unilateral or bilateral. If lumbopelvic
Figure 5.96 Correction: partial range heel slide
rotation UCM presents bilaterally, one side may
be better or worse than the other.
Clinical assessment note for direction-specific position with control of the lumbopelvic
motor control testing rotation UCM.
Ideally, the pelvis should not rotate and the
If some other movement (e.g. a small amount of flexion ASIS positions should remain symmetrical as the
or extension) is observed during a motor control hip flexes and returns. A small change in pressure
(dissociation) test of rotation control, do not score this as of less than 5 mmHg (2 graduations) is accepta-
uncontrolled rotation. The flexion and extension motor
ble while the leg is moving, so long as both pads
uncontrolled. A test for lumbopelvic rotation UCM is only
can be stabilised at 40 mmHg when the leg is
positive if uncontrolled lumbopelvic rotation is stationary. The person should self-monitor the
demonstrated. lumbopelvic alignment and control with a variety
of feedback options (T17.3). There should be no
provocation of any symptoms within the range
that the rotation UCM can be controlled.
During any unilateral or asymmetrical limb
Rating and diagnosis of lumbopelvic load a rotational force is transmitted to the lum-
rotation UCM bopelvic region. The lumbopelvic rotation stabil-
(T17.1 and T17.2) ity muscles control this rotational stress. The
oblique abdominal muscles, anterior fascicles of
psoas major and the superficial fibres of lumbar
Correction multifidus, which stabilise trunk rotation, must
With the person lying supine with legs extended coordinate with the hip flexor/rotator muscles,
and the feet together, both PBUs are set at which concentrically slide the leg up and eccentri-
40 mmHg. If no PBUs are available the control of cally return the leg to the start position. The
lumbopelvic position should be monitored uncontrolled lumbopelvic rotation is often asso-
with palpation and visual feedback. The person ciated with inefficiency of the trunk stabilisers
is instructed to keep the pelvis as level as possible (especially the oblique abdominals) to coordi-
(no pressure change) and to slide one heel nate with the limb muscles. (For example, the left
up along the floor beside the other (straight) external obliques and the right internal obliques
knee but only as far as neutral lumbopelvic rota- control the lumbopelvic rotation stability as the
tion can be controlled (monitored with feedback) right leg flexes and returns). If control is poor
(Figure 5.96). At the point in range that the the person lies supine and actively contracts the
lumbopelvic region starts to lose control of lateral oblique abdominal muscles to improve
rotation the movement should stop. The lum- control of lumbopelvic rotation. The contralat-
bopelvic position is restabilised; then hold this eral external oblique abdominals and the ipsilat-
position for a few seconds and return to the start eral internal oblique abdominals can be facilitated
166
T17.1 Assessment and rating of low threshold recruitment efficiency of the Single Heel Slide Test
from the Single Heel Slide Test
SINGLE HEEL SLIDE TEST – SUPINE
Site Direction Pelvis to the Pelvis to the position
left (L) right (R)
(check box) (check box) watch the movement
Lumbopelvic Rotation ! ! Adhesive tape Skin tension for tactile feedback
(open chain)
control of position
correction observer
167
separately to identify which is more effective at

controlling the rotation UCM.
External oblique abdominal recruitment

The instruction to actively pull the anterior lower
ribcage down and posteriorly in towards the spine
on the contralateral side is a good facilitation cue
for the external oblique abdominals. This should
be coordinated with the cue to ‘pull in’ the whole
abdominal wall at the same time. (Do not use the
transversus abdominis facilitation cue of only
‘hollowing’ the lower abdominal wall. Transver-
sus abdominis does not adequately control trunk
rotation.) Discourage bracing or bulging out of Figure 5.97 Progression: heel slide foot unsupported
the abdominal wall.
neutral position into rotation. It is also useful
Internal oblique abdominal recruitment to palpate the posterolateral iliac crest on the
The instruction to actively push or lift the ipsilat- ipsilateral (leg movement) side for loss of pelvic
eral ASIS in an anterior or forward direction is a neutral position. Some people will also need to
good facilitation cue for the internal oblique have their head supported in flexion so that they
abdominals. Visualise ‘pushing a button’ with the can use visual feedback and watch for the loss of
ipsilateral ASIS. This should be coordinated with control.
the cue to ‘pull in’ the whole abdominal wall at Once effective oblique abdominal facilitation
the same time. Discourage bracing or bulging out has been achieved, the person is then instructed
of the abdominal wall. to slowly slide one heel up towards the other
With an efficient ‘preset’ contraction of the knee. The heel slide can continue only as far as
appropriate oblique abdominals, the pressure there is no rotation of the pelvis at all.
should increase by 8–10 mmHg (from 40 mmHg As the ability to control the lumbopelvic region
to approximately 48–50 mmHg) on both PBU during independent hip rotation gets easier and
pads. This also provides a counter-rotation force the pattern of dissociation feels less unnatural the
for the uncontrolled lumbopelvic rotation under exercise can be progressed. A basic progression
unilateral limb load. If a PBU is not available, the would be to perform this movement then lift the
subject should palpate the ASIS on the contralat- heel beside the straight knee and hold it 5 cm off
eral side for feedback regarding loss of pelvic the floor (Figure 5.97).
168
T18 SUPINE: BENT KNEE FALL OUT TEST


lower the bent knee (heel beside the straight
knee) by moving the hip through abduction/
lateral rotation and back while in supine lying.
During any unilateral or asymmetrical limb load
or movement, a rotational force is transmitted to
the lumbopelvic region.
Test procedure Figure 5.98 Preparation to set the PBU base pressure at
40 mmHg
In supine lying, place two PBUs, clipped together,
under the lumbar lordosis (centred about L3 with
the join along the spine). Alternatively, place one
PBU on one side of the spine and a folded towel (Figure 5.99). If no PBUs are available the control
on the other side. While lying relaxed with the of lumbopelvic position should be monitored
legs straight, inflate the pad(s) to a base pressure with palpation and visual feedback. Using the
of 40 mmHg. The PBU at this pressure maintains PBU with the greatest pressure change to monitor
the neutral lordosis. A loss of control into rota- the precision of lumbopelvic rotation control, the
tion causes a pressure change on the pad(s). An person is instructed to keep the pelvis absolutely
increase in pressure on a pad indicates rotation level (no pressure change) and to slowly lower
of the lumbopelvic region towards that side. A the bent leg out to the side, keeping the foot sup-
decrease in pressure on a pad indicates rotation ported beside the straight leg. Ideally, the bent leg
of the lumbopelvic region away from that side. should be able to be lowered out through at least
No pressure change = no loss of neutral position 45° of the available range of hip abduction and
= good control. lateral rotation (Figure 5.100) and returned,
without associated pelvic rotation. A small change
in pressure of less than 5 mmHg (2 graduations)
When using two PBUs, if lumbopelvic rotation occurs, is acceptable while the leg is moving, so long as
one pad will increase pressure while the other pad will both pads can be stabilised on 40 mmHg when
decrease pressure. The change in pressure indicates the the leg is stationary.
direction of lumbopelvic rotation (e.g. if the pressure in The unilateral hip rotation must be independ-
the right pad increases while the left decreases, then the ent of any lumbopelvic rotation. Assess both
pelvis is rotating to the right). Usually, one PBU sides. Note any excessive lumbopelvic rotation
demonstrates a greater pressure change than the other.
under hip rotation load. The therapist should not
For testing and retraining it is best that the person only
has to monitor one PBU. They should monitor
rely solely on the PBU. They should also use pal-
lumbopelvic rotation control only with the PBU that has pation of the pelvis and visual observation to
the greatest change. determine whether the control of rotation is ade-
quate. This test should be performed without any
feedback (self-palpation, vision, tape, etc.) or
With the person lying supine and with legs cueing for correction. The person is allowed to
extended and the feet together, both ASIS are watch the PBU, however, because it is required for
checked for symmetry in the anteroposterior the precision of the testing range.
plane and both PBUs are set at 40 mmHg (Figure
5.98). The person moves one heel up beside the
Lumbopelvic rotation UCM
other knee. Ideally, the pelvis should not be
rotated here (no pressure change). If some rota- The person complains of unilateral symptoms in
tion is present, correct the pelvic alignment to get the lumbar spine. During any unilateral or
the pelvis level (both PBUs back at 40 mmHg) asymmetrical limb load a rotational force is
169
Figure 5.99 Start position of bent knee fall out test Figure 5.100 Benchmark bent knee fall out test
– reposition pelvis to achieve PBU pressure of 40 mmHg
transmitted to the lumbopelvic region. The trunk The person is unable to dissociate movement in
rotation stabilisers are not able to effectively the hip from the lumbar spine and pelvis. A
control this rotation force. The lumbar spine has change in pressure of 5 mmHg (2 graduations) or
UCM into rotation relative to the hips under uni- more is not acceptable while the leg is moving.
lateral hip rotation load. As the bent leg is lowered This indicates uncontrolled lumbopelvic rota-
out to the side, the pelvis begins to rotate to tion. Uncontrolled lumbopelvic rotation is also
follow the hip movement before 45° of rotation identified if both pads cannot be symmetrically
range is achieved. Uncontrolled lumbopelvic stabilised on 40 mmHg when the leg is
rotation is also identified if both pads cannot be stationary.
symmetrically stabilised on 40 mmHg when the During the attempt to dissociate the lumbopel-
bent knee fall out leg is stationary. The rotation vic rotation from independent unilateral hip
UCM is demonstrated by pressure increasing on flexion, the person either cannot control the UCM
the PBU on the side of leg movement as the low or has to concentrate and try hard to dissociate
back and pelvis rotates onto the pad (ipsilateral the lumbopelvic rotation from independent hip
ASIS moves posteriorly) or pressure decreasing on movement. The movement must be assessed on
PBU on the contralateral side to the leg move- both sides. Note the direction that the rotation
ment as the low back and pelvis rotates away from cannot be controlled (i.e. is there uncontrolled
the pad (contralateral ASIS moves anteriorly). lumbopelvic rotation to the left or the right). It
170
may be unilateral or bilateral. If lumbopelvic lumbopelvic alignment and control with a variety
rotation UCM presents bilaterally, one side may of feedback options (T18.3). There should be no
be better or worse than the other. provocation of any symptoms within the range
During any unilateral or asymmetrical limb
Clinical assessment note for direction-specific load a rotational force is transmitted to the lum-
motor control testing bopelvic region. The lumbopelvic rotation stabil-
ity muscles control this rotational stress. The
If some other movement (e.g. a small amount of flexion oblique abdominal muscles, anterior fascicles of
or extension) is observed during a motor control psoas major and the superficial fibres of lumbar
(dissociation) test of rotation control, do not score this as multifidus, which stabilise trunk rotation, must
coordinate with the hip adductor/rotator muscles,
which eccentrically lower the leg out to the side
positive if uncontrolled lumbopelvic rotation is and concentrically return the leg to the start posi-
demonstrated. tion. The uncontrolled lumbopelvic rotation is
often associated with inefficiency of the trunk sta-
bilisers (especially the oblique abdominals) to
coordinate with the limb muscles. For example,
Rating and diagnosis of lumbopelvic the left external obliques and the right internal
rotation UCM obliques control the lumbopelvic rotation stabil-
(T18.1 and T18.2) ity as the right leg lowers out to the side. If control
is poor, the person actively contracts the lateral
oblique abdominal muscles to improve control
Correction of lumbopelvic rotation. The contralateral exter-
With the person lying supine and with legs nal oblique abdominals and the ipsilateral
extended and the feet together, both PBUs are set internal oblique abdominals can be facilitated
at 40 mmHg. If no PBUs are available, the control separately to identify which is more effective at
of lumbopelvic position should be monitored controlling the rotation UCM.
with palpation and visual feedback. The person
is instructed to keep the pelvis as level as possible
(no pressure change) and to place one heel up External oblique abdominal recruitment
beside the other knee. If some rotation is present, The instruction to actively pull the anterior lower
correct the pelvic alignment to get the pelvis level ribcage down and posteriorly in towards the spine
(both PBUs back at 40 mmHg). Then, keeping on the contralateral side is a good facilitation cue
the pelvis absolutely level (no pressure change), for the external oblique abdominals. This should
slowly lower the bent leg out to the side, but only be coordinated with the cue to ‘pull in’ the whole
as far as neutral lumbopelvic rotation can be con- abdominal wall at the same time. (Do not use the
trolled (monitored with feedback). Hold this transversus abdominis facilitation cue of only
position for a few seconds and then return the leg ‘hollowing’ the lower abdominal wall. Transver-
out to the start position. At the point in range that sus abdominis does not adequately control trunk
the lumbopelvic region starts to lose control of rotation.) Discourage bracing or bulging out of
rotation the movement should stop. The lum- the abdominal wall.
bopelvic position is restabilised, then hold this
position for a few seconds and return to the start
position with control of the lumbopelvic rotation Internal oblique abdominal recruitment
UCM. The instruction to actively push or lift the ipsilat-
Ideally, the pelvis should not rotate and the eral ASIS in an anterior or forward direction is a
ASIS positions should remain symmetrical as the good facilitation cue for the internal oblique
leg rotates and returns. A small change in pressure abdominals. Visualise ‘pushing a button’ with the
of less than 5 mmHg (2 graduations) is accepta- ipsilateral ASIS. This should be coordinated with
ble while the leg is moving, so long as both pads the cue to ‘pull in’ the whole abdominal wall at
can be stabilised at 40 mmHg when the leg is the same time. Discourage bracing or bulging out
stationary. The person should self-monitor the of the abdominal wall.
171
T18.1 Assessment and rating of low threshold recruitment efficiency of the Bent Knee Fall Out Test
from the Bent Knee Fall Out Test
BENT KNEE FALL OUT TEST – SUPINE
left (L) right (R)
(open chain)
correction observer
control of position
172
With an efficient ‘preset’ contraction of the Once effective oblique abdominal facilitation
appropriate oblique abdominals, the pressure has been achieved, the person is then instructed
should increase by 8–10 mmHg (from 40 mmHg to slowly slide and lower one knee out to the side.
to approximately 48–50 mmHg) on both PBU The bent knee fall out can continue only as far as
pads. This also provides a counter-rotation force there is no rotation of the pelvis at all.
for the uncontrolled lumbopelvic rotation under As the ability to control the lumbopelvic region
unilateral limb load. If a PBU is not available, the during independent hip rotation gets easier and
subject should palpate the ASIS on the contralat- the pattern of dissociation feels less unnatural,
eral side for feedback regarding loss of pelvic the exercise can be progressed. A basic progres-
neutral position into rotation. It is also useful to sion would be to perform this movement with the
palpate the posterolateral iliac crest on the ipsilat- leg unsupported. That is, lift the heel of the bent
eral (leg movement) side for loss of pelvic neutral leg 5 cm off the supporting surface and control
position. Some people will also need to have their lumbopelvic rotation during an unsupported
head supported in flexion so that they can use bent knee fall out.
visual feedback and watch for the loss of control.
173
performed without any feedback (self-palpation,

T19 SIDE-LYING: TOP LEG TURN OUT TEST vision, flexicurve, etc.) or cueing for correction.
(tests for lumbopelvic rotation UCM) The therapist should use visual observation of the
pelvis to determine whether the control of lum-
This dissociation test assesses the ability to actively bopelvic rotation is adequate when feedback is
dissociate and control lumbopelvic rotation and removed for testing.
lift the top knee (hip and knee flexion) by lifting
the top hip through abduction/lateral rotation Lumbopelvic rotation UCM
and back while in side-lying position During any
unilateral or asymmetrical limb load or move- The person complains of unilateral symptoms in
ment, a rotational force is transmitted to the lum- the lumbar spine. The lumbar spine has UCM
bopelvic region. into rotation relative to the hips under unilateral
hip rotation load. As the top leg turns up and out
to the side, the pelvis begins to rotate to follow
Test procedure the hip movement before 15° of rotation range
The person lies on one side with hips flexed to above horizontal is achieved. Uncontrolled lum-
45° and the knees flexed to 90° and the feet bopelvic rotation is also identified if the ASIS
together (Figure 5.101). The pelvis should be rotates away from contact with the flexicurve
positioned in neutral rotation. For initial teaching before 15° of lateral rotation range above hori-
of the test movement, a ‘flexicurve’ can be posi- zontal is achieved (Figure 5.103).
tioned so that one end of the ‘flexicurve’ contacts
the ASIS of the pelvis to provide a reference
marker for the control of lumbopelvic rotation.
The person is instructed to keep the pelvis from
rotating backwards (maintain ASIS contact with
the flexicurve) and slowly lift the uppermost knee
up and out to the side while keeping the heels
together. Ideally, the top leg should be able to
turn up and out to at least 15° (above horizontal)
of hip abduction and lateral rotation (Figure
5.102) and return, without associated lumbopel-
vic rotation.
The unilateral hip rotation must be independ-
ent of any lumbopelvic rotation. Assess both
sides. Note any excessive lumbopelvic rotation
under hip rotation load. This test should be Figure 5.102 Benchmark top leg turn out test
Figure 5.103 Monitoring uncontrolled movement with a

Figure 5.101 Start position top leg tun out test flexicurve
174
During the attempt to dissociate the lumbopel- Ideally, the pelvis should not rotate as the leg
vic rotation from independent unilateral hip turns out and returns. The person should self-
lateral rotation and abduction, the person either monitor the lumbopelvic alignment and control
cannot control the UCM or has to concentrate with a variety of feedback options (T19.3). There
and try hard to dissociate the lumbopelvic rota- should be no provocation of any symptoms
tion from independent hip movement. The move- within the range that the rotation UCM can be
ment must be assessed on both sides. Note the controlled.
direction that the rotation cannot be controlled During any unilateral or asymmetrical limb
(i.e. is there uncontrolled lumbopelvic rotation to load a rotational force is transmitted to the lum-
the left or the right). It may be unilateral or bilat- bopelvic region. The lumbopelvic rotation stabil-
eral. If lumbopelvic rotation UCM presents bilat- ity muscles control this rotational stress. The
erally, one side may be better or worse than the oblique abdominal muscles, anterior fascicles of
other. psoas major and the superficial fibres of lumbar
multifidus, which stabilise trunk rotation, must
coordinate with the hip abductor/rotator muscles,
Clinical assessment note for direction-specific which concentrically lift the leg out to the side
motor control testing and eccentrically lower the leg to the start posi-
tion. The uncontrolled lumbopelvic rotation is
or extension) is observed during a motor control
often associated with inefficiency of the trunk sta-
(dissociation) test of rotation control, do not score this as bilisers (especially the oblique abdominals) to
uncontrolled rotation. The flexion and extension motor coordinate with the limb muscles. (For example,
control tests will identify if the observed movement is the left external obliques and the right internal
uncontrolled. A test for lumbopelvic rotation UCM is only obliques control the lumbopelvic rotation stabil-
positive if uncontrolled lumbopelvic rotation is ity as the right leg lifts out to the side.) If control
demonstrated. is poor, the person actively contracts the lateral
of lumbopelvic rotation. The contralateral exter-
nal oblique abdominals and the ipsilateral inter-
Rating and diagnosis of lumbopelvic nal oblique abdominals can be facilitated
rotation UCM separately to identify which is more effective at
(T19.1 and T19.2) controlling the rotation UCM.
Correction External oblique abdominal recruitment

With the person side-lying and the hips flexed to The instruction to actively pull the anterior lower
45°, the knees flexed to 90° and the feet together, ribcage down and posteriorly in towards the spine
the pelvis should be positioned in neutral rota- on the contralateral side is a good facilitation cue
tion. The person is instructed to keep the pelvis for the external oblique abdominals. This should
vertical and prevent the pelvis from rotating back- be coordinated with the cue to ‘pull in’ the whole
wards as they lift the top leg up and out to the abdominal wall at the same time. (Do not use the
side. The heels stay together, and the ‘turn out’ is transversus abdominis facilitation cue of only
produced from independent hip lateral rotation ‘hollowing’ the lower abdominal wall. Transver-
and abduction. The top leg lifts into the turn out sus abdominis does not adequately control trunk
only as far as neutral lumbopelvic rotation can be rotation.) Discourage bracing or bulging out of
controlled (monitored with feedback). Hold this the abdominal wall.
position for a few seconds and then lower the leg
out to the start position. At the point in range that
the lumbopelvic region starts to lose control of Internal oblique abdominal recruitment
rotation the movement should stop. The lum- The instruction to actively push or lift the ipsilat-
bopelvic position is restabilised, then hold this eral ASIS in an anterior or forward direction is a
position for a few seconds and return to the start good facilitation cue for the internal oblique
position with control of the lumbopelvic rotation abdominals. Visualise ‘pushing a button’ with the
UCM. ipsilateral ASIS. This should be coordinated with
175
T19.1 Assessment and rating of low threshold recruitment efficiency of the Top Leg Turn Out Test
from the Top Leg Turn Out Test
TOP LEG TURN OUT TEST – SIDE-LYING
left (L) right (R)
(open chain)
correction observer
176
the cue to ‘pull in’ the whole abdominal wall at retraining exercise on the floor with the pelvis,
the same time. Discourage bracing or bulging out thoracic spine and heels supported back against
of the abdominal wall. a wall for additional support and feedback.
Once effective oblique abdominal facilitation As the ability to control the lumbopelvic region
has been achieved, the person is instructed to during independent hip rotation gets easier and
slowly lift the top knee up and out to the side. the pattern of dissociation feels less unnatural the
The top leg turn out can continue only as far as exercise can be progressed. A basic progression
there is no rotation of the pelvis at all. would be to perform this movement with the leg
If lumbopelvic rotation control is very poor, the unsupported. That is, lift the heel of the top leg
use of the ‘flexicurve’ positioned at the ASIS, or 5 cm from the other heel and control lumbopel-
using hand palpation on the iliac crest to self- vic rotation during an unsupported top leg turn
monitor the lumbopelvic rotation control, is out.
essential. It may even be useful to perform the
177
moving the foot from one side to the other.

T20 PRONE: SINGLE HIP ROTATION TEST Moving the foot out to the side medially rotates
(tests for lumbopelvic rotation UCM) the hip (Figure 5.105) while moving the foot in
across the body laterally rotates the hip (Figure
This dissociation test assesses the ability to actively 5.106). Ideally, the neutral lumbopelvic position
dissociate and control lumbopelvic rotation and should be controlled through at least 30° hip
rotate hip through medial and lateral rotation medial and lateral rotation each side of neutral
while lying prone. During any unilateral or asym- (vertical lower leg) and returned, without associ-
metrical limb load or movement, a rotational ated pelvic rotation.
force is transmitted to the lumbopelvic region. The unilateral hip rotation must be independ-
ent of any lumbopelvic rotation. Assess both
sides. Note any excessive lumbopelvic rotation
Test procedure
under hip rotation load. This test should be per-
The person lies in prone with the legs extended formed without any feedback (self-palpation,
and the lumbopelvic region supported in neutral. vision, etc.) or cueing for correction. When feed-
The hip is positioned in neutral rotation and one back is removed for testing the therapist should
knee is flexed to 90° with the lower leg vertical use visual observation of the pelvis to determine
(Figure 5.104). The person is instructed to prevent whether the control of lumbopelvic rotation is
lumbopelvic rotation and rotate the hip by adequate.
Figure 5.105 Benchmark single hip rotation test (medial

Figure 5.104 Start position single hip rotation test rotation)
178
bilaterally, one side may be better or worse than

the other.


(dissociation) test of rotation control, do not score this as
positive if uncontrolled lumbopelvic rotation is
demonstrated.
Rating and diagnosis of lumbopelvic

rotation UCM
(T20.1 and T20.2)
Correction
The person lies prone with the legs extended and
together with the lumbopelvic region supported
in neutral. One knee is flexed to 90°and the hip
is positioned in neutral rotation with the lower
leg vertical. They are instructed to maintain a
neutral pelvic position and prevent the pelvis
from rotating to either side as the hip rotates to
Figure 5.106 Benchmark single hip rotation test (lateral each side. The hip should rotate only as far as
rotation)
neutral lumbopelvic rotation can be controlled
(monitored with feedback). At the point in range
that the lumbopelvic region starts to lose control
of rotation the movement should stop. The lum-
The person complains of unilateral symptoms in bopelvic position is restabilised, then hold this
the lumbar spine. The lumbar spine has UCM position for a few seconds and return to the start
into rotation relative to the hips under unilateral position with control of the lumbopelvic rotation
hip rotation load. As the hip rotates medially or UCM.
laterally, the pelvis begins to rotate to follow the Ideally, the pelvis should not rotate as the hip
hip movement before 30° of rotation range is rotates and returns. The person should self-
achieved. monitor the lumbopelvic alignment and control
During the attempt to dissociate the lumbopel- with a variety of feedback options (T20.3). Self-
vic rotation from independent unilateral hip palpation of the pelvis is especially useful (Figures
lateral rotation and abduction, the person either 5.107 and 5.108). There should be no provoca-
cannot control the UCM or has to concentrate tion of any symptoms within the range that the
and try hard to dissociate the lumbopelvic rota- rotation UCM can be controlled.
tion from independent hip movement. The move- During any unilateral or asymmetrical limb
ment must be assessed on both sides. Note the load a rotational force is transmitted to the lum-
direction that the rotation cannot be controlled bopelvic region. The lumbopelvic rotation stabil-
(i.e. is there uncontrolled lumbopelvic rotation to ity muscles control this rotational stress. The
the left or the right). It may be unilateral or bilat- oblique abdominal muscles, anterior fascicles of
eral. If lumbopelvic rotation UCM presents psoas major and the superficial fibres of lumbar
179
T20.1 Assessment and rating of low threshold recruitment efficiency of the Single Hip Rotation Test
from the Single Hip Rotation Test
SINGLE HIP ROTATION TEST – PRONE
left (L) right (R)
(open chain) (L) hip lateral (R) hip lateral
rotation rotation
correction observer
(R) hip medial (L) hip medial
rotation rotation
180
Figure 5.107 Self-monitoring of rotation control Figure 5.108 Self-monitoring of rotation control
multifidus, which stabilise trunk rotation, must External oblique abdominal recruitment
coordinate with the hip extensor/rotator muscles, The instruction to actively pull the anterior lower
which eccentrically lower the leg to the side and ribcage down and posteriorly in towards the spine
concentrically return the leg to the start position. on the contralateral side is a good facilitation cue
The uncontrolled lumbopelvic rotation is often for the external oblique abdominals. This should
associated with inefficiency of the trunk stabilis- be coordinated with the cue to ‘pull in’ the whole
ers (especially the oblique abdominals) to coor- abdominal wall at the same time. (Do not use the
dinate with the limb muscles. For example, the transversus abdominis facilitation cue of only
left external obliques and the right internal ‘hollowing’ the lower abdominal wall. Transver-
obliques control the lumbopelvic rotation stabil- sus abdominis does not adequately control trunk
ity as the right leg moves out to the side. If control rotation.) Discourage bracing or bulging out of
is poor, the person actively contracts the lateral the abdominal wall.
of lumbopelvic rotation. The contralateral exter-
nal oblique abdominals and the ipsilateral Internal oblique abdominal recruitment
internal oblique abdominals can be facilitated The instruction to actively push or lift the ipsilat-
separately to identify which is more effective at eral ASIS in an anterior or forward direction is a
controlling the rotation UCM. good facilitation cue for the internal oblique
181
abdominals. Visualise ‘pushing a button’ with the can rotate only as far as there is no rotation of the
ipsilateral ASIS. This should be coordinated with pelvis at all.
the cue to ‘pull in’ the whole abdominal wall at As the ability to control the lumbopelvic region
the same time. Discourage bracing or bulging out during independent hip rotation gets easier, and
of the abdominal wall. the pattern of dissociation feels less unnatural,
Once effective oblique abdominal facilitation the exercise can be progressed. A basic progres-
has been achieved, the person is then instructed sion would be to perform this movement with a
to slowly rotate the leg out to the side. The leg boot or light weight attached to the foot.
182
soon as any lumbopelvic rotation occurs (indicat-

T21 PRONE: SINGLE KNEE FLEXION TEST ing a loss of neutral), the knee flexion must stop
(tests for lumbopelvic rotation UCM) and return back to the start position. This test
should be performed without any feedback (self-
This dissociation test assesses the ability to actively palpation, vision, flexicurve, etc.) or cueing for
dissociate and control lumbopelvic rotation and correction. When feedback is removed for testing
then actively flex one knee to engage the point the therapist should use visual observation of the
where rectus femoris tension starts to pull the pelvis to determine whether the control of lum-
pelvis into rotation while lying prone. bopelvic rotation is adequate.
Test procedure femoris tension pulling the pelvis into rotation as
In prone lying, the lumbar spine is positioned in evidenced by maintenance of the lumbar spine in
neutral alignment (long shallow lordosis) by a neutral position during active knee flexion to
actively anteriorly or posteriorly tilting the pelvis 120°. Normally, there will be paraspinal muscle
from the sacrum (Figure 5.109). The person is activation but there should be no increase in lum-
instructed to bend one knee. The lumbopelvic bopelvic rotation. This test should be performed
region should maintain a neutral position and without any feedback (self-palpation, vision,
not move into lumbopelvic rotation (monitor tape, etc.) or cueing for correction.
lumbar spine and sacrum) as the knee actively
flexes to approximately 120° (Figure 5.110). As Lumbopelvic rotation UCM
The person complains of unilateral symptoms in
the lumbar spine. The lumbar spine has uncon-
trolled movement into rotation relative to the
hips under unilateral knee flexion load. As the
knee flexes, the pelvis begins to rotate before
120° of knee flexion range.
vic rotation from independent unilateral knee
flexion and rectus femoris tension, the person
trate and try hard to dissociate the lumbopelvic
rotation from independent leg movement. The
movement must be assessed on both sides. Note
the direction that the rotation cannot be control-
Figure 5.109 Start position single knee flexion test led (i.e. is there uncontrolled lumbopelvic rota-
tion to the left or the right). It may be unilateral
or bilateral. If lumbopelvic rotation UCM presents
bilaterally, one side may be better or worse than
the other.


demonstrated.
Figure 5.110 Benchmark single knee flexion test
183
Rating and diagnosis of lumbopelvic The knee flexes only as far as neutral lumbopel-
rotation UCM vic rotation can be controlled (monitored with
feedback). Hold this position for a few seconds
(T21.1 and T21.2) and then lower the leg out to the start position.
At the point in range that the lumbopelvic region
starts to lose control of rotation the movement
Correction should stop. The lumbopelvic position is restabi-
In prone lying, position the lumbar spine in lised and the leg is returned to the start position
neutral alignment (long shallow lordosis). with control of the lumbopelvic rotation UCM.
Monitor lumbopelvic motion by placing the one Ideally, the pelvis should not rotate as the knee
hand (opposite to the knee flexion) with fingers flexes. The person should self-monitor the lum-
spread across the low lumbar vertebrae and across bopelvic alignment and control with a variety of
the sacrum (alternative lumbopelvic monitoring: feedback options (T21.3). There should be no
place hands on lateral iliac crest). The person is provocation of any symptoms within the range
instructed to bend one knee. that the rotation UCM can be controlled.
184
T21.1 Assessment and rating of low threshold recruitment efficiency of the Single Knee Flexion Test
from the top Single Knee Flexion Test
SINGLE KNEE FLEXION TEST – PRONE
Site Direction To the left To the right position
(L) (R)
(open chain)
correction observer
185
lumbopelvic motion. Assess both sides. Note any

T22 PRONE (TABLE): HIP EXTENSION LIFT excessive lumbopelvic rotation under unilateral
TEST hip extension load. This test should be performed
(tests for lumbopelvic rotation UCM) without any feedback (self-palpation, vision,
tape, etc.) or cueing for correction.
dissociate and control lumbopelvic rotation, Lumbopelvic rotation UCM
when actively extending one hip while lying
prone with hips over the edge of a table. During
the lumbar spine. The lumbar spine has UCM
any unilateral or asymmetrical limb load or
into rotation relative to the hips under unilateral
movement, a rotational force is transmitted to the
hip extension load. The pelvis rotates before the
lumbopelvic region.
hip reaches horizontal (0° extension).
Test procedure vic rotation from independent unilateral hip
The person supports their trunk on a table, plinth extension, the person either cannot control the
or bed with the pelvis at the edge of the table and UCM or has to concentrate and try hard to dis-
both feet supported on the floor (the knees sociate the lumbopelvic rotation from independ-
slightly flexed) (Figure 5.111). The lumbar spine ent hip movement. The movement must be
is positioned in neutral alignment (long shallow assessed on both sides. Note the direction that the
lordosis) by actively anteriorly or posteriorly rotation cannot be controlled (i.e. is there uncon-
tilting the pelvis from the sacrum. The person is trolled lumbopelvic rotation to the left or the
instructed to slowly extend one knee and then to right). It may be unilateral or bilateral. If lum-
slowly lift the straight leg off the floor into hip bopelvic rotation UCM presents bilaterally, one
extension to reach the horizontal position (0° side may be better or worse than the other.
hip ‘neutral’). The lumbopelvic region should
maintain a neutral position with no lumbopelvic Clinical assessment note for direction-specific
rotation (monitor lumbar spine and sacrum) as motor control testing
the hip actively extends to where the thigh is
approximately horizontal (Figure 5.112). As soon If some other movement (e.g. a small amount of flexion
as any movement indicating a loss of neutral into or extension) is observed during a motor control
lumbopelvic rotation is observed, the movement (dissociation) test of rotation control, do not score this as
must stop and return back to the start position. uncontrolled rotation. The flexion and extension motor
Ideally, the lumbopelvic region should main- control tests will identify if the observed movement is
tain a neutral position as the hip actively extends uncontrolled. A test for lumbopelvic rotation UCM is only
as far as neutral (i.e. approximately horizontal).
demonstrated.
The hip extension must be independent of any
Figure 5.111 Start position hip extension lift test Figure 5.112 Benchmark hip extension lift test
186
Rating and diagnosis of lumbopelvic Ideally, the person should have the ability
rotation UCM to dissociate the lumbar spine and pelvis as evi-
denced by maintenance of lumbar spine in a
(T22.1 and T22.2) neutral position during active hip extension to 0°
or thigh horizontal. The abdominal and gluteal
muscles are co-activated to control the neutral
spine and to prevent excessive lumbar extension.
Correction Only lift the hip into extension as far as the
The person supports their trunk on a table, with neutral lumbopelvic position (monitored with
both feet supported on the floor and the lumbar feedback) can be maintained. The person should
spine positioned in neutral alignment (long self-monitor the lumbopelvic alignment and
shallow lordosis). Monitor lumbopelvic motion control with a variety of feedback options (T22.3).
by placing the one hand (opposite to the leg Palpation feedback is the most useful retraining
extension) with fingers spread across the low tool. There should be no provocation of any
lumbar vertebrae and across the sacrum (alterna- symptoms within the range that the extension
tive lumbopelvic monitoring: place hands on UCM can be controlled. There must be no loss of
lateral iliac crest). The person is instructed to neutral or UCM into lumbopelvic rotation.
slowly extend one knee and then to slowly lift the If control is poor, the person may only be able
straight leg off the floor into hip extension. to dissociate the lumbar spine (neutral) from uni-
Hip extension should be initiated and main- lateral hip extension to within 40° from horizon-
tained by gluteus maximus. The hamstrings will tal. As the ability to control lumbopelvic rotation
participate in the movement but should not dom- gets easier and the pattern of dissociation feels
inate. There will be good contralateral paraspinal less unnatural, the exercise can be progressed to
muscle activation (asymmetrically biased) but hip extension level with the horizontal (0°) and
there should be no increase in lumbopelvic eventually into the full range of hip extension
rotation. (10–15° of extension above the horizontal).
187
T22.1 Assessment and rating of low threshold recruitment efficiency of the Hip Extension Lift Test
from the Hip Extension Lift Test
HIP EXTENSION LIFT TEST – PRONE (TABLE)
Site Direction To the left To the right position
(L) (R)
(open chain)
correction observer
188
acromions vertical over the ischiums (do not lean

T23 SITTING: SINGLE KNEE EXTENSION backwards) (Figure 5.113.). Without letting the
TEST lumbopelvic region move they should then
(tests for lumbopelvic rotation UCM) straighten one knee to within 10–15° of full
extension, keeping the back straight (neutral
spine) and without leaning back or allowing lum-
bopelvic rotation (Figure 5.114). Ideally, the
dissociate and control lumbopelvic rotation
person should have the ability to maintain the
while sitting, then actively extend one knee to
lumbopelvic region neutral and prevent the ham-
engage the point where hamstring tension starts
strings pulling the pelvis into lumbopelvic rota-
to unilaterally pull the pelvis into rotation. During
tion. This test should be performed without any
feedback (self-palpation, vision, tape, etc.) or
cueing for correction.
lumbopelvic region.
Test procedure Lumbopelvic rotation UCM

The person sits tall with the feet off the floor and The person complains of unilateral symptoms in
with the lumbar spine and pelvis positioned in the lumbar spine. The lumbar spine has UCM
neutral and with both feet off the floor. Make the into rotation under unilateral hamstring tension
spine as tall or as long as possible to position and lumbopelvic rotation occurs before the knee
the normal curves in an elongated ‘S’ with the reaches 10–15° from full extension.
Figure 5.113 Start position single knee extension test Figure 5.114 Benchmark single knee extension test
189
During the attempt to dissociate the lumbopel- in the neutral. They should monitor the lum-
vic rotation from unilateral hamstring tension, bopelvic rotation control by palpating the iliac
the person either cannot control the UCM or crest or sacrum. The person is instructed to keep
has to concentrate and try hard to dissociate the the back straight (neutral spine) and without
lumbopelvic rotation. The movement must be leaning back, slowly straighten one knee and
assessed on both sides. Note the direction that the prevent the pelvis from rotating backwards as
rotation cannot be controlled (i.e. is there uncon- tension is produced in the hamstrings. Only
trolled lumbopelvic rotation to the left or the move as far as neutral lumbopelvic rotation can
right). It may be unilateral or bilateral. If lum- be controlled (monitored with feedback). Hold
bopelvic rotation UCM presents bilaterally, one this position for a few seconds and then lower the
side may be better or worse than the other. leg to the start position. At the point in range that
the lumbopelvic region starts to lose control of
rotation the movement should stop. The lum-
Clinical assessment note for direction-specific bopelvic position is restabilised and the leg is
motor control testing returned to the start position with control of the
lumbopelvic rotation UCM.
If some other movement (e.g. a small amount of flexion Ideally, the pelvis should not rotate as the knee
or extension) is observed during a motor control extends. The person should self-monitor the lum-
bopelvic alignment and control with a variety of
feedback options (T23.3). Visual feedback (e.g.
uncontrolled. A test for lumbopelvic rotation UCM is only observation in a mirror) is also a useful retraining
positive if uncontrolled lumbopelvic rotation is tool. There should be no provocation of any
demonstrated. symptoms within the range that the rotation
UCM can be controlled.
If control is poor, it is acceptable to start with
unilateral (then progress to bilateral) knee exten-
Rating and diagnosis of lumbopelvic sion with a straight back, but only as far as the
rotation UCM neutral lumbopelvic position can be maintained.
(T23.1 and T23.2) Beware neurodynamic symptoms associated with
positive slump responses. Unload the neural
system with ankle plantarflexion or partial cervi-
Correction cal extension. Once the pattern of dissociation is
The person sits tall with the feet off the floor efficient and feels familiar it should be integrated
and with the lumbar spine and pelvis positioned into various functional postures and positions.
190
T23.1 Assessment and rating of low threshold recruitment efficiency of the Single Knee Extension Test
from the Single Knee Extension Test
SINGLE KNEE EXTENSION – SITTING
left (L) right (R)
(open chain)
correction observer
191
trunk by pushing down onto the floor. This test

Tests of closed chain rotation should be performed without any feedback (self-
control palpation, vision, etc.) or cueing for correction.
When feedback is removed for testing the thera-
pist should use visual observation of the pelvis to
T24 CROOK LYING: SINGLE LEG BRIDGE determine whether the control of lumbopelvic
EXTENSION TEST rotation is adequate.

lift the pelvis into a bridge and straighten one leg The person complains of unilateral symptoms in
while in supine lying. During any unilateral or the lumbar spine. During any unilateral or asym-
asymmetrical limb load or movement, a rota- metrical limb load a rotational force is transmit-
tional force is transmitted to the lumbopelvic ted to the lumbopelvic region. The trunk rotation
region. stabilisers are not able to effectively control this
rotation force. The lumbar spine has UCM into
rotation under unilateral long lever leg load. As
Test procedure
the weight is transferred to one foot and the other
The person lies in crook lying with the heels and leg extends, the pelvis begins to rotate and drop
knees together (Figure 5.115). Keeping the spine down on the unweighted extended leg side. The
in neutral, lift the pelvis just clear (5 cm) of the person is unable to control lumbopelvic rotation.
floor and hold this position. Slowly shift weight Cramping of the weight bearing hamstrings (sub-
onto one foot and extend the other knee, keeping stitution) indicates an inefficient pattern of gluteal
the knees and thighs side by side. Ideally, there recruitment.
should be no change to hip position (no flexion During the attempt to dissociate the lumbopel-
or extension). Maintain the neutral lumbopelvic vic rotation from unilateral leg loading, the
position and do not allow the pelvis to rotate or person either cannot control the UCM or has to
to shift laterally during the weight transfer and concentrate and try hard to control the lumbopel-
the unilateral leg extension (Figure 5.116). Return vic rotation. The movement must be assessed on
the foot to the floor and repeat the movement both sides. Note the direction that the rotation
with the opposite leg. As soon as any lumbopelvic cannot be controlled (i.e. is there uncontrolled
rotation (indicating a loss of neutral) or cramping lumbopelvic rotation to the left or the right). It
of the weight bearing hamstrings occurs, the may be unilateral or bilateral. If lumbopelvic
movement must stop and return back to the start rotation UCM presents bilaterally, one side may
position. Do not allow the arms to brace the be better or worse than the other.
Figure 5.115 Start position single leg bridge extension Figure 5.116 Benchmark single leg bridge extension
192
restabilised, then hold this position for a few

seconds and return to the start position (crook
lying with pelvis resting) with control of the lum-
If some other movement (e.g. a small amount of flexion bopelvic rotation UCM. Make sure that good
or extension) is observed during a motor control control of lumbopelvic rotation and side-shift is
(dissociation) test of rotation control, do not score this as maintained. Make sure that the gluteal muscles
uncontrolled rotation. The flexion and extension motor on the weight bearing leg are active and do not
control tests will identify if the observed movement is allow the hamstrings to cramp.
uncontrolled. A test for lumbopelvic rotation UCM is only A final progression would be to maintain lum-
positive if uncontrolled lumbopelvic rotation is bopelvic neutral and extend the knee as above
demonstrated. (no rotation or pelvic tilt), and then slowly flex
the hip and knee. Hip and knee flexion continues
until there is 90° of both hip and knee flexion
Rating and diagnosis of lumbopelvic (Figure 5.118). Then the hip and knee are extended
rotation UCM to reach the starting position but the hip contin-
ues to extend until the heel is lowered to the
(T24.1 and T24.2)
horizontal position (Figure 5.119). The hip then
Correction
Starting in crook lying with the feet and knees
together, the person lifts the pelvis 5 cm off the
floor while maintaining neutral alignment. Ini-
tially, transfer weight to one foot and only lift the
other heel a few centimetres from the floor (Figure
5.117). A further progression is to transfer weight
to one foot and only lift the other foot a few
centimetres from the floor while partially extend-
ing the unweighted leg. The unweighted leg is
progressively extended until full extension is
achieved. The person should only lift and extend
the unweighted leg as far as neutral lumbopelvic
rotation can be controlled (monitored with feed-
back). At the point in range that the lumbopelvic
region starts to lose control of rotation the move- Figure 5.118 Progression: bridge with hip and knee flexion
ment should stop. The lumbopelvic position is to 90°
Figure 5.117 Correction: bridge with weight transfer and Figure 5.119 Progression: bridge with hip and knee
single heel lift extension to horizontal
193
returns to the starting position. At all times the foot and only take partial weight off the other
pelvis stays unsupported and hip and knee move- foot (e.g. heel marching – heel lift but continue
ment occurs only as far as the rotation is control- to take weight on the ball of the foot).
led and as far as any restriction allows. The person can actively recruit the lateral
The person should self-monitor the lumbopel- oblique abdominal muscles to control pelvic
vic alignment and control with a variety of feed- rotation. The contralateral external oblique
back options (T24.3). There should be no abdominals are facilitated with contralateral
provocation of any symptoms within the range ribcage depression and the ipsilateral internal
that the rotation UCM can be controlled. oblique abdominals can be facilitated by holding
During any unilateral or asymmetrical limb the ASIS forward. This should be coordinated
load a rotational force is transmitted to the lum- with the cue to ‘hollow’ or ‘pull the whole abdom-
bopelvic region. The lumbopelvic rotation stabil- inal wall in’ at the same time. Discourage bracing
ity muscles control this rotational stress. In or bulging out of the abdominal wall. Also, preset
closed chain rotation control training, the trunk a deep gluteal contraction. Palpate for definite
rotator stabiliser muscles (the oblique abdominal contraction near the superior ischium without a
muscles, anterior fascicles of psoas major and the maximal lateral gluteal contraction posterior to
superficial fibres of lumbar multifidus) must the trochanter. Discourage the maximal ‘butt
coordinate with the hip rotator stabiliser muscles squeeze’ or the ‘butt gripping’ action.
(the deep gluteals, adductor brevis, pectineus and Once oblique abdominal and deep gluteal facil-
iliacus) to control lumbopelvic rotation from itation has been achieved in crook lying with the
above and below the pelvis. The uncontrolled heels and knees together, the person is then
lumbopelvic rotation is often associated with instructed to keep the spine and pelvis in neutral,
inefficiency of the trunk stabilisers (especially the then lift the pelvis just clear of the floor and hold
oblique abdominals) to coordinate with the limb this position. In this neutral bridge position, the
muscles (especially the gluteals). The person is person is then instructed to slowly shift weight
encouraged and trained to actively contract the onto one foot and, keeping the knees together,
lateral oblique abdominal muscles and the deep extend the other knee. One knee is extended and
gluteals to improve control of lumbopelvic returned to the floor, but only as far as the neutral
rotation. lumbopelvic position can be maintained. There
If control is very poor, starting in crook lying must be no loss of neutral or give into rotation.
with the feet and knees together, the person lifts There should be no provocation of any symptoms
the pelvis 5 cm off the floor while maintaining under unilateral load, so long as the lumbopelvic
neutral alignment. Initially, transfer weight to one rotation UCM can be controlled.
194
T24.1 Assessment and rating of low threshold recruitment efficiency of the Single Leg Bridge Extension Test
from the Single Leg Bridge Extension Test
SINGLE LEG BRIDGE EXTENSION TEST
– CROOK LYING position
Site Direction Pelvis to the Pelvis to the
left (L) right (R)
watch the movement
(check box) (check box)
Lumbopelvic Rotation ! !
(closed chain)
control of position
correction observer
195
the knees and dorsiflexing the ankles while

T25 STANDING: THORACIC ROTATION keeping both heels on the floor, as if sliding the
TEST back down a wall. Keep the trunk vertical and do
(tests for lumbopelvic rotation UCM) not lean the trunk forwards (Figure 5.120). Keep
the knees a little further apart than the heels to
orientate the long axis of the femur (the line of
the thigh) out over the middle toes.
Then, while standing with feet under hips, with
rotate the thoracic spine while standing. During
arms crossed and hands touching opposite shoul-
any asymmetrical or non-sagittal trunk move-
ders, the person is instructed to rotate the shoul-
ment a rotational force is transmitted to the lum-
ders and upper trunk around to each side (to
bopelvic region.
approximately 40°) but keep the low lumbar
spine and pelvis from moving. They should have
the ability to actively rotate the upper trunk and
Test procedure
thoracic spine independently of the lumbopelvic
The person stands with the feet hip-width apart region. Ideally, there should be symmetrical rota-
(heels approximately 10–15 cm apart) with the tion of the thoracic spine to both sides without
inside borders of the feet parallel (not turned lumbopelvic rotation. Ultimately, there should be
out). Stand upright with the upper body vertical approximately 40° of independent thoracic rota-
and the weight balanced over the midfoot. tion, without any pelvic rotation or lateral shift/
Perform a ‘small knee bend’ (SKB) by flexing at weight transfer (Figure 5.121). As soon as any
Figure 5.120 Start position thoracic rotation Figure 5.121 Benchmark thoracic rotation
196
lumbopelvic rotation occurs, the movement must The uncontrolled lumbopelvic rotation is often
stop and return back to the start position. This associated with inefficiency of the stability func-
test should be performed without any feedback tion of the oblique abdominals or the hip rota-
(self-palpation, vision, etc.) or cueing for correction stabilisers. (For example, the left external
tion. The therapist should use visual observation obliques and the right internal obliques control
of the pelvis to determine whether the control of the lumbopelvic rotation UCM to the right, while
lumbopelvic rotation is adequate when feedback the right posterior gluteus medius and maximus
is removed for testing. Assess both sides. control pelvic rotation to the right when weight
bearing.) During any asymmetrical or non-sagittal
Lumbopelvic rotation UCM trunk movement, a rotational force is transmitted
to the lumbopelvic region. The lumbopelvic rota-
The person complains of unilateral symptoms in tion stability muscles control this rotational load.
the lumbopelvic region. Lumbopelvic rotation The oblique abdominal muscles, anterior fasci-
begins to follow the upper trunk before the thorax cles of psoas major and superficial fibres of
reaches 40° of independent rotation range. The lumbar multifidus, which stabilise trunk rotation,
lumbar spine has UCM into rotation relative to must coordinate with the weight bearing deep hip
the thoracic spine under rotation load. In some muscles, which concentrically and eccentrically
cases the lumbopelvic region may even initiate control rotation of the pelvis from below.
the upper trunk rotation. During the attempt to dissociate the lumbopel-
If the lumbopelvic rotation stabilisers are not vic rotation from thoracic rotation, the person
able to effectively control this rotation force many either cannot control the UCM or has to concen-
maladaptive substitution strategies may be trate and try hard to control the lumbopelvic rota-
observed during rotation of the upper trunk: tion. The movement must be assessed on both
• Rotation of the pelvis (hip rotation) to sides. Note the direction that the rotation cannot
follow the upper trunk rotation. There is no be controlled (i.e. is there uncontrolled lum-
dissociation of rotation between the lumbar bopelvic rotation to the left or the right). It may
and thoracic regions. Instead they appear be unilateral or bilateral. If lumbopelvic rotation
rigid and the rotation occurs primarily at the UCM presents bilaterally, then one side may be
hips. better or worse than the other.
• Rotation of the pelvis initiates the movement
and the upper trunk appears to ‘tag along’
after the pelvis. Clinical assessment note for direction-specific
• Counter rotation of the pelvis occurs in the motor control testing
opposite direction to upper trunk rotation.
Occasionally, the pelvic counter-rotation may If some other movement (e.g. a small amount of flexion
initiate the movement. or extension) is observed during a motor control
• During rotation, the trunk flexes (this is
often related to a restriction of thoracic control tests will identify if the observed movement is
rotation). uncontrolled. A test for lumbopelvic rotation UCM is only
• During rotation, the pelvis sways forwards positive if uncontrolled lumbopelvic rotation is
into uncontrolled extension. demonstrated.
• During rotation, the thoracolumbar region
extends (sternal lift) along with scapular
retraction (rhomboids substituting for
thoracis paraspinal stabilisers to rotate the
thorax). rotation UCM
• During rotation, there is lateral shift of body (T25.1 and T25.2)
weight and the lumbopelvic region moves
into side-shift of the pelvis away from the
side of rotation (most common). Correction
Occasionally, it side-shifts towards the side The person stands in a ‘small knee bend’ with the
of rotation. Side-bending of the trunk feet hip width apart (heels approx 10–15 cm
accompanies lateral movement of the pelvis. apart) with the inside borders of the feet parallel
197
(not turned out), flexing at the knees and dorsi-

flexing the ankles while keeping both heels on the
floor, as if sliding the back down a wall. Then,
with the arms crossed, the person is instructed to
actively rotate the upper trunk and thoracic spine
independently of the lumbopelvic region to
each side. Only rotate the thorax as far as lum-
bopelvic rotation can be controlled (monitored
with self-feedback). At the point in range that
the lumbopelvic region starts to lose control of
rotation the movement should stop. The lum-
bopelvic position is restabilised, then hold this
position for a few seconds and return to the start
position with control of the lumbopelvic rotation
UCM.
back options (T25.3). There should be no
If control is particularly poor, the pattern of
correct movement may be taught with the person
sitting in neutral trunk alignment on a fixed chair
with the feet on the floor. The lumbopelvic region
should be either manually supported or sup-
ported by a low lumbar back support during the
active thoracic rotation. Once the pattern of
dissociation is established, progress to standing
where the person positions the ischiums (touch-
ing but not weight bearing) against the edge of a
table or bench for feedback about lumbopelvic Figure 5.122 Correction with ischial support
rotation control (Figure 5.122).
Additional facilitation can come from active
setting of the scapula in neutral and by active pre-
setting of the oblique abdominals.
198
T25.1 Assessment and rating of low threshold recruitment efficiency of the Thoracic Rotation Test
from the Thoracic Rotation Test
THORACIC ROTATION TEST – STANDING:
SMALL KNEE BEND position
left (L) right (R)
watch the movement
(closed chain)
correction observer
199
and dorsiflexing the ankles while keeping both

T26 STANDING: DOUBLE KNEE SWING heels on the floor, as if sliding the back down a
TEST wall. Keep the trunk vertical and do not lean the
(tests for lumbopelvic rotation UCM) trunk forwards (Figure 5.123). Keep the knees a
little further apart than the heels to orientate the
long axis of the femur (the line of the thigh) out
over the middle.
Then, while standing with the feet under hips
asymmetrically rotate legs while standing. During
in the SKB, with arms relaxed, the person is
instructed to keep the trunk and pelvis from
moving and swing both knees at least 20–30°
lumbopelvic region.
(hip rotation) to the same side (Figure 5.124).
This requires simultaneous but asymmetrical
Test procedure hip rotation to be coordinated with lumbopelvic
rotation control. When the knees swing to the
The person stands with the feet hip width apart right, the right hip laterally rotates while the left
(heels approx 10–15 cm apart) with the inside hip simultaneously medially rotates and vice
borders of the feet parallel (not turned out). versa to the other side. It is essential the foot
Stand upright with the upper body vertical and pronation and supination coordinates with the
the weight balanced over the midfoot. Perform a hip movement. So, when the knees swing to the
‘small knee bend’ (SKB) by flexing at the knees right, the right foot should supinate as the knee
Figure 5.123 Start position double knee swing Figure 5.124 Benchmark double knee swing
200
moves lateral to the 2nd metatarsal; and the left must coordinate with the weight bearing deep hip
foot should pronate when the knee moves medial muscles, which concentrically and eccentrically
to the 2nd metatarsal. control rotation of the pelvis from below.
Many people will experience a sensation of a During the attempt to dissociate the lumbopel-
lack of the required hip rotation range. This is vic rotation from thoracic rotation, the person
rarely a real loss of hip rotation as evidenced by either cannot control the UCM or has to concen-
assessment of hip rotation when moving each hip trate and try hard to control the lumbopelvic rota-
independently, one at a time. This test requires tion. The movement must be assessed on both
that, during testing for UCM, the knees swing at sides. Note the direction that the rotation cannot
least 20–30° each side so that the compensation be controlled (i.e. is there uncontrolled lum-
and UCM can be identified. bopelvic rotation to the left or the right). It may
Ideally, there should be approximately 20–30° be unilateral or bilateral. If lumbopelvic rotation
of independent double knee swing (asymmetrical UCM presents bilaterally, then one side may be
hip rotation), without any lumbopelvic rotation, better or worse than the other.
lateral pelvic shift or weight transfer at the feet.
Body weight should stay equally distributed on
each foot and there should be no lateral shift of Clinical assessment note for direction-specific
the pelvis. The feet should supinate and pronate motor control testing
following the knee movement. The 1st metatarsal
head (at the base of the big toe) should stay in
contact with the floor as the foot supinates on the (dissociation) test of rotation control, do not score this as
laterally rotating side. The metatarsal head should uncontrolled rotation. The flexion and extension motor
not lift off into foot inversion. This test should be control tests will identify if the observed movement is
performed without any feedback (self-palpation, uncontrolled. A test for lumbopelvic rotation UCM is only
vision, etc.) or cueing for correction. When feed- positive if uncontrolled lumbopelvic rotation is
back is removed for testing the therapist should demonstrated.
use visual observation of the pelvis to determine
whether the control of lumbopelvic rotation is
adequate. Assess both directions. Rating and diagnosis of lumbopelvic
rotation UCM
Lumbopelvic rotation UCM (T26.1 and T26.2)
the lumbopelvic region. Lumbopelvic rotation Correction
begins to rotate to follow the hips before the The person stands in a SKB position with the
double knee swing reaches 20–30° of independ- trunk supported, leaning against a wall. They
ent range. The lumbar spine has UCM into rota- should monitor lumbopelvic rotation control by
tion relative to the hips under rotation load. palpating both iliac crests for feedback regarding
The uncontrolled lumbopelvic rotation is often loss of position. Some people will also need to
associated with inefficiency of the stability func- use a mirror so that they can watch for the loss of
tion of the oblique abdominals or the hip rota- control. The person should actively contract the
tion stabilisers. (For example, the left external lateral abdominal muscles (especially the exter-
obliques and the right internal obliques control nal obliques with ribcage depression) to flatten
the lumbopelvic rotation UCM to the right, while the lumbar spine, especially on the contralateral
the right posterior gluteus medius and maximus side to knee swing. This also provides a counter-
control pelvic rotation to the right when weight rotation force for the uncontrolled lumbopelvic
bearing.) During any asymmetrical or non-sagittal rotation. The lumbar spine may be supported in
trunk movement, a rotational force is transmitted a neutral position with a folded towel if desired.
to the lumbopelvic region. The lumbopelvic rota- While maintaining a neutral lumbopelvic posi-
tion stability muscles control this rotational load. tion and using the wall for support, the person is
The oblique abdominal muscles, anterior fasci- instructed to actively swing the knees to the side,
cles of psoas major and superficial fibres of only as far as there is no rotation of the pelvis at
lumbar multifidus, which stabilise trunk rotation, all. At the point in range that the lumbopelvic
201
region starts to lose control of rotation, the knee the person is then instructed to swing one knee at
movement should stop, the lumbopelvic position a time to the left then to the right (photo sequence
is restabilised and the knees return to the start A (R) leg only: Figures 5.125, 5.126, 5.127; photo
position with control of the lumbopelvic rotation sequence B one leg at a time swing to (R): Figures
UCM. Allow the feet to roll into supination and 5.128, 5.129). Allow the feet to roll into supina-
pronation to follow the knees. As the ability to tion and pronation but keep all metatarsal heads
control the lumbopelvic region during independ- on the floor. Next, practise the same movement
ent hip rotation gets easier and the pattern of with both knees moving to the same side but one
dissociation feels less unnatural the exercise can after the other (not simultaneously). Then repeat
be progressed. A basic progression would be to the pattern to the other side. Finally, progress to
perform this movement without the support of swinging both knees to the same side, at the same
the wall. time, with the trunk still supported against the
The person should self-monitor the lumbo- wall.
pelvic alignment and control with a variety of An alternative option is to use a walk stance or
feedback options (T26.3). There should be no lunge position with the trunk upright and the
provocation of any symptoms within the range lumbopelvic region in neutral and facing for-
that the rotation UCM can be controlled. wards (Figure 5.130). Take approximately 2 3 of
If control is poor, the pattern of correct move- the weight on the front foot and 1 3 of the weight
ment may be taught with the person in the small on the rear foot. Maintain control of lumbopelvic
knee bend position with the trunk supported, rotation and swing the front knee independently
leaning against a wall. Maintaining a neutral lum- from side to side to rotate the hip (Figures 5.131
bopelvic position and using the wall for support, and 5.132). Maintain control of lumbopelvic
rotation and swing the rear knee independently
from side to side to rotate the hip (Figures 5.133
and 5.134). Practise with the right foot forward
and left foot forward.
Figure 5.125 Correction sequence A(i): start position Figure 5.126 Correction sequence A(ii): one leg swings out
202
Figure 5.127 Correction sequence A(iii): same leg swings in Figure 5.129 Correction sequence B(ii): other leg swings in
Figure 5.128 Correction sequence B(i): one leg swings out Figure 5.130 Correction sequence C(i) 1
2 lunge: start
position
203
Figure 5.131 Correction sequence C(ii) 1

2 lunge: front leg Figure 5.133 Correction sequence C(iv) 1
2 lunge: rear leg
swings in swings in
Figure 5.132 Correction sequence C(iii) 1

2 lunge: front leg Figure 5.134 Correction sequence C(v) 1
2 lunge: rear leg
swings out swings out
204
T26.1 Assessment and rating of low threshold recruitment efficiency of the Double Knee Swing Test
from the Double Knee Swing Test
DOUBLE KNEE SWING TEST – STANDING:
SMALL KNEE BEND position
left (L) right (R)
watch the movement
(closed chain)
correction observer
205
stationary against the wall, they are instructed to

T27 STANDING: TRUNK SIDE-BEND TEST side-bend against the wall, first to one side, then
(tests for lumbopelvic rotation UCM) the other. Ideally, there should be at least 30°
lateral flexion range (measured from the mid-
This dissociation test assesses the ability to actively sternal line) throughout the spine, without any
dissociate and control lumbopelvic rotation and lumbopelvic rotation, lateral tilt or side-shift of
side-bend the trunk while standing. During any the pelvis (Figure 5.136). There should be no
asymmetrical or non-sagittal trunk movement, a increase in spinal flexion or extension in the
rotational force is transmitted to the lumbopelvic attempt to reach 30° side-bend. There should
region. also be good symmetry of range to each side. This
procedure requires that during testing for UCM,
the spine side-bends to at least 30° each side so
that any compensation and UCM can be
Test procedure identified.
The person stands with the back resting on a wall, This test should be performed without any extra
the feet at least shoulder width apart, and with feedback (self-palpation, vision, etc.) or cueing
the knees slightly flexed (hip flexors unloaded for correction. When feedback is removed for
and wide base of support). The arms are crossed testing the therapist should use visual observa-
with hands touching opposite shoulders and the tion of the pelvis relative to the wall to determine
pelvis rolled back to flatten the back onto the wall whether the control of lumbopelvic rotation is
(Figure 5.135). Then, keeping the pelvis level and adequate. Assess both directions.
Figure 5.135 Start position trunk side-bend test Figure 5.136 Benchmark trunk side-bend test
206
Lumbopelvic rotation UCM • Side-bending movement of the trunk can be

initiated with lateral shift of the pelvis (i.e.
The person complains of unilateral symptoms in the pelvis moving under the trunk instead of
the lumbopelvic region. Lumbopelvic rotation or the trunk moving of the pelvis).
lateral shift or lateral tilt occurs before the spinal • One of the most common compensations is
side-bend on the wall reaches 30° of independent to rotate the pelvis and extend the trunk or to
range. The lumbopelvic region has UCM into rotate the pelvis and flex the trunk into
rotation relative to the trunk under side-bending side-bending function. Lumbar side-bending
load. Look for the presence of a segmental hinge or lateral flexion movement can be associated
as well as multi-segmental rotation and extension with excessive or asymmetrical pelvic
UCM. (Beware – acute discal pathology may rotation. Rotation forward of the ipsilateral
produce protective responses that may be pelvis is frequently combined with spinal
misinterpreted.) extension or pelvic forward sway, while
The uncontrolled lumbopelvic rotation or rotation backward of the ipsilateral pelvis is
lateral shift is often associated with inefficiency frequently combined with spinal flexion.
of the stability function of the oblique abdomi-
nals or the hip rotation stabilisers. (For example, During side-bending of the trunk with the back
the left external obliques and the right internal flattened on the wall (or neutral), the person
obliques control the lumbopelvic rotation UCM lacks the ability to keep the back flat on the wall
to the right, while the right posterior gluteus during this movement. There are a variety of com-
medius and maximus control pelvic rotation to pensatory patterns of substitution dysfunction: i)
the right when weight bearing.) During any asym- the pelvis may rotate and twist off the wall; ii) the
metrical or non-sagittal trunk movement, a rota- pelvis may laterally shift or tilt excessively on
tional force is transmitted to the lumbopelvic the wall; iii) the lumbar spine may extend off the
region. The lumbopelvic rotation stability muscles wall; iv) the pelvis may sway forwards off the wall;
control this rotational load. The oblique abdomi- and v) the upper back may flex and roll off the
nal muscles, anterior fascicles of psoas major and wall. All of these compensations, when present
superficial fibres of lumbar multifidus, which sta- with side-bending away from the midline, are
bilise trunk rotation, must coordinate with the biomechanically linked to uncontrolled lum-
weight bearing deep hip muscles, which concen- bopelvic rotation.
trically and eccentrically control rotation of the During the attempt to dissociate the lumbopel-
pelvis from below. vic rotation from spinal side-bending, the person
There may be significant compensation within either cannot control the UCM or has to concen-
side-bending motion as a means of adapting to trate and try hard to control the lumbopelvic rota-
either asymmetry of length or a myofascial restriction. The movement must be assessed on both
tion of quadratus lumborum or iliocostalis, or sides. Note the direction that the rotation cannot
due to asymmetry of stabiliser control. If the lum- be controlled (i.e. is there uncontrolled lum-
bopelvic rotation stabilisers are not able to effec- bopelvic rotation to the left or the right). It may
tively control rotation force, many maladaptive be unilateral or bilateral. If lumbopelvic rotation
substitution strategies can be observed during UCM presents bilaterally, one side may be better
spinal side-bending: or worse than the other.
• A marked pelvic tilt down (dropping) on the
side-bending side, associated with unlocking Clinical assessment note for direction-specific
the ipsilateral knee and allowing the pelvis motor control testing
to drop into lateral tilt to follow the spinal
side-bend. If some other movement (e.g. a small amount of flexion
• A marked pelvic tilt up (hitching) on the or extension) is observed during a motor control
contralateral side to the side-bending (dissociation) test of rotation control, do not score this as
movement is associated with shifting body uncontrolled rotation. The flexion and extension motor
weight onto the ipsilateral leg and lifting the control tests will identify if the observed movement is
contralateral heel. This allows the pelvis to uncontrolled. A test for lumbopelvic rotation UCM is only
lift into lateral tilt to follow the spinal
demonstrated.
side-bend.
207
Rating and diagnosis of lumbopelvic maintained on the wall without compensation or

rotation UCM substitution. At the point in range that the lum-
bopelvic region starts to lose control of rotation,
(T27.1 and T27.2) the spinal side-bending movement must stop, the
lumbopelvic position is restabilised and the trunk
returned to the start position with control of the
lumbopelvic rotation UCM. There must be no
Correction pelvic or trunk rotation. Likewise, there should be
The person stands in a wide stance SKB position no lumbar extension or anterior pelvic tilt, no
with the trunk supported, leaning against a wall. trunk flexion or forward sway of the pelvis and
They should monitor lumbopelvic rotation no lateral tilt or shift of the pelvis.
control by palpating both iliac crests for feedback Side-bending is performed only through the
regarding loss of position. Some people will also range that the UCM can be actively controlled
need to use a mirror so that they can watch for and as far as any restriction allows. Easy control
the loss of control. The person should actively through symmetry of range is the goal. As the
contract the lateral abdominal muscles (espe- ability to control the UCM gets easier and the
cially the external obliques with ribcage depres- pattern of dissociation feels less unnatural,
sion) to flatten the lumbar spine, and to resist the exercise can be progressed to an unsupported
lumbopelvic rotation. (The lumbar spine may be position away from the wall in free standing. The
supported in a neutral position with a folded person should self-monitor the lumbopelvic
towel if desired.) alignment and control with a variety of feedback
Then, keeping the pelvis level and stationary options (T27.3). There should be no provocation
against the wall, they are instructed to side-bend of any symptoms within the range that the rota-
to the side, only moving as far as the back can be tion UCM can be controlled.
208
T27.1 Assessment and rating of low threshold recruitment efficiency of the Trunk Side-Bend Test
from the Trunk Side-Bend Test
TRUNK SIDE-BEND TEST – STANDING: WALL
left (L) right (R)
(closed chain)
correction observer
209
(Figure 5.137). Then, keeping the shoulders level

T28 STANDING: PELVIC SIDE-SHIFT TEST and stationary against the wall, they are instructed
(tests for lumbopelvic rotation UCM) to side-shift the pelvis laterally against the wall,
first to one side, then the other. Ideally, there
This dissociation test assesses the ability to actively should be at least 5 cm lateral pelvis movement
dissociate and control lumbopelvic rotation and without any lumbopelvic rotation, lateral tilt of
side-shift the pelvis while standing. During any the shoulders or side-shift of the chest (Figure
asymmetrical or non-sagittal trunk movement, a 5.138). There should be no increase in spinal
rotational force is transmitted to the lumbopelvic flexion or extension in the attempt to reach 5 cm
region. lateral pelvic shift. There should also be good
symmetry of range to each side. This procedure
requires that during testing for UCM, the pelvis
Test procedure
side-shifts to at least 5 cm each side so that any
The person stands with the back resting on a wall, compensation and UCM can be identified.
the feet at least shoulder width apart and with the This test should be performed without any extra
knees slightly flexed (hip flexors unloaded and feedback (self-palpation, vision, etc.) or cueing
wide base of support). The arms are crossed with for correction. When feedback is removed for
hands touching opposite shoulders and the pelvis testing the therapist should use visual observa-
rolled back to flatten the back onto the wall tion of the pelvis relative to the wall to determine
Figure 5.137 Start position pelvic side-shift test Figure 5.138 Benchmark pelvic side-shift test
210
whether the control of lumbopelvic rotation is to rotate the pelvis and flex the trunk into
adequate. Assess both directions. lateral side-shift function.
During side-shift of the pelvis with the back flat-
Lumbopelvic rotation UCM tened on the wall (or neutral), the person lacks
The person complains of unilateral symptoms in the ability to keep the back flat on the wall during
the lumbopelvic region. Lumbopelvic rotation or this movement. There are a variety of com-
lateral tilt of the chest occurs before the lateral pensatory patterns of substitution dysfunction.
pelvic shift on the wall reaches 5 cm of inde- The pelvis may rotate and twist off the wall. The
pendent range. The lumbopelvic region has UCM shoulders may laterally tilt excessively on the
into rotation relative to the trunk under a wall. The lumbar spine may extend off the wall.
side-shift load. (Beware – acute discal pathology The pelvis may sway forward off the wall. The
may produce protective responses that may be upper back may flex and roll off the wall. All of
misinterpreted.) these compensations, when present with pelvic
The uncontrolled lumbopelvic rotation is often side-shift away from the midline, are biomecha-
associated with inefficiency of the stability func- nically linked to uncontrolled lumbopelvic
tion of the oblique abdominals or the hip rota- rotation.
tion stabilisers. During any asymmetrical or During the attempt to dissociate the lumbopel-
non-sagittal trunk movement, a rotational force vic rotation from pelvic side-shift, the person
is transmitted to the lumbopelvic region. The either cannot control the UCM or has to concen-
lumbopelvic rotation stability muscles control trate and try hard to control the lumbopelvic rota-
this rotational load. The oblique abdominal tion. The movement must be assessed on both
muscles, anterior fascicles of psoas major and sides. Note the direction that the rotation cannot
superficial fibres of lumbar multifidus, which sta- be controlled (i.e. is there uncontrolled lum-
bilise trunk rotation, must coordinate with the bopelvic rotation to the left or the right). It may
weight bearing deep hip muscles, which concen- be unilateral or bilateral. If lumbopelvic rotation
trically and eccentrically control rotation of the UCM presents bilaterally, one side may be better
pelvis from below. or worse than the other.
There may be significant compensation within
side-bending motion as a means of adapting to
either asymmetry of length or a myofascial restric- Clinical assessment note for direction-specific
tion of quadratus lumborum or iliocostalis, or motor control testing:
due to asymmetry of stabiliser control. If the lum-
bopelvic rotation stabilisers are not able to effec- If some other movement (e.g. a small amount of flexion
tively control rotation force, many maladaptive or extension) is observed during a motor control
substitution strategies can be observed during (dissociation) test of rotation control, do not score this as
spinal side-bending: uncontrolled rotation. The flexion and extension motor
• A marked shift of the head and shoulders uncontrolled. A test for lumbopelvic rotation UCM is only
along with the shift of the pelvis to follow positive if uncontrolled lumbopelvic rotation is
the pelvic shift. This transfers body weight demonstrated.
onto one leg.
• A marked lateral tilt (drop) of the shoulders
and lateral flexion of the upper trunk away
from the pelvic shift to adapt to the pelvic
shift.
• A marked pelvic tilt up (hitching) on the rotation UCM
side of the pelvis side-shift movement is (T28.1 and T28.2)
associated with excessive substitution of
quadratus lumborum and iliocostalis
mobiliser muscles instead of the trunk Correction
rotation stabiliser muscles. The person stands in a wide stance SKB position
• One of the most common compensations is with the trunk supported, leaning against a wall.
to rotate the pelvis and extend the trunk or They should monitor lumbopelvic rotation
211
T28.1 Assessment and rating of low threshold recruitment efficiency of the Pelvic Side-Shift Test
from the Pelvic Side-Shift Test
PELVIC SIDE-SHIFT TEST – STANDING: WALL
left (L) right (R)
(closed chain)
correction observer
212
control by palpating both iliac crests for feedback rotation. Likewise, there should be no lumbar
regarding loss of position. Some people will also extension or anterior pelvic tilt, no trunk flexion
need to use a mirror so that they can watch for or forward sway of the pelvis and no lateral tilt of
the loss of control. The person should actively the shoulders and head.
contract the lateral abdominal muscles (espe- Pelvic side-shift is performed only through the
cially the external obliques with ribcage depres- range that the UCM can be actively controlled
sion) to flatten the lumbar spine, and to resist and as far as any restriction allows. Easy control
lumbopelvic rotation. (The lumbar spine may be through symmetry of range is the goal. As
supported in a neutral position with a folded the ability to control the UCM gets easier and the
towel if desired.) pattern of dissociation feels less unnatural, the
Then, keeping the shoulders level and the head exercise can be progressed to an unsupported
and chest stationary against the wall, they are position away from the wall in free-standing. The
instructed to side-shift the pelvis laterally, only person should self-monitor the lumbopelvic
moving as far as the back can be maintained on alignment and control with a variety of feedback
the wall without compensation or substitution. options (T28.3). There should be no provocation
At the point in range that the lumbopelvic region of any symptoms within the range that the rota-
starts to lose control of rotation, the pelvic side- tion UCM can be controlled.
shift movement must stop, the lumbopelvic posi-
tion is restabilised and the trunk returned to the
Rotation (unilateral) UCM summary
start position with control of the lumbopelvic
rotation UCM. There must be no pelvic or trunk (Tables 5.6 and 5.7).
Table 5.6 Summary and rating of lumbopelvic open chain rotation tests

LUMBAR ROTATION (OPEN) !
(L) (R)
Supine: single heel slide
Supine: bent knee fall out
Side-lying: top leg turn out
Prone: single hip rotation
Prone: single knee flexion
Prone: hip extension lift
Sitting: single knee extension
213
Table 5.7 Summary and rating of lumbopelvic closed chain rotation tests

LUMBAR ROTATION (CLOSED) !
(L) (R)
Crook lying: single leg bridge extension
Standing: thoracic rotation
Standing: double knee swing
Standing: trunk side-bend
Standing: pelvic side-shift
REFERENCES
Airaksinen, O., Brox, J.I., Cedraschi, C., classification approach to physical low back pain. Spine 26 (11),
Hildebrandt, J., Klaber-Moffett, J., therapy. Journal of Orthopaedic and E243–E248.
Kovacs, F., et al., 2006. COST B13 Sports Physical Therapy 37 (6), Hodges, P.W., 2003. Core stability
Working Group on Guidelines for 290–302. exercise in chronic low back pain.
Chronic Low Back Pain. Chapter 4. Gombatto, S.P., Collins, D.R., Orthopedic Clinics of North America
European guidelines for the Sahrmann, S.A., Engsberg, J.R., 34 (2), 245–254.
management of chronic nonspecific Van Dillen, L.R., 2007. Patterns of Hungerford, B., Gilleard, W., Hodges, P.,
low back pain. European Spine lumbar region movement during 2003. Evidence of altered
Journal 15 (Suppl. 2), S192–S300. trunk lateral bending in 2 lumbopelvic muscle recruitment in
Bogduk, N., 1997. Clinical anatomy of subgroups of people with low back the presence of sacroiliac joint pain.
the lumbar spine and sacrum, ed 3. pain. Physical Therapy 87 (4), Spine 28 (14), 1593–1600.
Churchill Livingstone, Edinburgh. 441–454. Hungerford, B., Gilleard, W., Lee, D.,
Cibulka, M.T., 2002. Understanding Greenman, P.E., 2003. Principles of 2004. Altered patterns of pelvic bone
sacroiliac joint movement as a guide manual medicine, 3rd ed. Lippincott motion determined in subjects with
to the management of a patient with Williams & Wilkins. posterior pelvic pain using skin
unilateral low back pain. Manual Hall, L., Tsao, H., Macdonald, D., markers. Clinical Biomechanics
Therapy 7 (4), 215–221. Coppieters, M., Hodges, P.W., 2007. (Bristol, Avon) 19 (5), 456–464.
Dankaerts, W., O’Sullivan, P., Burnett, Immediate effects of co-contraction Hungerford, B.A., Gilleard, W.,
A., Straker, L., 2006. Altered patterns training on motor control of the Moran, M., Emmerson, C., 2007.
of superficial trunk muscle activation trunk muscles in people with Evaluation of the ability of physical
during sitting in nonspecific chronic recurrent low back pain. Journal of therapists to palpate intrapelvic
low back pain patients: importance Electromyography and Kinesiology motion with the Stork test on the
of subclassification. Spine 31 (17), 19 (5), 763–773. support side. Physical Therapy 87
2017–2023. Hamilton, C., Richardson, C., 1998. (7), 879–887.
Dankaerts, W., O’Sullivan, P.B., Burnett, Active control of the neutral Jull, G., Richardson, C.A., Toppenberg,
A.F., Straker, L.M., 2007. The use of a lumbopelvic posture: a comparison R., Comerford, M., Bui, B., 1993.
mechanism-based classification between back pain and non back Towards a measurement of active
system to evaluate and direct pain subjects. In: Vleeming, A., muscle control for lumbar
management of a patient with Mooney, V., Tilsher, H., Dorman, T., stabilisation. Australian Journal of
non-specific chronic low back pain Snijders, C. (Eds.), 3rd Physiotherapy 39, 187–193.
and motor control impairment – a Interdisciplinary World Congress on Laslett, M., Aprill, C.N., McDonald, B.,
case report. Manual Therapy 12 (2), low back pain and pelvic pain, Young, S.B., 2005. Diagnosis of
181–191. Vienna, Austria. sacroiliac joint pain: validity of
Fritz, J.M., Cleland, J.A., Childs, J.D., Hides, J.A., Jull, G.A., Richardson, C.A., individual provocation tests and
2007. Subgrouping patients with low 2001. Long-term effects of specific composites of tests. Manual Therapy
back pain: evolution of a stabilizing exercises for first-episode 10 (3), 207–218.
214
Lee, D., 2004. The pelvic girdle. Elsevier, Moseley, L., 2002. Combined stabilising exercises in the treatment
Edinburgh. physiotherapy and education is of chronic low back pain with
Luomajoki, H., Kool, J., de Bruin, E.D., efficacious for chronic low back radiological diagnosis of spondylosis
Airaksinen, O., 2007. Reliability of pain. Australian Journal of or spondylolisthesis. Spine 22 (24),
movement control tests in the Physiotherapy 48 (4), 297–302. 2959–2967.
lumbar spine. BMC Musculoskeletal O’Sullivan, P., 2005. Diagnosis and Oh, J.S., Cynn, H.S., Won, J.H., Kwon,
Disorders 8, 90. classification of chronic low back O.Y., Yi, C.H., 2007. Effects of
Luomajoki, H., Kool, J., de Bruin, E.D., pain disorders: maladaptive performing an abdominal
Airaksinen, O., 2008. Movement movement and motor control drawing-in maneuver during prone
control tests of the low back: impairments as underlying hip extension exercises on hip and
evaluation of the difference between mechanism. Manual Therapy 10 (4), back extensor muscle activity and
patients with low back pain and 242–255. amount of anterior pelvic tilt.
healthy controls. BMC O’Sullivan, P.B., Beales, D.J., 2007a. Journal of Orthopaedic and Sports
Musculoskeletal Disorders 9, Changes in pelvic floor and Physical Therapy 37 (6), 320–324.
170. diaphragm kinematics and Panjabi, M.M., 1992. The stabilising
Luomajoki, H., Kool, J., de Bruin, E.D., respiratory patterns in subjects with system of the spine. Part II. Neutral
Airaksinen, O., 2010. Improvement sacroiliac joint pain following a zone and instability hypothesis.
in low back movement control, motor learning intervention: a case Journal of Spinal Disorders 5 (4),
decreased pain and disability, series. Manual Therapy 12 (3), 390–397.
resulting from specific exercise 209–218. Pool-Goudzwaard, A.L., Vleeming, A.,
intervention. Sports Medicine, O’Sullivan, P.B., Beales, D.J., 2007b. Stoeckart, R., Snijders, C.J., Mens,
Arthroscopy, Rehabilitation, Therapy Diagnosis and classification of pelvic J.M., 1998. Insufficient lumbopelvic
and Technology 23 (2), 11. girdle pain disorders. Part 2: stability: a clinical, anatomical and
Macedo, L.G., Maher, C.G., Latimer, J., illustration of the utility of a biomechanical approach to
McAuley, J.H., 2009. Motor control classification system via case studies. ‘a-specific’ low back pain. Manual
exercise for persistent, nonspecific Manual Therapy 12 (2), e1–e12. Therapy 3 (1), 12–20.
low back pain: a systematic review. O’Sullivan, P.B., Grahamslaw, K.M., Richardson, C.A., Jull, G.A., Toppenberg,
Physical Therapy 89 (1), 9–25. Epub Kendell, M., Lapenskie, S.C., Möller, R., Comerford, M.J., 1992.
2008. N.E., Richards, K.V., 2002a. The Techniques for active lumbar
Maitland, G., Hengeveld, E., Banks, K., effect of different standing and stabilisation for spinal protection: a
English, K., 2005. Maitland’s sitting postures on trunk muscle pilot study. Australian Journal of
vertebral manipulation. Butterworth activity in a pain-free population. Physiotherapy 38, 105–112.
Heinemann, Oxford. Spine 27 (11), 1238–1244. Richardson, C.A., Snijders, C.J., Hides,
Maluf, K.S., Sahrmann, S.A., Van Dillen, O’Sullivan, P.B., Beales, D.J., Beetham, J.A., 2002. The relationship between
L.R., 2000. Use of a classification J.A., Cripps, J., 2002b. Altered motor the transversus abdominis muscles
system to guide nonsurgical control strategies in subjects with sacroiliac joint mechanics and low
management of a patient with sacroiliac joint pain during the active back pain. Spine 27 (4), 399–405.
chronic low back pain. Physical straight leg raise test. Spine 27 (1), Riddle, D.L., Freburger, J.K., 2002.
Therapy 80 (11), 1097–1111. E1–E8. Evaluation of the presence of
Mens, J.M., Vleeming, A., Snijders, C.J., O’Sullivan, P.B., Burnett, A., Floyd, A.N., sacroiliac joint region dysfunction
Koes, B.W., Stam, H.J., 2002. Validity Gadsdon, K., Logiudice, J., Miller, D., using a combination of tests: a
of the active straight leg raise test for et al., 2003. Lumbar repositioning in multicenter intertester reliability
measuring disease severity in a specific low back pain population. study. Physical Therapy 82 (8),
patients with posterior pelvic pain Spine 28 (10), 1074–1079. 772–781.
after pregnancy. Spine (Phila Pa O’Sullivan, P.B., Grahamslaw, K.M., Roussel, N.A., Nijs, J., Mottram, S., van
1976) 27 (2), 196–200. Kendell, M., Lapenskie, S.C., Moller, Moorsel, A., Truijen, S., Stassijns, G.,
Mitchell, F., Moran, P., Pruzzo, N., N.E., Richards, K.V., 2002. The effect 2009. Altered lumbopelvic
1979. An evaluation and treatment of different standing and sitting movement control but not
manual of osteopathic muscle energy postures on trunk muscle activity in generalised joint hypermobility is
procedures. Mitchell Moran and a pain-free population. Spine 27 associated with increased injury in
Pruzzo Associates, Missouri. (11), 1238–1244. dancers. A prospective study. Manual
Morrissey, D., Morrissey, M.C., Driver, O’Sullivan, P.B., Mitchell, T., Bulich, P., Therapy 14 (6), 630–635.
W., King, J.B., Woledge, R.C., 2008. Waller, R., Holte, J., 2006. The Sahrmann, S.A., 2002. Diagnosis and
Manual landmark identification and relationship between posture and treatment of movement impairment
tracking during the medial rotation back muscle endurance in industrial syndromes. Mosby, St Louis.
test of the shoulder: an accuracy workers with flexion-related low Stuge, B., Veierod, M.B., Laerum, E.,
study using three dimensional back pain. Manual Therapy 11 (4), Vollestad, N., 2004. The efficacy of a
ultrasound and motion analysis 264–271. treatment program focusing on
measures. Manual Therapy 13 (6), O’Sullivan, P.B., Twomey, L., Allison, G., specific stabilizing exercises for
529–535. 1997. Evaluation of specific pelvic girdle pain after pregnancy: a
215
two-year follow-up of a randomized Trudelle-Jackson, E., Sarvaiya-Shah, S.A., Van Dillen, L.R., Maluf, K.S., Sahrmann,
clinical trial. Spine 29 (10), Wang, S.S., 2008. Interrater reliability S.A., 2009. Further examination of
E197–E203. of a movement impairment-based modifying patient-preferred
Sturesson, B., Selvic, G., Uden, A., classification system for lumbar movement and alignment strategies
1989. Movements of the sacroiliac spine syndromes in patients with in patients with low back pain
joints: a roentgen chronic low back pain. Journal of during symptomatic tests. Manual
stereophotogrammetric analysis. Orthopaedic and Sports Physical Therapy 14 (1), 52–60.
Spine 14 (2), 162–165. Therapy 38 (6), 371–376. Vibe Fersum, K., O’Sullivan, P.B., Kvåle,
Teyhen, D.S., Flynn, T.W., Childs, J.D., Tsao, H., Hodges, P.W., 2008. A., Skouen, J.S., 2009. Inter-examiner
Abraham, L.D., 2007. Persistence of improvements in reliability of a classification system
Arthrokinematics in a subgroup of postural strategies following motor for patients with non-specific low
patients likely to benefit from a control training in people with back pain. Manual Therapy 4 (5),
lumbar stabilization exercise recurrent low back pain. Journal of 555–561.
program. Physical Therapy 87 (3), Electromyography and Kinesiology
313–325. 18 (4), 559–567.
216
CHAPTER 6
THE CERVICAL SPINE
Low cervical flexion control

T29 Occiput lift test 226
T30 Thoracic flexion test 230
T31 Overhead arm lift test 233
Upper cervical flexion control

T32 Forward head lean test 237
T33 Arm extension test 242
Upper cervical extension control

T34 Backward head lift test 247
T35 Horizontal retraction test 252
Mid-cervical translation (during extension) control

T36 Head back hinge test 255
T37 Chin lift hinge test 259
Cervical side-bend control

T38 Head turn test 270
Cervical rotation control

T39 Head tilt test 276
Low cervical side-bend control

T40 Upper neck tilt test 281
Upper cervical side-bend control

T41 Lower neck lean test 285
Chapter 6
The cervical spine
do this effectively and efficiently the cervical

INTRODUCTION muscle system, comprising both deep and super-
ficial muscles, must work in synergy and provide
In the past two decades there has been an increase the movement and stability. The ‘stability system’,
in research into cervical musculoskeletal disor- characterised by deep segmentally attaching
ders with many movement impairments and muscles, should be able to maintain control of
pathophysiological disorders subsequently iden- the cervical spine segments during low load pos-
tified. These include changes in the sensory and tural control tasks, functional movements and
motor systems, in sensorimotor function and psy- high load fatiguing activities. The co-activation of
chological features associated with whiplash, the stability muscles should control abnormal
headache and neck pain (Jull et al 2008). intersegmental translation at the motion seg-
Although the management of neck pain does ments, give segmental support to the spinal
include the assessment and retraining of muscle neutral curves, maintain the head balance on the
function, assessment of dynamic movement upper cervical spine and dynamically balance the
faults, known to be a significant factor in muscu- head and neck on the trunk. The anatomical con-
loskeletal disorders, are still poorly described, nections between the cervical spine, temporo-
utilised and researched in the cervical spine (Jull mandibular joint (TMJ), thorax and shoulder
et al 2008). Fritz & Brennan (2007) have high- girdle, with the musculoskeletal and neurovascu-
lighted the importance of developing a classifica- lar structures, make movement control function
tion system for subgroups of patients with neck complex. Further influences come from respira-
pain. This chapter sets out to explore the assess- tory function.
ment and retraining of uncontrolled movement There is evidence to demonstrate changes in
(UCM) in the cervical spine. Before details of the cervical and scapulothoracic muscle function in
assessment and retraining of UCM in the cervical people with neck pain. Falla & Farina (2007)
region are explained, a brief review of cervical describe in detail the altered control strategies
spine structure and function, changes in muscle and peripheral changes in cervical muscles in
function and movement and postural control in people with pain which lead to limited endur-
the region are presented. ance, greater fatiguability, less strength, altered
proprioception and reorganisation of muscle
coordination. Figure 6.1 illustrates the interrela-
Cervical spine muscle function tionships between pain, altered control strategies
The cervical spine supports and orients the head and peripheral changes in the cervical muscles
in space relative to the thorax (Jull et al 2008). To (Falla & Farina 2007). Similarly, recruitment of

DOI: 10.1016/B978-0-7295-3907-4.00006-2 219
Muscle Fatty Changes in muscle Reduced relative Reduced activation of

atrophy infiltration fibre/capillary ratio resting periods deep cervical muscles
Changes in muscle fibre Augmented superficial

type proportions muscle activity
Muscle Control
properties Outcomes strategies
Changes in muscle fibre Limited endurance Change in feedforward

contractile properties Greater fatiguability activation
Less strength
Altered proprioception
Reorganisation of muscle coordination
Prolonged muscle
Changes in muscle fibre
activity following
membrane properties Pain
voluntary contraction
Figure 6.1 Inter-relationships between pain, altered control strategies and peripheral changes in the cervical muscles (Falla &
Farina 2007)
the scapulothoracic muscles has been identified and C5–6 in people with disc degeneration
in people with neck pain (Nederhand et al 2000; (Miyazaki et al 2008). With disc degeneration the
Falla et al 2004b; Szeto et al 2005a; Johnston intersegmental motion changes from the normal
et al 2008b; Szeto et al 2008) along with histo- state to an unstable phase and subsequently to an
logical changes in upper trapezius (Lindman ankylosed stage with increased stability and loss
1991a, b). of function in late stage degeneration. Further
literature indicates how alteration in the cervical
motion is seen at segmental levels in subjects
UCM in the cervical spine with neck pain (White et al 1975; Amevo et al
The current literature suggests people with cervi- 1992; Panjabi 1992; Singer et al 1993; Dvorak
cal pain have altered movement control strategies et al 1998; Cheng et al 2007; Grip et al 2008).
and that these changes are associated with pain Changes in alignment in the cervical spine may
and disability (Falla et al 2004b; Johnston et al result in a forward head posture position demon-
2008a, b). Altered movement strategies have been strating an increase in low cervical flexion (Szeto
associated with the clinical presentations of whip- et al 2005b; Falla et al 2007; Fernández-de-las-
lash (Nederhand et al 2002; Jull et al 2004; Ster- Peñas et al 2007; Straker et al 2008). Yip and col-
ling et al 2003, 2005), cervicogenic headaches leagues (2008) noted the greater the forward
(Jull et al 2002; Fernández-de-las-Peñas et al head posture, the greater the disability. Regions
2008), neck pain (Jull et al 2004; O’Leary et al and segments of less mobility have been noted in
2007; Falla et al 2004a, b) and work-related mus- the cervical spine which will present clinically as
culoskeletal disorders (Johnston 2008a, b; Szeto regions of relative stiffness (Dall’Alba et al 2001,
et al 2008). The pathophysiological and psycho- Dvorak et al 1988).
social mechanisms identified in people with neck
pain are proposed to be a cause of respiratory Introduction to rehabilitation for
disorders (Kapreli et al 2008).
cervical spine dysfunction
These altered strategies will influence the
control of movement which can present as both Systematic reviews indicate that different
uncontrolled translatatory movement and uncon- treatment modalities have an effect on neck dis-
trolled range or physiological motion. Either orders with exercise being a key element in the
movement dysfunction will present clinically management of pain disability and dysfunction
as areas of relative flexibility. Increases in transla- (Kjellman et al 1999; Gross et al 2004; Verhagen
tional movements have been highlighted at C4–5 et al 2004). In addition, there is a growing body
220
The cervical spine Chapter |6|
of evidence that supports the efficacy of exercise UCM at the cervical spine region and describes
in the management of cervical pain (Jull et al retraining strategies.
2002; Falla et al 2006, 2007). Along with the
identification and correction of movement control
dysfunction, it is important to address the altered
control strategies and peripheral changes in the DIAGNOSIS OF THE SITE AND
cervical muscles (Jull et al 2008, ch. 4 p. 50). DIRECTION OF UCM IN THE
Psychosocial and physiological factors also have CERVICAL SPINE
a role in the development and maintenance of
cervical pain (Jull et al 2008 , ch. 7 p. 97) and The diagnosis of site and direction of UCM at the
influence how it is managed appropriately. cervical spine can be identified in terms of site:
It is important to consider other postural influ- upper cervical spine, mid-cervical spine and lower
ences when retraining the control of neck move- cervical spine, and direction of flexion, extension
ments as it has been demonstrated that there is and asymmetry (Table 6.1). As with all UCMs,
better recruitment of postural neck muscles with they can present as uncontrolled translational
facilitation of a good lumbar position (Falla et al movements (e.g. at C4/5 (Cheng et al 2007)) or
2007). Researchers have further demonstrated uncontrolled range movements (e.g. low cervical
that improving postural alignment of the thoracic flexion (Straker et al 2008)).
spine and the head and neck also has benefits for A diagnosis of UCM requires evaluation of
recruitment of the deep neck stability muscles. its clinical priority. This is based on the relation-
Changes in muscle function have been identified ship between the UCM and the presenting symp-
in functional activities, highlighting the impor- toms. The therapist should look for a link between
tance of linking the rehabilitation of movement the direction of UCM and the direction of
control with functional activities (Falla et al symptom provocation: a) does the site of uncon-
2004b; Szeto et al 2008). trolled movement relate to the site or joint that
the patient complains of as the source of symp-
Identifying UCM in the toms? b) does the direction of movement or load
testing relate to the direction or position of prov-
cervical spine
ocation of symptoms? This identifies the clinical
This body of evidence indicates it is important to priorities.
be able to identify control impairments in people The site and direction of UCM at the cervical
with neck pain and relate these to their symptom spine can be linked with different clinical presen-
presentation and disability. The classification in tations, postures and activities aggravating symp-
terms of site and direction of UCM has been pro- toms. The typical assessment findings in the
posed (Mottram 2003; Comerford & Mottram cervical spine are identified in Table 6.2.
2011), and a diagnosis based on movement
impairment (Sahrmann 2002; McDonnell et al
2005; Caldwell et al 2007). The influence of the
scapula on neck symptoms and range of move- IDENTIFYING THE SITE AND DIRECTION
ment needs to be considered in treating UCM in OF UCM AT THE CERVICAL SPINE
the cervical spine. Passive scapula elevation has
been shown to decrease neck symptoms and The key principles for assessment and classifica-
increase range of movement (Van Dillen et al tion of UCM have previously been described in
2007). This chapter details the assessment of Chapter 3. All dissociation tests are performed
Table 6.1 Site and direction of UCM in the cervical spine
UPPER CERVICAL SPINE MID-CERVICAL SPINE LOW CERVICAL SPINE

Direction • Extension • Extension • Flexion
• Flexion • Rotation/side-bend • Rotation/side-bend
• Rotation/side-bend
221
Table 6.2 The link between site and direction of UCM at the cervical spine and different clinical presentations
SITE AND DIRECTION OF UCM CLINICAL EXAMPLES OF PROVOCATIVE MOVEMENTS,

SYMPTOM/PRESENTATIONS POSTURES AND ACTIVITIES
LOWER CERVICAL FLEXION • Symptoms in low cervical spine, Symptoms provoked by flexion
Can present as: cervicothoracic region and movements and postures (especially
• uncontrolled translation at one posterior shoulder sustained); for example, reading,
segment or uncontrolled range of • ± Referral from myofascial, driving, office work, sustained sitting,
the cervicothoracic region into articular and neural structures bending forwards
flexion • May present with segmental
(± hypermobile flexion range) pain pattern
UPPER CERVICAL EXTENSION • Localised upper cervical pain Symptoms provoked with extension
Can present as: • Headaches – referral to head stress to upper cervical spine; for
• uncontrolled translation at one and face example, reading, driving, office
segment or uncontrolled range of • ± TMJ signs and symptoms work, sustained sitting, looking up,
the cervicothoracic region into • Often associated with thoracic sustained extension
extension outlet symptoms
(± hypermobile extension range)
UPPER CERVICAL FLEXION • Localised upper cervical pain Symptoms often provoked by both
Uncommon: • ± Signs and symptoms of upper flexion and extension activities and
• usually presents following a flexion cervical spine instability; for posture; for example, lifting the head
based mechanism of injury; for example, unilateral tongue up from supine lying, sustained
example, fall from horse, dive into anaesthesia, persistent/ rotation, sustained arm loading,
shallow water, whiplash into flexion worsening non-radicular deep looking down
or pathological instability (e.g. neck pain, dizziness
rheumatoid arthritis)
MID-CERVICAL TRANSLATION (into • Localised mid-cervical pain Symptoms provoked with extension
EXTENSION) • ± Referral (articular, myofascial, stress to upper cervical spine; for
Can present as: neural) example, reading, driving, office
• uncontrolled translation (shear) work, sustained sitting, looking up,
especially at C3–4–5, and sustained extension
uncontrolled range into extension
(± hypermobile extension range)
ROTATION/SIDE-BEND ASYMMETRY • Unilateral symptoms ± unilateral Unilateral symptoms provoked by
(superimposed on any UCM above) radiation movements or sustained postures
Can present as: • Symptom can be localised to the away from the midline; for example,
• uncontrolled rotation or uncontrolled upper, the middle or the lower rotation or side-bend with symptoms
side-bend in either the upper cervical cervical regions usually worse in one direction more
spine or the mid/lower cervical spine. • Coupled with any of the above than another
The rotation or side-bend UCM is (upper, mid- or low cervical Unilateral symptoms provoked by
usually more pronounced to either spine) UCM either flexion or extension activities
the right or left side or sustained postures linked to the
above UCM
222
with the cervical spine in the neutral training Generally, the occiput should be positioned
region. about 1–2 cm forward of a line connecting the
sacrum and thoracic kyphosis. That is, 1–2 cm
forward of a wall in standing/sitting or 1–2 cm
Cervical spine neutral: positioning forward of the plinth in lying supine. The low
cervical, scapula and cervical spine should not feel like it is at end-
temporomandibular neutral range extension. If the thoracic kyphosis is flattened
the occiput may rest on the wall in standing or sitting
• Guideline to assess and reposition low
or on the plinth in lying. If the thoracic spine has an
cervical neutral exaggerated kyphosis the occiput may be 3–5 cm away
Position the mid–low cervical neutral line in from the wall or the plinth.
neutral alignment by placing an appropriate See Figure 6.2. Visualise a line across the upper
thickness of folded towel behind the occiput so neck (A), which follows the line of the jaw towards
that the low cervical line is vertical in standing C2. Bisect this line (i). Visualise a second line
or sitting and horizontal in lying. It is acceptable across the lower neck (B), which follows the line
for the low cervical neutral line to be positioned of the clavicle towards the cervicothoracic junc-
within 10° of vertical in standing/sitting or tion. Bisect this line (ii). A line (C) that joins the
horizontal in lying (neutral ± 10° is within bisectors (i) and (ii) ideally should be vertical in
acceptable variability for a normal population standing and sitting or horizontal in lying or
distribution). within 10° of forward inclination.
Upper cervical
Mid–low cervical A
ii
Figure 6.2 Guidelines for determining the upper and lower cervical neutral alignment (reproduced with permission of
Movement Performance Solutions)
223
• Guideline to assess and reposition upper the available neutral region (somewhere midway
cervical neutral between the ends of range). If the attempt to posi-
tion the low cervical line in an ‘ideal’ neutral
Position the upper cervical neutral line parallel to
results in the low cervical joints being sustained
the mid–low cervical neutral line. The upper cer-
at end range of the restricted extension, it then
vical spine should not be in end-range flexion or
becomes necessary to reposition the low cervical
‘chin tuck’.
spine within mid-range; preferably close to the
See Figure 6.2. Visualise a line in the plane of
neutral line. Box 6.1 illustrates some clinical
the face (D). This line ideally should be parallel
pointers which may help the clinician achieve the
to or within 10° of the low cervical neutral line
neutral training position.
(C).
• Guideline to assess and reposition

scapula neutral
Box 6.1 Clinical pointers which may help the
Position the scapula midway between elevation clinician achieve the neutral training position
and depression and let the scapula relax on the
wall in standing or back towards the plinth in • A plumb line from the ear lobe should drop just
lying. posterior to the clavicle (with the scapula in neutral).
The plumb line falling on or forward of the clavicle
indicates a forward head posture.
• Guideline to assess and reposition
• Viewed from the side, the plane of the anterior neck
temporomandibular joint (TMJ) neutral
and the line of the lower jaw should be distinctly
Place the tip of the tongue on the roof of the different (i.e. not a continuous curve).
mouth behind the teeth and rest the tongue on • Retracted chin posture (loss of normal lordosis) is
the roof of the hard palate. Then allow the jaw to often indicative of guarding or protective spasm.
relax open. Ideally, the teeth should separate • A mid-cervical crease, at rest, may be indicative of a
about 1 cm. Do not force the jaw open. Once the mid-cervical translational pivot.
jaw is relaxed open, allow the tongue to rest natu- • A line from the mid-thoracic region to the sacrum
rally. Do not maintain the tongue held against the should be slightly posterior to the back of the head
roof of the mouth as this provides increased distal (1–2 cm).
fixation for the hyoids and encourages substitu- • When assessing asymmetry (rotation/lateral flexion)
tion from these cervical mobilisers. ask the person how a corrected neutral feels – if it
feels ‘odd’ then an asymmetrical alignment is
The cervical spine neutral position needs to be
indicated.
observed with consideration of thoracic and
• A flat multisegmental region between T2 and T6 may
lumbar postures in sitting, standing and func- reflect a neural response, overactive or short
tional positions as one region may influence rhomboids or serratus posterior superior indicative of
another (Straker et al 2008). Cervical postural poor scapular control, or stiff cervicothoracic
dysfunction is frequently most evident in sitting, segments, which are compensated for by increased
but both sitting and standing will often demon- thoracic extension.
strate significant lumbopelvic alignment abnor- • Check what influence correction of lumbopelvic
malities, which may influence cervicothoracic alignment has on cervical posture.
alignment. Facilitation of lumbopelvic and tho- • Neural sensitivity issues may influence postural
racolumbar neutral alignment may well change alignment. There is usually an elevated shoulder girdle
cervical posture. It is important to consider the at rest.
positions of symptom provocation in function. • Alignment assessment should differentiate between
Resting posture is individual, and people with upper cervical extension (chin poke) and mid-cervical
restrictions may not present with an ‘ideal’ resting extension (head back posture).
position. Instead, they present with a resting or • Alignment assessment should differentiate between
‘natural’ alignment that reflects how they have upper cervical extension (chin poke) or mid-cervical
extension (head back posture) and head forward
adapted to their restrictions. For example, if
posture, although both often occur together.
someone has a marked restriction of low cervical
• The mastoid, acromion and ischium should be in
extension, they may develop a head forward
vertical alignment.
posture as they adaptively find a mid-point within
224
lordosis during flexion. At the end of neck

CERVICAL SPINE TESTS FOR UCM flexion range the cervical lordosis does not
flatten or reverse. The restriction may be due
to a loss of articular motion or due to a loss
Cervical flexion control of extensibility of myofascial structures.
Cervical flexion joint mobility can be tested
passively, and passive manual examination
OBSERVATION AND ANALYSIS will identify any significant articular
OF NECK FLEXION restriction of segmental flexion range of
motion. Posterior myofascial restrictions of
Description of ideal pattern flexion can be tested with passive
extensibility of the suboccipital extensors,
While sitting tall with feet unsupported and the sternocleidomastoid, splenius capitis, levator
pelvis in neutral, the low and upper cervical spine scapula and the ligamentum nuchae.
is positioned in the neutral training region. The • Restriction of thoracic flexion – mid- and upper
scapula and TMJ are also positioned in neutral. thoracic flexion restriction are not so
When instructed to flex the head forwards and common, but if present they are easily
look down towards the feet, a pattern of smooth tested.
and even cervicothoracic flexion should be
observed with flattening (or slight flexion) at the
upper and mid-cervical lordosis. There should be Relative flexibility (potential UCM)
concurrent upper and lower cervical movement.
The range should be such that the chin moves to • Cervicothoracic flexion – the low cervical spine
within two finger-breadths of the sternum without may initiate the movement into flexion; or,
compensation. during the return to neutral, the head may
stay in a head forward position. The posture
resulting from this is often described as a
Movement faults associated with cervicothoracic bump or dowager’s hump
cervical flexion and may be observed as excessive
In the assessment of flexion the UCM can be protuberance or ‘step’ of C6–T1 spinous
identified as either segmental or multisegmental. processes.
If only one spinous process is observed as promi- • Upper cervical flexion – this is uncommon but
nent and protruding ‘out of line’ compared to is usually associated with a traumatic forced
the other vertebrae, then the UCM is interpreted flexion incident (requires assessment of
as a segmental flexion hinge. The specific hinging upper cervical instability).
segment should be noted and recorded. If, on the
other hand, excessive cervicothoracic flexion is
observed, but no one particular spinous process Asymmetry
is prominent from the adjacent vertebrae, then • Asymmetry may be a feature with UCM into
the UCM is interpreted as a multisegmental rotation and side-bending. If deviation into
hyperflexion. rotation or side-bending is noted on sagittal
plane tests of flexion or extension control,
Relative stiffness (restrictions) detailed evaluation of rotation or side-
• Restriction of upper or mid-cervical flexion – the bending control tests should be
upper/mid-cervical spine maintains the independently assessed.
225
then to independently flex the upper cervical

Tests of low cervical spine by visualising sliding the occiput vertically
flexion control up an imaginary wall placed at the back of the
head. This should be a nodding action (through
a transverse axis of the upper cervical spine, not
T29 OCCIPUT LIFT TEST – NODDING a chin tuck or retraction action). There should be
(tests for low cervical flexion UCM) no low cervical flexion (head moving forwards)
or loss of scapula position (observe for scapula
This dissociation test assesses the ability to actively elevation, forward tilt or downward rotation).
dissociate and control low cervical flexion and The jaw should stay relaxed (Figure 6.4). Ideally,
move the upper cervical spine into flexion. the person should be able to easily maintain the
low cervical spine neutral alignment and prevent
the head moving forwards while actively moving
Test procedure the upper cervical spine through range from
The person sits tall with their feet unsupported extension to flexion (chin lift to chin drop) by
and the pelvis in neutral. The low and upper cer- using a ‘nodding’ action of the head.
vical spine is positioned in the neutral training While teaching, allow the person to initially
region. The scapula and TMJ are also positioned learn and practise the test movement using feed-
in neutral (Figure 6.3). Without letting the head back from a wall or the therapist’s hand. Keep the
move forwards, the person is instructed to lift the occiput in contact with a supporting surface to
chin into partial upper cervical extension and monitor and control the low cervical neutral
Figure 6.3 Start position occiput lift test Figure 6.4 Benchmark occiput lift test
226
position until awareness of the correct movement Rating and diagnosis of cervical
is achieved. The therapist should monitor the flexion UCM
control of the low cervical neutral position.
Scapula control is important. It may be necessary (T29.1 and T29.2)
to unload the neural and myofascial structures by
supporting the scapula in upward rotation. If the Correction
upper cervical spine has concurrent UCM, only
move the upper cervical spine from neutral to Initially, position the lower and upper cervical
flexion (no extension) to avoid provoking upper spine in neutral with the head supported. This
cervical symptoms. can be done in sitting or standing with the tho-
racic spine and the back of the head against a wall
(Figure 6.5). Using the feedback and support of
Low cervical flexion UCM the supporting surface, the person is trained to
The person complains of flexion-related symp- perform independent upper cervical flexion
toms at the cervicothoracic region. The low cervi- (nodding). The upper cervical spine can flex only
cal spine has greater movement into flexion than so far as there is no low cervical flexion and the
the upper cervical segments under flexion load. scapulae and TMJ do not lose their neutral posi-
During active upper cervical flexion, the cervicot- tion. If control is poor, start in supine lying with
horacic region demonstrates uncontrolled low the occiput supported on a small folded towel
cervical flexion. During the attempt to dissociate (Figure 6.6). Initially the scapula may need to be
the low cervical spine from independent upper supported. As the ability to control upper cervical
cervical flexion, the person either cannot control extension gets easier and the pattern of dissocia-
the movement or has to concentrate and try too tion feels less unnatural the exercise can be pro-
hard. gressed from head and shoulder girdle supported
to head and shoulder girdle unsupported
postures.
A useful progression is performed standing
• If only one spinous process is observed as prominent with the forearms vertical on a wall. Keep the
and protruding ‘out of line’ compared to the other scapula in mid-position and push the body and
head away from the wall (Figure 6.7). Keeping the
noted and recorded.
head back over the shoulders slowly perform
• If excessive cervicothoracic flexion is observed, but no
independent upper cervical flexion (nodding)
one particular spinous process is prominent from the (Figure 6.8). The upper cervical spine can flex
adjacent vertebrae, then the UCM is interpreted as a only so far as there is no low cervical flexion and
multisegmental hyperflexion. the scapulae do not lose their neutral position.
The person should self-monitor the control of
low cervical flexion UCM with a variety of feed-
back options (T29.3). There should be no provo-
Clinical assessment note for direction-specific cation of any symptoms within the range that the
motor control testing: flexion UCM can be controlled.
If some other movement (e.g. a small amount of cervical
Once the pattern of dissociation feels familiar
rotation) is observed during a motor control (dissociation) it should be integrated into various functional
test of low cervical flexion, do not score this as postures and positions. T29.4 illustrates some
uncontrolled low cervical flexion. The cervical rotation retraining options.
motor control tests will identify if the observed unrelated
movement is uncontrolled. A test for low cervical flexion
UCM is only positive if uncontrolled low cervical flexion
is demonstrated.
227
T29.1 Assessment and rating of low threshold recruitment efficiency of the Occiput Lift Test
from the Occiput lift test
OCCIPUT LIFT TEST – NODDING
Site Direction Segmental/multisegmental position
Low cervical Flexion Segmental flexion hinge ! Visual observation Observe in a mirror or directly
(indicate level) watch the movement
Multisegmental ! Adhesive tape Skin tension for tactile feedback
hyperflexion
correction observer
T29.4 Functional positions for retraining low cervical flexion control

• Sitting • Prone (bias posterior muscles)
• Standing • 4 point kneeling (bias posterior muscles)
• Supine (bias anterior muscles) • Incline sitting forwards (bias posterior muscles)
• Recline sitting backwards (bias anterior muscles) • Standing forward lean (bias posterior muscles)
• Side-lying • Functional activities
228
Figure 6.7 Progression: hands on wall, head unsupported

low cervical control – start position
Figure 6.5 Correction standing with wall support
Figure 6.8 Progression: hands on wall, head unsupported

– correction
Figure 6.6 Correction supine with folded towel
229
monitored by placing the thumb on the jaw and

T30 THORACIC FLEXION TEST the middle finger on the forehead. Without letting
(tests for low cervical flexion UCM) the head move forwards or down (monitor jaw
and forehead) allow the sternum to lower (drop)
This dissociation test assesses the ability to actively towards the pelvis. Ideally, the person should
dissociate and control low cervical flexion and have the ability to keep the head neutral while
move the thoracic spine into flexion. independently flexing the thoracic region from a
position of extension through to flexion, without
any movement of the head. Ideally, the person
Test procedure should be able to perform this dissociated move-
The person should have the ability to actively flex ment without feedback from their hands (Figure
the thoracic spine while controlling low cervical 6.10).
and head neutral. The person sits tall with feet
unsupported and pelvis neutral. The low and
Low cervical flexion UCM
upper cervical spine is positioned in the neutral
training region. The scapula and TMJ are also The person complains of flexion-related symp-
positioned in neutral. The plane of the face toms in the low cervical region. The low cervical
should be vertical (Figure 6.9). Thoracolumbar spine has greater give into flexion than the thora-
motion is monitored by placing one hand on columbar segments under flexion load. During
the sternum and head and cervical motion active thoracic flexion, the low cervical region
Figure 6.9 Start position thoracic flexion test Figure 6.10 Benchmark thoracic flexion test
230
gives excessively into flexion. During the attempt Correction

to dissociate the low cervical spine from inde- The person sits tall with feet unsupported and
pendent thoracic flexion, the person either cannot pelvis neutral. The low and upper cervical spine
control the UCM or has to concentrate and try is positioned in the neutral training region. The
too hard. scapula and TMJ are also positioned in neutral.
The plane of the face should be vertical. Monitor
thoracolumbar motion by placing one hand on
• If only one spinous process is observed as prominent the sternum. Monitor head and cervical motion
and protruding ‘out of line’ compared to the other by placing the thumb on the jaw and the middle
vertebrae, then the UCM is interpreted as a segmental finger on the forehead. Without letting the head
flexion hinge. The specific hinging segment should be move forwards or down (monitor jaw and fore-
noted and recorded.
head) allow the sternum to lower (drop) towards
the pelvis. Ideally, the person should have the
ability to keep the head neutral while independ-
multisegmental hyperflexion. ently flexing the thoracic region from a position
of extension through to flexion, without any
movement of the head. As the ability to inde-
pendently control movement of the low cervical
Clinical assessment note for direction-specific spine gets easier and the pattern of dissociation
motor control testing feels less unnatural, the exercise can be progressed
to performing the exercise without palpation
If some other movement (e.g. a small amount of cervical feedback.
rotation) is observed during a motor control (dissociation) The person should self-monitor the control of
test of low cervical flexion, do not score this as low cervical flexion UCM with a variety of feed-
uncontrolled low cervical flexion. The cervical rotation
movement is uncontrolled. A test for low cervical flexion
cation of any symptoms within the range that the
UCM is only positive if uncontrolled low cervical flexion flexion UCM can be controlled.
is demonstrated. Once the pattern of dissociation feels familiar
it should be integrated into various functional
postures and positions. T30.4 illustrates some
retraining options.
Rating and diagnosis of cervical
flexion UCM
(T30.1 and T30.2)
231
T30.1 Assessment and rating of low threshold recruitment efficiency of the Thoracic Flexion Test
from the Thoracic Flexion Test
THORACIC FLEXION TEST
hyperflexion
correction observer

• Supine (bias anterior muscles) • 4 point kneeling (bias posterior muscles)
• Recline sitting backwards (bias anterior muscles) • Incline sitting forwards (bias posterior muscles)
232
cervical spine and the head in the neutral posi-

T31 OVERHEAD ARM LIFT TEST tion and lift both arms overhead, through full
(tests for low cervical flexion UCM) 180° of shoulder flexion, and lower the arms
back to the side. The neutral arm rotation (palm
This dissociation test assesses the ability to actively in) should be maintained. Ideally, the person
dissociate and control low cervical flexion and should have the ability to keep the head neutral
move the shoulders through overhead flexion. while independently flexing the shoulders and
lifting the arms to a vertical overhead position
Test procedure (180° flexion) and lowering them back to the
side (Figure 6.12).
perform shoulder flexion through full range to the
Low cervical flexion UCM
overhead position while concurrently controlling
low cervical spine and head neutral. The person The person complains of flexion-related symp-
stands with the arms resting by the side in neutral toms in the low cervical region. The low cervical
rotation (palm in) and with the scapula in a neutral spine has greater give into flexion than the shoul-
position. The low and upper cervical spine is posi- der girdle under arm flexion load. During active
tioned in the neutral training region. The scapula shoulder flexion, the low cervical region gives
and TMJ are also positioned in neutral. The plane excessively into flexion. During the attempt to dis-
of the face should be vertical (Figure 6.11). sociate the low cervical spine from independent
Without letting the head move forwards or look shoulder flexion, the person either cannot control
down, the person is instructed to keep the low the UCM or has to concentrate and try too hard.
Figure 6.11 Start position overhead arm lift test Figure 6.12 Benchmark overhead arm lift test
233
• If only one spinous process is observed as prominent Rating and diagnosis of cervical
and protruding ‘out of line’ compared to the other flexion UCM
flexion hinge. The specific hinging segment should be (T31.1 and T31.2)
noted and recorded.
• If excessive cervicothoracic flexion is observed, but no Correction
The person stands with the arms resting by the side
multisegmental hyperflexion. in neutral rotation (palm in) and with the scapula
in a neutral position. The low and upper cervical
spine is positioned in the neutral training region.
Clinical assessment note for direction-specific The scapula and TMJ are also positioned in neutral.
motor control testing The plane of the face should be vertical.
Without letting the head move forwards or look
rotation) is observed during a motor control (dissociation)
down, lift both arms to a vertical overhead posi-
test of low cervical flexion, do not score this as tion (180° shoulder flexion). The person should
uncontrolled low cervical flexion. The cervical rotation keep the head neutral while independently flexing
motor control tests will identify if the observed unrelated the shoulder. If control is poor, stand with the
movement is uncontrolled. A test for low cervical flexion head and thoracic spine supported against a wall
UCM is only positive if uncontrolled low cervical flexion for feedback and support. Start doing unilateral
is demonstrated. arm lifts (Figure 6.13) and progress to bilateral
Figure 6.13 Correction standing with wall support, partial Figure 6.14 Progression: forearms on wall – low cervical
range control start position
234
arm lifts as control improves. Initially reduce the the head back over the shoulders, slowly slide
arm load by lifting a short lever (elbow bent) and one forearm vertically up the wall (Figures 6.15
only through reduced range (e.g. 90° then 120°, and 6.16) only so far as there is no low cervical
etc.). As the ability to independently control flexion.
movement of the low cervical spine gets The person should self-monitor the control of
easier and the pattern of dissociation feels less low cervical flexion UCM with a variety of feed-
unnatural, the exercise can be progressed to per- back options (T31.3). There should be no provo-
forming the exercise to long lever full overhead cation of any symptoms within the range that the
range against light resistance. flexion UCM can be controlled.
An alternative progression is to face the wall Once the pattern of dissociation feels familiar
with the forearms vertical on the wall. Keep the it should be integrated into various functional
scapula in mid-position and push the body and postures and positions. T31.4 illustrates some
head away from the wall (Figure 6.14). Keeping retraining options.
Figure 6.15 Progression: forearm wall slide – 90° Figure 6.16 Progression: forearm wall slide – arms overhead
235
T31.1 Assessment and rating of low threshold recruitment efficiency of the Overhead Arm Lift Test
from the Overhead Arm Lift Test
OVERHEAD ARM LIFT TEST
hyperflexion
correction observer

• Supine (bias anterior muscles) • Incline sitting forwards (bias posterior muscles)
• Recline sitting backwards (bias anterior muscles) • Functional activities
236
neutral (Figure 6.17). The therapist monitors the

Test of upper cervical upper cervical neutral position by palpating the
flexion control occiput with one finger and palpating the C2
spinous process with another finger (Figure 6.19).
T32 FORWARD HEAD LEAN TEST move, the upper cervical segments are able to
(tests for upper cervical flexion UCM) maintain neutral. If the palpating fingers move
apart, uncontrolled upper cervical flexion is
This dissociation test assesses the ability to actively identified.
dissociate and control upper cervical flexion and Without letting chin drop or tuck in, the person
move the low cervical spine into flexion. is instructed to move the low cervical spine
through flexion by tilting the head to lean for-
wards from the base of the neck. The person
Test procedure
is to only move through the range where the
The person sits tall with feet unsupported and ability to control the upper cervical spine is effec-
pelvis neutral. The low and upper cervical spine tive (Figure 6.18). There should be no upper
is positioned in the neutral training region. cervical flexion (palpating fingers move apart or
The scapula and TMJ are also positioned in chin drop or tuck is observed) or loss of scapula
Figure 6.17 Start position forward head lean test Figure 6.18 Benchmark forward head lean test
237
Figure 6.19 Therapist palpating for upper cervical movement Figure 6.20 Self-palpation for teaching and training
Upper cervical flexion UCM

position (especially observe for scapula elevation,
retraction or forward tilt). The jaw should stay The person complains of flexion-related symp-
relaxed. toms in the upper cervical spine region. The upper
Ideally, the person should be able to easily cervical spine has greater give into flexion than the
prevent the chin from tucking or dropping and lower cervical spine under flexion load. During
maintain the upper cervical spine neutral (palpat- active lower cervical flexion, the upper cervical
ing fingers do not move apart) while independ- gives excessively into segmental flexion and transla-
ently moving the lower cervical spine through tional shear. This uncontrolled flexion can occur
range from extension to flexion (head starts at the C0–1, the C1–2, or the C2–3 segmental
upright and leans forwards). levels. Segmental laxity can be confirmed with
While teaching, allow the person to initially manual articular assessment or upper cervical
learn and practise the test movement using feed- ligamentous stability tests. During the attempt to
back from palpation with their own fingers to dissociate the upper cervical spine from inde-
monitor and control the upper cervical neutral pendent lower cervical flexion, the person either
position until awareness of the correct movement cannot control the UCM or has to concentrate
is achieved (Figure 6.20). and try too hard.
238

positioned in neutral by actively lifting and drop-
and protruding ‘out of line’ compared to the other ping the chin through the full range of upper
vertebrae, then the UCM is interpreted as a segmental cervical movement, then positioning in the
flexion hinge. The specific hinging segment should be middle of this range. Ideally, the plane of the face
noted and recorded. should incline forwards about 45° (Figure 6.21).
• If excessive cervicothoracic flexion is observed, but no Using feedback from palpating the occiput with
one particular spinous process is prominent from the one finger and C2 with another finger, the person
adjacent vertebrae, then the UCM is interpreted as a is trained to perform independent lower cervical
multisegmental hyperflexion. flexion.
The person should prevent the chin from
tucking or dropping and maintain the upper cer-
vical spine neutral (palpating fingers do not
move apart) while independently moving the
lower cervical spine through range from exten-
If some other movement (e.g. a small amount of cervical sion to flexion (head starts upright and leans
rotation) is observed during a motor control (dissociation) forwards). The lower cervical spine can flex
test of upper cervical flexion, do not score this as and the head leans forwards from the base of
uncontrolled upper cervical flexion. The cervical rotation the neck only so far as there is no upper
motor control tests will identify if the observed unrelated cervical flexion and the scapula and TMJ do not
movement is uncontrolled. A test for upper cervical lose their neutral position. As the ability to
flexion UCM is only positive if uncontrolled upper cervical control upper cervical extension gets easier
flexion is demonstrated. and the pattern of dissociation feels less unnatu-
ral, the exercise can be progressed from head
and shoulder girdle supported to head and
shoulder girdle unsupported postures (Figure
Rating and diagnosis of cervical 6.22).
flexion UCM The person should self-monitor the control of
(T32.1 and T32.2) low cervical flexion UCM with a variety of feed-
Correction flexion UCM can be controlled.
Initially, in sitting or standing, the thoracic spine Once the pattern of dissociation feels familiar
and the back of the head should be supported it should be integrated into various functional
upright against a wall. The low cervical spine is postures and positions. T32.4 illustrates some
in slight extension. The upper cervical spine is retraining options.
239
Figure 6.21 Correction standing with wall support Figure 6.22 Correction with self-palpation and head
unsupported
240
T32.1 Assessment and rating of low threshold recruitment efficiency of the Forward Head Lean Test
from the Forward Head Lean Test
FORWARD HEAD LEAN TEST
Upper cervical Flexion Segmental flexion hinge ! Visual observation Observe in a mirror or directly
Multisegmental ! Cueing and verbal Listen to feedback from another
hyperflexion correction observer
T32.4 Functional positions for retraining upper cervical flexion control

• Sitting • 4 point kneeling (bias posterior muscles)
• Standing • Incline sitting forwards (bias posterior muscles)
• Functional activities
241
Without letting the chin tuck in towards the

T33 ARM EXTENSION TEST neck, or the scapula tilting forwards or retracting,
(tests for upper cervical flexion UCM) the person is instructed to keep the cervical spine
and the head in the neutral position and reach
This dissociation test assesses the ability to actively back with both arms, through 15–20° of shoul-
dissociate and control upper cervical flexion/head der extension. The neutral arm rotation (palm in)
retraction and move the shoulders through should be maintained. Ideally, the person should
extension. have the ability to keep the head and scapulae
neutral while independently extending the shoul-
ders and reaching back with the arms to end
Test procedure
range (Figure 6.24).
perform shoulder extension through full range
Upper cervical flexion UCM
while concurrently controlling cervical spine and
head neutral. The person stands with the arms The person complains of flexion-related symptoms
resting by the side in neutral rotation (palm in) in the upper cervical region. The upper cervical
and with the scapula in a neutral position. The spine has greater give into flexion than the
low and upper cervical spine is positioned in the shoulder girdle under arm extension load. During
neutral training region. The scapula and TMJ are active shoulder extension, the upper cervical
also positioned in neutral. The plane of the face region gives excessively into flexion or head
should be vertical (Figure 6.23). retraction. During the attempt to dissociate
Figure 6.23 Start position arm extension test Figure 6.24 Benchmark arm extension test
242
the upper cervical spine from independent

shoulder extension, the person either cannot
control the UCM or has to concentrate and try
too hard.

noted and recorded.


test of upper cervical flexion, do not score this as
uncontrolled upper cervical flexion. The cervical rotation
movement is uncontrolled. A test for upper cervical
flexion UCM is only positive if uncontrolled upper cervical
flexion is demonstrated.
Figure 6.25 Correction unilateral arm extension

flexion UCM feedback and support. Start doing unilateral arm
(T33.1 and T33.2) extension (Figure 6.25) and progress to bilateral
arm extension as control improves. Initially,
reduce the arm load by lifting a short lever (elbow
Correction bent) and only through reduced range (e.g. 5°
The person stands with the arm resting by the side then 10°, etc.). As the ability to independently
in neutral rotation (palm in) and with the scapula control movement of the upper and low cervical
in a neutral position. The low and upper cervical spine gets easier and the pattern of dissociation
spine is positioned in the neutral training region. feels less unnatural, the exercise can be progressed
The scapula and TMJ are also positioned in to performing the exercise to long lever full range
neutral. The plane of the face should be vertical. against light resistance.
Without letting the chin tuck in towards the The person should self-monitor the control of
neck, or the scapula tilting forwards or retracting, low cervical flexion UCM with a variety of feed-
the person is instructed to keep the cervical spine back options (T33.3). There should be no provo-
and the head in the neutral position and reach cation of any symptoms within the range that the
back with both arms, through 15–20° of shoul- flexion UCM can be controlled.
der extension. The person should keep the head Once the pattern of dissociation feels familiar
neutral while independently extending the shoul- it should be integrated into various functional
der. If control is poor, stand with the head and postures and positions. T33.4 illustrates some
thoracic spine supported against a wall for retraining options.
243
T33.1 Assessment and rating of low threshold recruitment efficiency of the Arm Extension Test
from the Arm Extension Test
ARM EXTENSION TEST
Site Direction Segmental/ position
multisegmental
Upper cervical Flexion Segmental flexion ! watch the movement
Multisegmental ! correction observer
hyperflexion
T33.4 Functional positions for retraining upper and low cervical flexion control
244
excessively displacing anteriorly and translating

Cervical extension control forwards ‘out of line’ compared to the other ver-
tebrae, then the UCM is interpreted as a segmental
extension hinge. The specific hinging segment
OBSERVATION AND ANALYSIS OF NECK
should be noted and recorded.
EXTENSION
Relative stiffness (restrictions)
• Upper cervicothoracic restriction of extension
While sitting tall with their feet unsupported and – this can be assessed by passive low cervical
the pelvis in neutral, the low and upper cervical extension. Stabilise the upper back below T2
spine is positioned in the neutral training region. and position the upper cervical in flexion
The scapula and TMJ are also positioned in (Figure 6.26). Passively move the head
neutral. When instructed to extend the neck back- backwards over the shoulders to extend the
wards and look up towards the ceiling, a pattern cervicothoracic junction. Ideally the mid–low
of smooth and even neck extension should be cervical neutral line should be 10–15° past
observed. There should be concurrent upper and vertical (Figure 6.27).
lower cervical movement. The range should be • Articular restriction – passive manual
such that the plane of the face gets to within examination will identify any significant
15–20° from horizontal without compensation. segmental articular restriction of extension
During active neck extension there is a normal range of motion.
palpation finding if translation is not excessive. • Myofascial restriction – scalene muscle relative
The therapist palpates the tip of the spinous stiffness and tightness can limit lower
process. As extension is initiated some normal cervical extension. If the anterior scalene
anterior translation is felt, but this stops early and muscle lacks extensibility, lower cervical
as the neck continues to extend the therapist extension is limited. Passive examination of
should feel that the vertebra then moves back- low cervical extension should be reassessed
wards as the head moves backwards over the with the cervicothoracic neuromuscular
shoulders. structures unloaded along with relative
stiffness and length changes in the scalenes.
cervical extension
If translation is excessive, the therapist feels the
initial anterior translation does not appear to
stop but instead seems to continue forwards. The
palpating finger tip may appear to be caught
between the spinous processes either side. When
anterior translation has been habitually excessive,
a skin crease develops transversely across the pos-
terior neck at the level of the UCM. This skin
crease is present even when the neck is in its
resting or neutral posture. (Note: there is always
a normal posterior skin crease at end-range
extension.)
In the assessment of extension, the UCM can be
identified as either segmental or multisegmental.
If excessive upper or mid-cervical extension is
observed but no one particular spinous process is
excessively displacing anteriorly from the adja-
cent vertebrae, then the UCM is interpreted as a
multisegmental hyperextension. If, on the other Figure 6.26 Passive test of low cervical extension range
hand, only one spinous process is observed as – hand position
245

• Upper cervical extension. The upper cervical
spine may initiate the movement into
extension. Cervicothoracic extension is often
limited or late. During the return to neutral
from extension the head may stay in upper
cervical extension with chin protrusion.
Excessive upper and mid-cervical extension
observed, but no one particular vertebral
level dominates. The UCM is interpreted as a
multisegmental hyperextension. The posture
resulting from this is often described as a
chin poke posture.
• Mid-cervical shear. This is more difficult to
observe but palpation is useful to identify
increased anterior translation and pain
provocation at C3–4–5 during active
extension. One spinous process is palpated
as excessively displacing anteriorly during
Figure 6.27 Passive test of low cervical extension range active neck extension ‘out of line’ compared
– ideal range to the other extending vertebrae then the
UCM is interpreted as a segmental extension
hinge. The specific hinging segment should
If the hyoid muscles lack extensibility,
end-range extension is only achieved if the
jaw is open. When the jaw is closed, a lack Asymmetry
of full end-range neck extension is noted. • Asymmetry may be a feature and UCM into
• Fascial restriction of extension – if the posterior rotation and side-bending. If deviation into
neck fascias (from a region of the occiput to rotation or side-bending is noted on sagittal
the posterior acromions to T4) are posturally plane tests of extension or flexion control,
short, they may compress the cervicothoracic detailed evaluation of rotation or side-
segments in flexion and limit normal bending control tests should be
extension. independently assessed.
246
Tests of upper cervical extension

control
T34 BACKWARD HEAD LIFT TEST

(tests for upper cervical extension
UCM)
This dissociation test assesses the ability to

actively dissociate and control upper cervical
extension and move the low cervical spine into
extension.
Test procedure
The person sits tall with feet unsupported and the
pelvis, scapula and TMJ are positioned in their
neutral training region. The low cervical spine is
positioned in flexion by allowing the head to
hang forwards fully. The upper cervical spine is
then positioned in neutral by actively lifting and
dropping the chin through the full range of upper
cervical movement, then positioning in the
middle of this range (Figure 6.28).
The therapist monitors the upper cervical
neutral position by palpating the occiput with
one finger and C2 with another finger. During
testing, if the palpating fingers do not move the
upper cervical segments are able to maintain
neutral. If the palpating fingers move closer Figure 6.28 Start position backward head lift test
together, uncontrolled upper cervical extension is
identified.
Without letting the chin lift or retract, the feedback from palpation with their own fingers
person is instructed to move the low cervical to monitor and control the upper cervical neutral
spine through extension by lifting the head position until awareness of the correct movement
upright. The head should move backwards from is achieved (Figure 6.30).
the base of the neck, only through range of good
upper cervical control. There should be no upper
Upper cervical extension UCM
cervical extension (palpating fingers move closer
together or chin lift or retraction is observed) or The person complains of extension-related symp-
loss of scapula position (especially observe for toms in the upper cervical spine region. The upper
scapula elevation, retraction or forward tilt). The cervical spine has greater give into extension than
jaw should stay relaxed (Figure 6.29). the lower cervical spine under extension load.
Ideally, the person should be able to easily During active lower cervical extension, the upper
prevent the chin from lifting or retracting and cervical gives excessively into segmental extension
maintain the upper cervical spine neutral (palpat- and translational shear (primarily at C0–1–2, but
ing fingers do not move together) while inde- potentially also at C2–3) or it gives excessively
pendently moving the lower cervical spine into upper cervical hyperextension. During the
through range from flexion to extension (head attempt to dissociate the upper cervical spine
starts forwards and lifts to upright) and return. from independent lower cervical extension, the
While teaching, allow the person to initially person either cannot control the UCM or has to
learn and practise the test movement using concentrate and try too hard.
247
Figure 6.29 Benchmark backward head lift test with Figure 6.30 Self-palpation for teaching and training
therapist palpation

extension hinge. The specific hinging segment should Rating and diagnosis of cervical
extension UCM
one particular spinous process is prominent from the (T34.1 and T34.2)
Correction
Clinical assessment note for direction-specific Initially, in sitting or standing with the thoracic
motor control testing spine supported upright against a wall, the head
is allowed to hang forwards so that the low cervi-
If some other movement (e.g. a small amount of cervical cal spine is in flexion. The upper cervical spine is
rotation) is observed during a motor control (dissociation) then positioned in neutral by actively lifting and
test of upper cervical extension, do not score this as dropping the chin through the full range of upper
uncontrolled upper cervical extension. The cervical cervical movement, then positioning in the
rotation motor control tests will identify if the observed middle of this range. Using feedback from palpat-
unrelated movement is uncontrolled. A test for upper
ing the occiput with one finger and C2 with
cervical extension UCM is only positive if uncontrolled
upper cervical extension is demonstrated.
another finger, the person is trained to perform
independent lower cervical extension.
248
Figure 6.31 Progression: hands on wall, head unsupported Figure 6.32 Progression: hands on wall, head unsupported
upper cervical control – start position – correction
Figure 6.33 Correction leaning forwards with table support Figure 6.34 Correction leaning backwards with chair
support
249
T34.1 Assessment and rating of low threshold recruitment efficiency of the Backward Head Lift Test
from the Backward Head Lift Test
BACKWARD HEAD LIFT TEST
multisegmental
Upper cervical Extension Segmental extension ! watch the movement
Multisegmental ! correction another observer
hyperextension
T34.4 Functional positions for retraining upper cervical extension control

• Supine (bias anterior muscles) • Standing forward lean (bias posterior muscles)
250
The person should prevent the chin from lifting scapula in mid-position and push the body and
or retracting and maintain the upper cervical allow the head to hang forwards. Position the
spine neutral (palpating fingers do not move upper cervical spine in neutral mid-position
together) while independently moving the lower (Figure 6.31). Keeping the upper cervical spine
cervical spine through range from flexion to neutral slowly lift the head back over the shoul-
extension (head starts forwards and lifts to ders only so far as there is no upper cervical exten-
upright). The lower cervical spine can extend and sion or chin poke (Figure 6.32).
the head lifts backwards from the base of the neck The person should self-monitor the control of
only so far as there is no upper cervical extension upper cervical extension UCM with a variety of
and the scapula and TMJ do not lose their neutral feedback options (T34.3). There should be no
position. As the ability to control upper cervical provocation of any symptoms within the range
extension gets easier and the pattern of dissocia- that the extension UCM can be controlled.
tion feels less unnatural, the exercise can be pro- Once the pattern of dissociation feels familiar
gressed from head and shoulder girdle supported it should be integrated into various functional
to head and shoulder girdle unsupported postures and positions (Figures 6.33 and 6.34).
postures. T34.4 illustrates some retraining options.
An alternative progression is to face the wall
with the forearms vertical on the wall. Keep the
251
in neutral. The plane of the face should be vertical

T35 HORIZONTAL RETRACTION TEST (Figure 6.35).
(tests for upper cervical extension Without letting the chin poke forwards (upper
UCM) cervical extension) or the head move forwards
(low cervical flexion), the person is instructed to
This dissociation test assesses the ability to actively keep the cervical spine and the head in the neutral
dissociate and control upper cervical extension position and pull both arms backwards. The
and move the shoulders through horizontal elbows should bend and the forearms stay hori-
extension and retraction. zontal and the scapulae should retract to reach
15–20° of shoulder horizontal extension. Ideally,
the person should have the ability to keep the head
Test procedure neutral while independently extending the shoul-
The person should have the ability to actively ders and reaching back with the arms to end range
perform shoulder extension through full range and bringing them back to the side (Figure 6.36).
while concurrently controlling cervical spine and
head neutral. The person stands with the arms
Upper cervical extension UCM
reaching forwards (at 90° flexion) and with the
scapula in a neutral position. The low and upper The person complains of extension-related symp-
cervical spine is positioned in the neutral training toms in the upper cervical region. The upper cervi-
region. The scapula and TMJ are also positioned cal spine has greater give into extension than the
Figure 6.35 Start position horizontal retraction test Figure 6.36 Benchmark horizontal retraction test
252
shoulder girdle under arm extension load. During

active shoulder horizontal retraction, the upper
cervical region gives excessively into extension.
During the attempt to dissociate the upper cervi-
cal spine from independent shoulder horizontal
retraction, the person either cannot control the
UCM or has to concentrate and try too hard.

extension hinge. The specific hinging segment should
adjacent vertebrae then the UCM is interpreted as a


test of upper cervical extension, do not score this as
uncontrolled upper cervical extension. The cervical
rotation motor control tests will identify if the observed
cervical extension UCM is only positive if uncontrolled
upper cervical extension demonstrated.
Figure 6.37 Correction – unilateral horizontal retraction with
trunk support on wall
extension UCM
(T35.1 and T35.2) support (Figure 6.37). Start doing unilateral hori-
zontal retraction and progress to bilateral arm
movement as control improves. Initially move
Correction only through reduced range (e.g. 5° then 10°,
The person stands with the arms reaching for- etc.). As the ability to independently control
wards (at 90° flexion) with the scapula in a movement of the upper and low cervical spine
neutral position. The low and upper cervical gets easier and the pattern of dissociation feels
spine is positioned in the neutral training region. less unnatural, the exercise can be progressed to
The scapula and TMJ are also positioned in performing the exercise to long lever full range
neutral. The plane of the face should be vertical. against light resistance.
Without letting the chin poke forwards (upper The person should self-monitor the control of
cervical extension) or the head move forwards upper cervical extension UCM with a variety of
(low cervical flexion), the person is instructed to feedback options (T35.3). There should be no
pull both arms backwards. The elbows should provocation of any symptoms within the range
bend and the forearms stay horizontal and the that the extension UCM can be controlled.
scapulae should retract to reach 15–20° of shoul- Once the pattern of dissociation feels familiar
der horizontal extension. If control is poor, stand it should be integrated into various functional
with the head and thoracic spine supported postures and positions. T35.4 illustrates some
against a wall (at a corner) for feedback and retraining options.
253
T35.1 Assessment and rating of low threshold recruitment efficiency of the Horizontal Retraction Test
from the Horizontal Retraction Test
HORIZONTAL RETRACTION TEST
multisegmental
Upper cervical Extension Segmental extension ! watch the movement
Multisegmental !
hyperextension
correction observer
T35.4 Functional positions for retraining upper and low cervical flexion control
254
Tests of mid-cervical extension

(translation) control
T36 HEAD BACK HINGE TEST

(tests for mid-cervical translation/
extension UCM)

dissociate and control mid-cervical translation
during extension and move the low cervical spine
into extension.
Test procedure
The person sits tall with feet unsupported and
pelvis, scapula and TMJ are positioned in their
neutral training region. The low cervical spine is
positioned in flexion by allowing the head to
hang forwards fully. The upper and mid-cervical
spine is then positioned in neutral by actively
lifting and dropping the chin through the full
range of upper cervical movement, then position-
ing in the middle of this range. The therapist
monitors the mid-cervical neutral position by
palpating (with one finger tip) the spinous process
of the hinge point: C3 or C4 (Figure 6.38).
Without letting the chin lift or retract, the
person is instructed to lift the head upright by
Figure 6.38 Start position head back hinge test
moving backwards from the base of the neck,
only through the range of mid-cervical control.
There should be no uncontrolled mid-cervical
hinge or palpable forward translation of the
spinous process during active low cervical exten- translation/extension than the lower cervical spine
sion. The person is instructed to lift the head back under extension load. During active lower cervi-
to the upright position by pushing back into the cal extension, the mid-cervical segments give
palpating finger on the spinous process (Figure excessively into segmental extension hinge and
6.39). The palpating finger should feel the spinous translational shear (primarily at C3–4 and C4–5,
process of C3 or C4 moving backwards and infe- and occasionally at C5–6). During the attempt to
riorly as the head lifts and the articular surface of dissociate the mid-cervical hinge from independ-
the upper segment glides backwards on the lower ent low cervical extension, the person either
segment (Box 6.2). There should be no chin lift cannot control the UCM or has to concentrate
or retraction, or loss of scapula position (espe- and try too hard.
cially observe for scapula elevation, retraction or If uncontrolled mid-cervical hinge or forward
forward tilt). The jaw should stay relaxed. translation occurs during extension, the palpating
finger of the spinous process of C3 or C4 sud-
Mid-cervical uncontrolled forward denly starts to sink into the neck, instead of
moving backwards with the head and the adja-
translation during extension
cent vertebrae. Occasionally, chin lift or retraction
The person complains of extension-related is observed, or loss of scapula position (especially
symptoms in the mid-cervical spine region. The observe for scapula elevation, retraction or
mid-cervical spine has greater give into forward forward tilt). The jaw should stay relaxed.
255
Box 6.2 Palpation of the mid-cervical spine

on extension
Normal translation during active extension

At the initiation of active extension the palpating finger
should feel the spinous process of C3 or C4 displace
slightly forwards (as the articular surfaces close and
compress). This forward displacement should then appear
to stop early in extension range. As the head lifts and
moves backwards over the shoulders, the spinous process
should then start to move posteriorly and inferiorly as the
articular surface of the upper segment glides backwards
on the lower segment.
Abnormal translation during active
extension
An abnormal mid-cervical translational shear or ‘hinge’ is
identified by palpation of one spinous process that during
active extension demonstrates excessive anterior
displacement of the spinous process (spinous process
moving forwards too far). The spinous process seems to
‘sink in’ to the neck excessively while the adjacent levels
above and below do not. As active neck extension
continues through range there is a lack of resistance to
the anterior displacement and a failure to feel the normal
posterior displacement as extension continues.
This is most commonly observed at C3 or C4. When
excessive anterior translation has been habitually excessive,
a postural skin crease develops transversely across the
posterior neck at the level of the uncontrolled translation.
This skin crease is present even when the neck is in its
Figure 6.39 Benchmark head back hinge test with therapist resting or neutral posture. (Note: there is always a normal
palpation posterior skin crease at end-range extension.)
Ideally, the person should be able to easily prevent
excessive forward translation of mid-cervical vertebrae
(palpating finger does not sink in to the neck) and
prevent the chin from lifting or retracting while
independently moving the lower cervical spine through
Clinical assessment note for direction-specific range from flexion to extension (head starts forwards and
motor control testing lift to upright) and return.
While teaching, allow the person to initially learn and
If some other movement (e.g. a small amount of cervical practise the test movement using feedback from
rotation) is observed during a motor control (dissociation) palpation with their own fingers to monitor and control
test of mid-cervical extension hinge, do not score this as the mid-cervical translation (hinge) until awareness of the
uncontrolled mid-cervical extension hinge. The cervical correct movement is achieved.
rotation motor control tests will identify if the observed
unrelated movement is uncontrolled. A test for mid-
cervical extension hinge UCM is only positive if Correction
uncontrolled mid-cervical extension hinge is
demonstrated. Initially, in sitting or standing with the thoracic
spine supported upright against a wall. The head
is allowed to hang forwards so that the low cervi-
Rating and diagnosis of cervical cal spine is in flexion. The upper and mid-cervical
spine is then positioned in neutral by actively
extension UCM
lifting and dropping the chin through the
(T36.1 and T36.2) full range of upper cervical movement, then
256
The person should prevent the chin from lifting

or retracting and maintain control of the mid-
cervical hinge. Maintain a backward pressure at
the spinous process during backward movement
(push back into the palpating finger tip) while
independently moving the lower cervical spine
through range from flexion to extension (head
starts forwards and lifts to upright). The lower
cervical spine can extend and the head lifts back-
wards from the base of the neck only so far as
there is no mid-cervical hinge and the scapula
and TMJ do not lose their neutral position.
As the ability to control upper cervical exten-
sion gets easier and the pattern of dissociation
from head and shoulder girdle supported to head
and shoulder girdle unsupported postures.
mid-cervical translation during extension UCM
with a variety of feedback options (T36.3). There
Figure 6.40 Self-palpation for teaching and training
should be no provocation of any symptoms
within the range that the extension UCM can be
positioning in the middle of this range. Using controlled.
feedback from palpating the spinous process Once the pattern of dissociation feels familiar
of C3 or C4, the person is trained to perform it should be integrated into various functional
independent lower cervical extension (Figure postures and positions. T36.4 illustrates some
6.40). retraining options.
257
T36.1 Assessment and rating of low threshold recruitment efficiency of the Head Back Hinge Test
from the Head Back Hinge Test
HEAD BACK HINGE TEST
Mid-cervical Translation Segmental extension ! Visual observation Observe in a mirror or directly
Extension hinge (indicate level) watch the movement
correction observer
T36.4 Functional positions for retraining mid-cervical translation (in extension) control
• Sitting • Incline sitting forwards (bias posterior muscles)
• Standing • Standing forward lean (bias posterior muscles)
• Supine (bias anterior muscles) • Functional activities
• Recline sitting backwards (bias anterior muscles)
• Side-lying
258
The therapist monitors the mid-cervical neutral

T37 CHIN LIFT HINGE TEST position by palpating (with one finger tip) the
(tests for mid-cervical translation/ spinous process of the hinge point: C3 or C4
extension UCM) (Figure 6.41).
Without letting the head move forwards or the
This dissociation test assesses the ability to actively chin poke forwards, the person is instructed to
dissociate and control mid-cervical translation independently lift the chin (vertically) through
during extension and move the upper cervical upper cervical extension, visualising flattening the
spine into extension. lordosis against an imaginary wall placed at the
back of the head. There should be no uncon-
trolled mid-cervical hinge or palpable forward
Test procedure
translation during active upper cervical extension.
The person sits tall with feet unsupported and The person is instructed to lift the chin up and
pelvis neutral. The low and upper cervical spine back (not up and forwards) and elongate the back
is positioned in the neutral training region. The of the neck by pushing back into the palpating
scapula and TMJ are also positioned in neutral. finger on the spinous process (Figure 6.42). The
Figure 6.42 Benchmark chin lift hinge test with therapist

Figure 6.41 Start position chin lift hinge test palpation
259
palpating finger should feel that the spinous

process of C3 or C4 does not move forwards
(’sink’ into the neck) as the chin lifts (see
T36.1 in the previous section). There should If some other movement (e.g. a small amount of cervical
be no low cervical flexion (head moving rotation) is observed during a motor control (dissociation)
forwards), chin poke forwards or loss of test of mid-cervical extension hinge, do not score this as
scapula position (especially observe for scapula uncontrolled mid-cervical extension hinge. The cervical
elevation or forward tilt). The jaw should stay rotation motor control tests will identify if the observed
relaxed. unrelated movement is uncontrolled. A test for mid-
Ideally, the person should be able to easily cervical extension hinge UCM is only positive if
prevent excessive forward translation of mid- uncontrolled mid-cervical extension hinge is
demonstrated.
cervical vertebrae (palpating finger does not sink
in to the neck) while independently moving the
upper cervical spine through range from flexion
to extension and return. Rating and diagnosis of cervical
While teaching, allow the person to initially extension UCM
learn and practise the test movement using feed-
back from palpation with their own fingers to (T37.1 and T37.2)
monitor and control the mid-cervical translation
(hinge) until awareness of the correct movement Correction
is achieved. Initially, position the lower cervical spine in
neutral with the head supported and the upper
cervical spine slightly flexed by allowing the chin
to drop towards the throat. This can be done in
sitting or standing with the thoracic spine and the
Mid-cervical uncontrolled back of the head against a wall. Using the feed-
forward translation during back and support of the supporting surface, the
person is trained to perform independent upper
extension
cervical extension (vertical chin lift). The person
The person complains of extension-related symp- is instructed to lift the chin up and back (not up
toms in the mid-cervical spine region. The mid- and forwards) and elongate the back of the neck
cervical spine has greater give into forward by pushing back into the palpating finger on the
translation/extension than the upper cervical spine spinous process. The palpating finger should feel
under extension load. During active upper that the spinous process of C3 or C4 does not
cervical extension, the mid-cervical segments move forwards (’sink’ into the neck) as the chin
give excessively into segmental extension hinge lifts.
and translational shear (primarily at C3–4 and The upper cervical spine can extend only so far
C4–5, and occasionally at C5–6). During the as there is no forward movement of the head, no
attempt to dissociate the mid-cervical hinge from forward chin poke and the scapula and TMJ do
independent upper cervical extension, the person not lose their neutral position. Using feedback
either cannot control the UCM or has to concen- from palpating the spinous process of C3 or C4
trate and try too hard. the person is trained to perform independent
If uncontrolled mid-cervical hinge or forward upper cervical extension while controlling mid-
translation occurs during extension, the palpating cervical translation. If control is poor, start in
finger of the spinous process of C3 or C4 sud- supine lying with the occiput supported on a
denly starts to ‘sink’ forwards into the neck, small folded towel. The person should prevent
instead of moving backwards with the head and the chin from poking forwards or the head from
the adjacent vertebrae. Occasionally, chin poke moving forwards and maintain control of the
and forward movement of the head is observed; mid-cervical hinge. Maintain a backward pressure
or loss of scapula position (especially observe for at the spinous process (push back into the palpat-
scapula elevation, retraction or forward tilt). The ing finger tip) while independently moving
jaw should stay relaxed. the upper cervical spine through range from
260
flexion to extension (vertical chin lift). Only The person should self-monitor the control of
move so far as there is no mid-cervical hinge and mid-cervical translation during extension UCM
the scapula and TMJ do not lose their neutral with a variety of feedback options (T37.3). There
position. should be no provocation of any symptoms
As the ability to control upper cervical exten- within the range that the extension UCM can be
sion gets easier and the pattern of dissociation controlled.
feels less unnatural, the exercise can be progressed Once the pattern of dissociation feels familiar
from head and shoulder girdle supported to head it should be integrated into various functional
and shoulder girdle unsupported postures (Figure postures and positions. T37.4 illustrates some
6.43). retraining options.
Figure 6.43 Correction with self-palpation
261
T37.1 Assessment and rating of low threshold recruitment efficiency of the Chin Lift Hinge Test
from the Chin Lift Hinge Test
CHIN LIFT HINGE TEST
multisegmental
Mid-cervical Translation Segmental extension ! watch the movement
Extension Multisegmental ! correction observer
hyperextension
T37.4 Functional positions for retraining mid-cervical translation (in extension) control
• Sitting • Incline sitting forwards (bias posterior muscles)
• Standing • Standing forward lean (bias posterior muscles)
• Supine (bias anterior muscles) • Functional activities
• Recline sitting backwards (bias anterior muscles)
• Side-lying
262
and not tilt into side-bending compensation or

Control of unilateral movements compensate with chin poke and upper cervical
– rotation (± side-bend) extension (Figure 6.44).
The range should be such that the head can turn
to 70–80° from the midline without compensa-
OBSERVATION AND ANALYSIS OF tion. There should be symmetrical range of rota-
NATURAL NECK ROTATION tion (Kapandji 1982) (Figure 6.45).
Description of ideal pattern Movement faults associated with

While sitting tall with their feet unsupported and cervical rotation
the pelvis in neutral, the person’s low and upper
cervical spine is positioned in the neutral training Relative stiffness (restrictions)
region. The scapula and TMJ are also positioned • This is noted by a significant asymmetry of
in neutral. When instructed to turn the head to rotation range or an obvious decrease in
the side to look behind over the shoulders, a standard normal range of motion when
pattern of smooth and even head rotation should compensations and uncontrolled motion are
be observed. There should be concurrent upper actively or passively controlled (Figure 6.46).
and lower cervical movement. The plane of the If natural head rotation demonstrates
face should stay vertical with the eyes horizontal reasonable range of motion but there is
Figure 6.44 Ideal rotation without chin poke Figure 6.45 Ideal rotation without side-bend
263
Figure 6.46 Significant restriction of neck rotation
observable compensation such as head

lateral tilt or chin poke, the therapist should
passively support and correct the movement
by preventing the compensation while the
person actively tries to rotate again. A
restriction of rotation is identified if there is
less than 70–80° range of rotation or if there
is significant asymmetry between left and
right sides. This does not identify if the
Figure 6.47 Unloading of ipsilateral scapula demonstrates
restriction is due to articular influences or increased neck rotation range
due to myofascial influences.
Useful guidelines for differentiation

between articular and myofascial restrictions • Myofascial/neural restriction. If the cervical
myofascial tissues and neural structures are
Absolute differentiation between structures is not unloaded ipsilaterally by passively lifting the
possible. However, this clinical analysis is useful scapula off the dropped shoulder position
for helping to differentiate between different and upwardly rotating/elevating the scapula,
tissues affecting functional movement. and full range of rotation returns or a
• Articular restriction. If the cervical myofascial significant increase in rotation range is
tissues and neural structures are unloaded achieved, then the myofascial or neural
ipsilaterally by passively upwardly rotating tissues are implicated as a source of
and elevating the scapula, and full range of functional restriction (Figure 6.47). This is
rotation (70–80°) cannot be achieved (there confirmed by re-loading these structures with
is no or only slight increased range of ipsilateral scapula depression and a
rotation), the articular structures are significant decrease in rotation range is
implicated as a source of restriction. This is noted (Figure 6.48).
confirmed with rotation manual segmental Excessive tension in either the levator
assessment (e.g. Maitland PPIVMs or scapula (upper cervical attachments) or the
PAIVMs) and treatment is directed towards scalenes (lower cervical attachments) on the
manual mobilisation or manipulation of the ipsilateral side is implicated with altered
segmental articular restriction. side-bend rotation coupling mechanics,
264
Figure 6.48 Ipsilateral scapular depression demonstrates Figure 6.49 Start position for myofascial and neural
decreased neck rotation range differentiation
producing a functional loss of head rotation. is a neural sensitisation/protection

Excessive tension can arise from abnormally problem or if the primary mechanism is a
shortened muscles pulling on the cervical myofascial extensibility or scapular control
attachments or from an abnormally dropped problem.
(downwardly rotated or depressed) scapula Load the ipsilateral myofascial and neural
adding excessive tension on the lateral neck structures together with scapula depression
via normal muscles. Treatment is directed plus shoulder abduction to 90° and external
towards stability rehabilitation of the scapula rotation with relaxed elbow extension,
± addressing neural sensitivity. Passive forearm supination and slight wrist and
elevation of the scapulae has been shown to finger extension. This incorporates the basic
decrease symptoms with rotation in neck elements of the upper limb tension test 1
pain patients (Van Dillen et al 2007). (ULTT1) (Butler 2000). Then rotate the head
• Differentiating between primary myofascial and towards the ipsilateral shoulder to engage
primary neural mechanisms in function (non- the point of restriction (Figure 6.49).
articular) restriction. If myofascial or neural Maintain the myofascial loading component
involvement contributes to a functional with scapula depression while unloading the
restriction, a useful clinical test can help to neural component by releasing the distal
differentiate whether the primary mechanism components of ULTT 1 (that is, flex the
265
of extensibility of the levator scapula or

scalene muscles. This can be confirmed
with muscle length tests. The increased
tension in the levator scapulae and the
scalene muscles and resultant functional
restriction may also be due to muscles of
normal length being placed under tension
by a dropped shoulder position. Increased
tension can result from a poor scapular
control and a dropped scapula position
placing passive tension on these muscles as
the shoulder girdle ‘hangs’ off the neck.
Analysis of scapula control will differentiate
this (see Chapter 8).
Clinical note: restriction of movement can
sometimes be observed when there is an
articular hypermobile uncontrolled segment.
This hypermobile motion contributes to a
relative impingement process which in turn
generates pain and subsequent protective
guarding responses. When this hypermobility
is actively stabilised with the deep neck
flexors, or passively stabilised, provocation is
controlled and range increases.

spine may compensate for a restriction of
rotation. Rotation may be limited due to
Figure 6.50 Maintaining myofascial loading while unloading articular or myofascial influences.
neural tissues
Compensation with excessive upper cervical
extension or a chin poke posture is observed
in the attempt to increase rotation functional
elbow, internally rotate the shoulder and range (Figure 6.51).
allow the wrist and fingers to relax into • Cervical side-bend. Restrictions of rotation
flexion) (Figure 6.50). It is normal for may be compensated for by tilting the
symptoms to decrease when the neural head in to side-bending in an attempt
system is unloaded, but if the range of to gain more functional range (Figure
rotation significantly increases when the 6.52).
neural system only is unloaded, neural • Segmental uncontrolled articular rotation. This
mobility or sensitivity is implicated as the is identified as hypermobile articular rotation
primary dysfunction and further assessment on passive manual assessment of
should be considered (Butler 2000; intersegmental articular mobility (e.g.
Shacklock 2005). increased motion on testing with Maitland
If range of rotation stays restricted when PPIVMs or PAIVMs).
the neural system is unloaded then the • Scapula compensation. The scapula may also
myofascial system is implicated as the demonstrate a variety of compensation
primary dysfunction. If myofascial tissue strategies associated with head rotation.
changes are identified as the primary Ideally, the scapula should be able to
mechanism implicated in the restriction, this maintain a relatively neutral or mid-range
may be related to increased tension and lack position and allow full unrestricted
266
Figure 6.51 Compensation during rotation with upper Figure 6.52 Compensation during rotation with
cervical extension/chin poke side-bending
functional range of head rotation. If the

scapula is depressed or downwardly rotated, Control of unilateral
increased passive tensile loading in shoulder movements – side-bend
girdle to neck muscles can contribute to a
myofascial restriction and the chain of
secondary compensation in the neck. Some OBSERVATION AND ANALYSIS OF
people actively use excessive scapula NATURAL NECK SIDE-BENDING
retraction to initiate or assist neck rotation; in
particular the rhomboids and levator scapula
muscles are dominant in this strategy. Some
people actively hitch the shoulder girdle into While sitting tall with the feet unsupported and
scapular elevation to unload any relative the pelvis in neutral, the low and upper cervical
myofascial restriction to allow more spine is positioned in the neutral training region.
functional range. With UCM associated with The scapula and TMJ are also positioned in
head rotation, the uncontrolled scapula is neutral. When instructed to tilt the head laterally
ipsilateral to (i.e. on the same side as) the to the side as if moving the top tip of the ear
direction of head rotation. towards the shoulder, a pattern of smooth and
267
even head side-bending should be observed. manual mobilisation or manipulation of the

There should be concurrent upper and lower cer- segmental articular restriction.
vical movement. The plane of the face should stay • Myofascial/neural restriction. If the cervical
facing ahead (in the frontal plane) and not turn myofascial tissues and neural structures are
into rotation compensation or compensate with unloaded contralaterally by passively lifting
chin poke and upper cervical extension. the scapula off the dropped shoulder
The range should be such that the head can position and upwardly rotating/elevating the
side-bend to 40–45° from the mid-line without scapula, and full range of side-bending
compensation. There should be symmetrical returns or a significant increase in rotation
range of side-bending (Kapandji 1982). range is achieved, then the myofascial or
neural tissues are implicated as a source of
functional restriction. This is confirmed by
reloading these structures with contralateral
cervical side-bend scapula depression and a significant decrease
Relative stiffness (restrictions) in side-bending range is noted.
Excessive tension in either the levator
• This is noted by a significant asymmetry of scapula (upper cervical attachments) or the
side-bend range or an obvious decrease in scalenes (lower cervical attachments) on the
standard normal range of motion when contralateral side is implicated with altered
compensations and uncontrolled motion are side-bend rotation coupling mechanics
actively or passively controlled. If natural producing a functional loss of head side-
head side-bending demonstrates reasonable bending. Excessive tension can arise from
range of motion but there is observable abnormally shortened muscles pulling on
compensation, such as head rotation or chin the cervical attachments or from an
poke, the therapist should passively support abnormally dropped (downwardly rotated or
and correct the movement by preventing the depressed) scapula adding excessive tension
compensation while the person actively tries on the lateral neck via normal muscles.
to side-bend again. A restriction of side- Treatment is directed towards stability
bending is identified if there is less than rehabilitation of the scapula ± addressing
40–45° range of lateral side-bend or if there neural sensitivity. Passive elevation of the
is significant asymmetry between left and scapulae has been shown to decrease
right sides. This does not identify if the symptoms with side-bending in neck pain
restriction is due to articular influences or patients (Van Dillen et al 2007).
due to myofascial influences. • Differentiating between primary myofascial
and primary neural mechanisms in function
Guidelines for differentiation between (non-articular) restriction. If myofascial or
articular and myofascial restrictions neural involvement contributes to a
functional restriction, a useful clinical test
Absolute differentiation between structures is not
can help to differentiate whether the primary
possible. However, this clinical analysis is useful
mechanism is a neural sensitisation/
for helping to differentiate between different
protection problem or if the primary
components of the movement system.
mechanism is a myofascial extensibility or
• Articular restriction. If the cervical myofascial scapular control problem.
tissues and neural structures are unloaded Load the contralateral myofascial and
contralaterally by passively upwardly rotating neural structures together with scapula
and elevating the scapula, and full range of depression plus shoulder abduction to 90°
side-bending (40–45°) cannot be achieved and external rotation with relaxed elbow
(there is no or only slight increase in the extension, forearm supination and slight
range of side-bend), the articular structures wrist and finger extension. This incorporates
are implicated as a source of restriction. This the basic elements of the upper limb tension
is confirmed with lateral flexion manual test 1 (ULTT1) (Butler 2000). Then, tilt the
segmental assessment (e.g. Maitland PPIVMs head laterally (towards the contralateral
or PAIVMs) and treatment is directed towards shoulder) to the point of restricted side-bend.
268
Maintain the myofascial loading component limited due to articular or myofascial

with scapula depression while unloading the influences. Compensation with excessive
neural component by releasing the distal upper cervical extension or a chin poke
components of ULTT 1. (That is, flex the posture is observed in the attempt to
elbow, internally rotate the shoulder and increase side-bending functional range.
allow the wrist and fingers to relax into • Cervical rotation. Restrictions of side-bending
flexion.) It is normal for symptoms to may be compensated for by turning the head
decrease when the neural system is unloaded, in to rotation in an attempt to gain more
but if the range of side-bending significantly functional range.
increases when the neural system only is • Segmental uncontrolled articular side-bending.
unloaded, neural mobility or sensitivity is This is identified as hypermobile articular
implicated as the primary dysfunction and side-bending on passive manual assessment
further assessment should be considered of intersegmental articular mobility (e.g.
(Butler 2000; Shacklock 2005). increased motion on testing with Maitland
If range of side-bending stays restricted PPIVMs or PAIVMs).
when the neural system is unloaded, then • Segmental upper cervical. Increased upper
the myofascial system is implicated as the cervical side-bending may be observed as
primary dysfunction. If myofascial tissue compensation for either an articular or
changes are identified as the primary myofascial restriction of low cervical
mechanism implicated in the restriction, this side-bending.
may be related to increased tension and lack • Segmental lower cervical. Increased lower
of extensibility of the levator scapula or cervical side-bending may be observed as
scalene muscles. This can be confirmed with compensation for either an articular or
muscle length tests. The increased tension in myofascial restriction of upper cervical
the levator scapulae and the scalene muscles side-bending.
and resultant functional restriction may also • Scapula compensation. The scapula may also
be due to muscles of normal length being demonstrate a variety of compensation
placed under tension by a dropped shoulder strategies associated with head side-bending.
position. Increased tension can result from a Ideally, the scapula should be able to
poor scapular control and a dropped scapula maintain a relatively neutral or mid-range
position placing passive tension on these position and allow full unrestricted
muscles as the shoulder girdle ‘hangs’ off the functional range of head side-bending. If the
neck. Analysis of scapula control will scapula is depressed or downwardly rotated,
differentiate this (see Chapter 8). increased passive tensile loading in shoulder
Clinical note: restriction of movement can girdle to neck muscles can contribute to a
sometimes be observed when there is an myofascial restriction and the chain of
articular hypermobile uncontrolled segment. secondary compensation in the neck. Some
This hypermobile motion contributes to a people actively hitch the shoulder girdle into
relative impingement process which in turn scapular elevation to unload any relative
generates pain and subsequent protective myofascial restriction to allow more
guarding responses. When this hypermobility functional range. With UCM associated with
is actively stabilised with the deep neck head rotation, the uncontrolled scapula is
flexors, or passively stabilised, provocation is contralateral to (i.e. on the opposite side to)
controlled and range increases. the direction of head side-bending.

spine may compensate for a restriction of
side-bending range. Side-bending may be
269
is identified. The TMJ is also positioned in

Tests of rotation/side-bend control neutral and the jaw should stay relaxed
(Figure 6.53).
The person is instructed to fully rotate the
T38 HEAD TURN TEST
head by turning to look over one shoulder then
(tests for rotation/side-bend UCM) the other. This should be a pure axial rotation
and the person should be able to turn the head
This dissociation test assesses the ability to actively through approximately 70–80° of rotation,
dissociate and control cervical side-bend and keeping the eyes horizontal (Figure 6.54). There
move the cervical spine into rotation. should be no side-bending (lateral flexion com-
pensating for poor rotation control) and there
should be no chin poke (upper extension
Test procedure compensating for poor rotation control) or
The person sits tall with feet unsupported mid-cervical hinging into extension (translation).
and pelvis neutral. The low and upper cervical There should be no forward movement of the
spine is positioned in the neutral training head (low cervical flexion) compensating for
region. The scapula is actively positioned in its poor rotation control. The scapula should actively
neutral training region. Controlling the scapula maintain a neutral position with scapula-trunk
neutral position is especially important if a muscles dominant to the scapula-neck muscles.
myofascial restriction of functional head rotation Ideally, the person should be able to easily prevent
Figure 6.53 Start position head turn test Figure 6.54 Benchmark head turn test
270
compensation and UCM and rotate the head

through the 70–80° range.
While teaching, allow the person to initially
learn and practise the test movement using feed- If some other movement (e.g. a small amount of thoracic
back from head contact on a wall or observation flexion) is observed during a motor control (dissociation)
using mirrors. Keep the occiput in contact with a test of cervical side-bend, do not score this as
supporting surface to monitor that the head turns uncontrolled cervical side-bend. The thoracic flexion
into rotation (axial movement) and does not roll motor control tests will identify if the observed unrelated
(side-bend) into rotation. Using a wall also pro- movement is uncontrolled. A test for cervical side-bend
vides support and feedback about scapula posi- UCM is only positive if uncontrolled cervical side-bend is
tion and control during head rotation. demonstrated.
UCM during rotation Rating and diagnosis of cervical

The person complains of unilateral symptoms in rotation/side-bend UCM
the neck. The cervical spine demonstrates UCM (T38.1 and T38.2)
resulting from a variety of compensation strate-
gies associated with head rotation (Table 6.3).
The inability to prevent these compensation strat- Correction
egies during active rotation identifies UCM. The person sits or stands with the thoracic spine
During the attempt to dissociate these compen- and head supported against a wall. Using a wall
sations from independent cervical axial rotation, also provides support and feedback about scapula
the person either cannot control the UCM or has position and control during head rotation. Some
to concentrate and try too hard. people may find that initial retraining in sup-
The identification of UCM during head rotation ported supine positions is the preferred starting
needs to be assessed on both sides. Note the level (Figure 6.55). The low and upper cervical
direction that the rotation cannot be controlled spine is positioned in the neutral training region.
(i.e. does the chin poke or side-bend during rota- The TMJ is also positioned in neutral and the jaw
tion occur to the left or the right). It may be should stay relaxed.
unilateral or bilateral. The ipsilateral scapula is initially passively posi-
The assessment of restricted motion is tioned in upward rotation ± elevation to unload
reliable only if any compensations/UCM are any myofascial restriction. The scapula is actively
either actively or passively controlled. When com- held against the wall for support and feedback.
pensations are eliminated, a lack of 70–80° range Controlling the scapula neutral position is espe-
of head rotation identifies ‘real’ restriction which cially important if a myofascial restriction of func-
may be due to either a myofascial or articular tional head rotation is identified. Some people
restriction, or both combined. The uncontrolled
rotation of the head may also be associated with
a myofascial restriction holding the scapula in
depression, or downward rotation caused by inef-
ficiency of the stability function of the scapula-
trunk muscles (serratus anterior and middle and
lower trapezius).
Table 6.3 Compensation strategies associated with

uncontrolled head rotation
• Cervical side-bend • Scapular depression
• Upper cervical extension • Scapular downward
• Low cervical flexion rotation
• Mid-cervical hinge • Scapular retraction
• Scapular elevation
Figure 6.55 Correction in supine with head support
271
Figure 6.56 Correction standing with wall support and Figure 6.57 Correction sitting unsupported with active
shoulder girdle unloaded shoulder control
may need to passively support their ipsilateral contact with the wall to monitor that the head
shoulder girdle with their other hand at the elbow turns into rotation (axial movement) and does
(like a sling), or use the armrest of a chair to main- not roll (side-bend) into rotation. The scapula
tain the unloaded shoulder girdle, or use taping in should actively maintain a neutral position
order to prevent the ipsilateral scalenes and levator without depression, downward rotation, retrac-
scapula from generating increased tension and tion or elevation.
adding to the myofascial restriction. As control improves and symptoms decrease,
The person is instructed to fully rotate the the person should begin to actively control the
head by turning to look over one shoulder then scapula position supported on the wall during the
the other (Figure 6.56). This should be a pure neck rotation dissociation. The person should
axial rotation and the person should be able to eventually progress to active control of the unsup-
turn the head through approximately 70–80° of ported shoulder girdle off the wall while training
rotation, keeping the eyes horizontal. There neck rotation dissociation exercises through 70–
should be no side-bending (lateral flexion com- 80° range of rotation.
pensating for poor rotation control) and there As the ability to control cervical rotation gets
should be no chin poke (upper and mid-cervical easier and the pattern of dissociation feels less
extension compensating for poor rotation unnatural, the exercise can be progressed from
control). There should be no forward movement head and shoulder girdle supported to head and
of the head (low cervical flexion compensating shoulder girdle unsupported postures (Figure
for poor rotation control). Keep the occiput in 6.57).
272
Figure 6.58 Correction unsupported with neural loading Figure 6.59 Correction unsupported with neural unloading
The person should self-monitor the control of postures and positions. T38.4 and Figures 6.58
cervical side-bend UCM with a variety of feedback and 6.59 illustrate some retraining positions
options (T38.3). There should be no provocation (Figure 6.58 + neural load) (Figure 6.59 + neural
of any symptoms within the range that the side- unload).
bend UCM can be controlled.
Once the pattern of dissociation feels familiar it
should be integrated into various functional
273
T38.1 Assessment and rating of low threshold recruitment efficiency of the Head Turn Test
T38.2 Diagnosis of the site and direction of UCM from the Head Turn Test
HEAD TURN TEST

Site Direction To the (L) To the (R)
Cervical • Side-bend ! !
Upper cervical • Extension ! !
Mid-cervical • Hinge (into extension) ! !
Low cervical • Flexion ! !
Scapula • Depression ! !
• Downward rotation ! !
• Retraction ! !
• Elevation ! !
274
T38.3 Feedback tools to monitor retraining T38.4 Functional positions for retraining cervical
rotation control
FEEDBACK TOOL PROCESS • Sitting • 4 point kneeling
Self-palpation Palpation monitoring of joint • Standing (bias posterior muscles)
position • Supine (bias anterior • Incline sitting forwards
muscles) (bias posterior muscles)
Visual observation Observe in a mirror or directly • Recline sitting backwards • Standing forward lean
watch the movement (bias anterior muscles) (bias posterior muscles)
Cueing and verbal Listen to feedback from • Side-lying • Functional activities
275
The person is instructed to fully side-bend the

T39 HEAD TILT TEST head by tilting the head towards one shoulder
(tests for rotation and/or side-bend then the other. This should be a pure coronal side-
UCM) bending and the person should be able to
tilt the head through approximately 40° of side-
bending keeping the plane of the face facing for-
This dissociation test assesses the ability to actively wards in the frontal plane (Figure 6.61). There
dissociate and control cervical and scapula com- should be no turning (rotation compensating for
pensations and move the cervical spine into poor side-bend control) and there should be no
side-bend. chin poke (upper cervical extension compensating
for poor side-bend control) or mid-cervical trans-
Test procedure
lation. There should be no forward movement of
The person sits tall with feet unsupported and the head (low cervical flexion) compensating for
pelvis neutral. The low and upper cervical spine poor side-bend control. The scapula should
is positioned in the neutral training region. actively maintain a neutral position with scapula-
The scapula is actively positioned in its neutral trunk muscles dominant to scapula-neck muscles.
training region. Controlling the scapula neutral Ideally, the person should be able to easily
position is especially important if a myofascial prevent chin poke, rotation or head forward com-
restriction of functional head rotation is identi- pensation with a neutral scapular position and
fied. The TMJ is also positioned in neutral and the side-bend the cervical spine through 40° range of
jaw should stay relaxed (Figure 6.60). motion.
Figure 6.60 Start position head tilt test Figure 6.61 Benchmark head tilt test
276
Table 6.4 Compensation strategies associated with Clinical assessment note for direction-specific
uncontrolled head side-bend motor control testing
• Cervical rotation • Scapular depression
• Upper cervical extension • Scapular downward If some other movement (e.g. a small amount of thoracic
• Low cervical flexion rotation flexion) is observed during a motor control (dissociation)
• Mid-cervical hinge • Scapular elevation test of cervical rotation, do not score this as uncontrolled
cervical rotation. The thoracic flexion motor control tests
will identify if the observed unrelated movement is
uncontrolled. A test for cervical rotation UCM is only
positive if uncontrolled cervical rotation is demonstrated.
While teaching, allow the person to initially
learn and practise the test movement using feed-
back from a wall or mirror. Keep the occiput in
contact with a supporting surface to monitor
that the head tilts into side-bend (coronal move-
ment) and does not turn into rotation. Using a rotation/side-bend UCM
wall also provides support and feedback about (T39.1 and T39.2)
scapula position and control during head
rotation.
Correction
The person sits or stands with the thoracic spine
UCMs during side-bend
and head supported against a wall. Using a wall
The person complains of unilateral symptoms in also provides support and feedback about scapula
the neck. The cervical spine demonstrates UCM position and control during head side-bending.
resulting from a variety of compensation strate- The low and upper cervical spine is positioned in
gies associated with head side-bending (Table the neutral training region. The TMJ is also posi-
6.4). The inability to prevent these compensation tioned in neutral and the jaw should stay relaxed.
strategies during active side-bending identifies The contralateral scapula is initially passively
UCM. positioned in upward rotation ± elevation to
During the attempt to dissociate these compen- unload any myofascial restriction. The scapula is
sations from independent cervical coronal side- actively held against the wall for support and
bending, the person either cannot control the feedback (Figure 6.62). Controlling the scapula
UCM or has to concentrate and try too hard. neutral position is especially important if a myo-
The identification of UCM during cervical side- fascial restriction of functional head side-bending
bending and head lateral tilt needs to be assessed is identified. Some people may need to passively
on both sides. Note the direction that the side- support their contralateral shoulder girdle with
bending cannot be controlled (i.e. does the chin their other hand at the elbow (like a sling), or use
poke or rotation during side-bending occur to the armrest of a chair to maintain the unloaded
the left or the right). It may be unilateral or shoulder girdle, or use taping in order to prevent
bilateral. the contralateral scalenes and levator scapula
The assessment of restricted motion is reliable from generating increased tension and adding to
only if any compensations/UCM are either the myofascial restriction.
actively or passively controlled. When compensa- The person is instructed to fully side-bend the
tions are eliminated, a lack of 40° range of head head by tilting the ear towards one shoulder then
side-bending identifies ‘real’ restriction which the other. This should be a pure coronal side-
may be due to either a myofascial or articular bending and the person should be able to tilt the
restriction or both combined. The uncontrolled head through approximately 40° of side-bending
side-bending of the head may also be associated keeping the plane of the face facing forwards in
with a myofascial restriction holding the scapula the frontal plane. There should be no turning
in depression or downward rotation caused by (rotation compensating for poor side-bend
inefficiency of the stability function of the scapula- control) and there should be no chin poke (upper
trunk muscles (serratus anterior and middle and and mid-cervical extension compensating for
lower trapezius). poor side-bend control). There should be no
277
forward movement of the head (low cervical As the ability to control cervical side-bending
flexion) compensating for poor side-bend control. gets easier and the pattern of dissociation feels
Keep the occiput in contact with the wall to less unnatural, the exercise can be progressed
monitor that the head tilts into side-bending from head and shoulder girdle supported to head
(coronal movement) and does not turn into rota- and shoulder girdle unsupported postures (Figure
tion. The scapula should actively maintain a 6.63).
neutral position without depression, downward The person should self-monitor the control of
rotation, retraction or elevation. cervical rotation UCM with a variety of feedback
As control improves and symptoms decrease, options (T39.3). There should be no provocation
the person should begin to actively control the of any symptoms within the range that the rota-
scapula position supported on the wall during the tion UCM can be controlled.
neck side-bending dissociation. The person Once the pattern of dissociation feels familiar
should eventually progress to active control of the it should be integrated into various functional
unsupported shoulder girdle off the wall while postures and positions: (Figure 6.64 + neural
training neck side-bending dissociation exercises load) (Figure 6.65 + neural unload). T39.4 illus-
through 40° range of side-bending. trates some retraining options.
Figure 6.62 Correction standing with wall support and Figure 6.63 Correction sitting unsupported with active
shoulder girdle unloaded shoulder control
278
T39.1 Assessment and rating of low threshold recruitment efficiency of the Head Tilt Test
T39.2 Diagnosis of the site and direction of UCM from the Head Tilt Test
HEAD TILT TEST

Site Direction To the (L) To the (R)
Cervical • Rotation ! !
Upper cervical • Extension ! !
Mid-cervical • Hinge (into extension) ! !
Low cervical • Flexion ! !
Scapula • Depression ! !
• Downward rotation ! !
• Elevation ! !
279
T39.3 Feedback tools to monitor retraining T39.4 Functional positions for retraining cervical
side-bend control
FEEDBACK TOOL PROCESS • Sitting • 4 point kneeling (bias
Self-palpation Palpation monitoring of joint • Standing posterior muscles)
position • Recline sitting backwards • Incline sitting forwards
(bias anterior muscles) (bias posterior muscles)
Visual observation Observe in a mirror or directly • Side-lying • Standing forward lean
watch the movement (bias posterior muscles)
Cueing and verbal Listen to feedback from • Functional activities
Figure 6.64 Correction unsupported with neural loading Figure 6.65 Correction unsupported with neural unloading
280
The person is instructed to prevent side-bending

T40 UPPER NECK TILT TEST in the low cervical spine (do not move at the base
(tests for rotation/side-bend UCM) of the neck) and then actively tilt the head through
the available range of upper cervical side-bend
This dissociation test assesses the ability to actively by tilting the head at the base of the skull. As the
dissociate and control low cervical side-bend and ear drops towards the shoulder, the chin should
move the upper cervical spine into side-bend. move towards the opposite side (Figure 6.67).
There should be no low cervical side-bend
(monitor the C4–7 transverse or spinous proc-
Test procedure esses) or uncontrolled compensation (e.g. head
The person sits tall with feet unsupported and rotation or chin poke). This should be a pure
pelvis neutral. The low and upper cervical spine coronal side-bending keeping the plane of the face
is positioned in the neutral training region. The facing forwards in the frontal plane. The scapula
scapula is actively positioned in its neutral should actively maintain a neutral position.
training region. Controlling the scapula neutral
position is especially important if a myofascial Low cervical side-bend UCM
restriction of functional head rotation is identi-
fied. The TMJ is also positioned in neutral and the The person complains of unilateral symptoms at
jaw should stay relaxed (Figure 6.66). The thera- the base of the neck and low cervical spine. The
pist monitors low cervical side-bend control by low cervical spine and upper trunk has greater
palpating the C4–7 spinous processes. give into side-bend relative to the upper cervical
Figure 6.66 Start position upper neck tilt test Figure 6.67 Benchmark upper neck tilt test
281
Table 6.5 Compensation strategies associated with

uncontrolled side-bend
• Low cervical side-bend • Scapular elevation
• Upper cervical extension
• Upper cervical rotation
spine and head under head side-bending or uni-

lateral arm loading.
The person complains of unilateral symptoms
in the lower neck and across the top of the shoul-
ders. The cervical spine demonstrates UCM result-
ing from a variety of compensation strategies
associated with head side-bending (Table 6.5).
The inability to prevent these compensation strat-
egies during active side-bending identifies UCM.
During the attempt to dissociate these compen-
sations from independent upper cervical side-
bending (face in the frontal plane), the person
trate and try too hard.
The identification of UCM during upper cervi-
cal side-bending and head lateral tilt needs to be
assessed on both sides. Note the direction that the
side-bending cannot be controlled (i.e. does the
chin poke or rotation during side-bending occur
to the left or the right). It may be unilateral or
bilateral.
The assessment of restricted motion is reliable
only if any compensations/UCM are either actively
Figure 6.68 Correction standing with wall support and
or passively controlled. When compensations are shoulder girdle unloaded
eliminated, a lack of end range of upper cervical
side-bending identifies ‘real’ restriction which
may be due to either a myofascial or articular
restriction or both combined. The uncontrolled Rating and diagnosis of cervical
upper cervical side-bending of the head may also
be associated with a myofascial restriction holding rotation/side-bend UCM
the scapula in depression or downward rotation (T40.1 and T40.2)
caused by inefficiency of the stability function of
the scapula-trunk muscles (serratus anterior and
Correction
middle and lower trapezius).
The person sits or stands with the thoracic spine
Clinical assessment note for direction-specific and head supported against a wall. Using a wall
motor control testing also provides support and feedback about scapula
position and control during head side-bending.
If some other movement (e.g. a small amount of thoracic The low and upper cervical spine is positioned in
flexion) is observed during a motor control (dissociation) the neutral training region. The TMJ is also posi-
test of low cervical side-bend, do not score this as tioned in neutral and the jaw should stay relaxed.
uncontrolled low cervical side-bend. The thoracic flexion The contralateral scapula is initially passively
motor control tests will identify if the observed unrelated positioned in upward rotation ± elevation to
movement is uncontrolled. A test for low cervical
unload any myofascial restriction. The scapula is
side-bend UCM is only positive if uncontrolled low
cervical side-bend is demonstrated.
actively held against the wall for support and
feedback (Figure 6.68). Some people may need to
282
Figure 6.69 Correction – hand position for feedback Figure 6.70 Correction with feedback
passively support their contralateral shoulder while training neck side-bending dissociation
girdle with their other hand at the elbow (like a exercises.
sling), or use the armrest of a chair to maintain An alternative progression is to face the wall
the unloaded shoulder girdle, or use taping in with the forearms vertical on the wall. Keep the
order to prevent the contralateral scalenes and scapula in mid-position and push the body and
levator scapula from generating increased tension head away from the wall, then clasp hands with
and adding to the myofascial restriction. the thumbs abducted and position the thumbs
The person monitors low cervical side-bend on the chin for feedback and support (Figure
control by palpating the C4–7 transverse and 6.69). Keeping the elbows on the wall, the head
spinous processes. The person can also use their back over the shoulders and the chin in contact
hand to provide manual fixation and support for with the thumbs, slowly tilt the head side to side
the low cervical spine if necessary. The person is only so far as there is no low cervical side-bend
then instructed to actively tilt the head through (Figure 6.70). Pivot the chin off the thumbs to
the available range of upper cervical side-bend by ensure that the movement is localised to the
tilting the head at the base of the skull while upper cervical spine.
preventing side-bending in the low cervical spine. The person should self-monitor the control of
As the ear drops towards the shoulder the chin low cervical side-bend UCM with a variety of
should move towards the opposite side. feedback options (T40.3). There should be no
As control improves and symptoms decrease provocation of any symptoms within the range
the person should begin to actively control the that the side-bend UCM can be controlled.
scapula position supported on the wall during Once the pattern of dissociation feels familiar
the neck side-bending dissociation. The person it should be integrated into various functional
should eventually progress to active control of postures and positions. T40.4 illustrates some
the unsupported shoulder girdle off the wall retraining options.
283
T40.1 Assessment and rating of low threshold recruitment efficiency of the Upper Neck Tilt Test
from the Upper Neck Tilt Test
UPPER NECK TILT TEST
Site Direction To the (L) To the (R) position
Low cervical • Side-bend ! ! Visual observation Observe in a mirror or directly
watch the movement
Upper cervical • Rotation ! !
• Extension Cueing and verbal Listen to feedback from
Scapula • Elevation ! !
T40.4 Functional positions for retraining low cervical side-bend control

284
The person is instructed to prevent side-bending

T41 LOWER NECK LEAN TEST in the upper cervical spine (do not move at the
(tests for rotation/side-bend UCM) base of the skull) and then actively lean the head
through the available range of low cervical side-
This dissociation test assesses the ability to actively bend by tilting the head at the base of the neck.
dissociate and control upper cervical side-bend As the head leans towards the shoulder, the chin
and move the low cervical spine into side-bend. should move towards the same side (Figure 6.72).
There should be no upper cervical side-bend
(monitor the C1–3 spinous processes) or uncon-
Test procedure
trolled compensation (upper cervical rotation or
The person sits tall with feet unsupported and extension and low cervical flexion). This should
pelvis neutral. The low and upper cervical spine be a pure coronal side-bending keeping the plane
is positioned in the neutral training region. of the face facing forwards in the frontal plane.
The scapula is actively positioned in its neutral The scapula should actively maintain a neutral
training region. Controlling the scapula neutral position with scapula-trunk muscles dominant to
position is especially important if a myofascial scapula-neck muscles.
restriction of functional head rotation is identi-
fied. The TMJ is also positioned in neutral and the
Upper cervical side-bend UCM
jaw should stay relaxed (Figure 6.71). The thera-
pist monitors upper cervical side-bend control The person complains of unilateral symptoms
by palpating the C1–3 transverse and spinous in the upper cervical spine or at the base of the
processes. skull. The upper cervical spine has greater give
Figure 6.71 Start position lower neck lean test Figure 6.72 Benchmark lower neck lean test
285
Table 6.6 Compensation strategies associated with Rating and diagnosis of cervical
uncontrolled side-bend rotation/side-bend UCM
• Upper cervical side-bend • Scapular elevation (T41.1 and T41.2)
• Upper cervical rotation
• Low cervical flexion
Correction
into side-bend relative to the low cervical spine and The person sits or stands with the thoracic spine
head under head side-bending or unilateral arm and head supported against a wall. Using a wall
loading. also provides support and feedback about scapula
The person complains of unilateral symptoms position and control during head side-bending.
in the lower neck and across the top of the shoul- The low and upper cervical spine is positioned in
ders. The cervical spine demonstrates UCM result- the neutral training region. The TMJ is also posi-
ing from a variety of compensation strategies tioned in neutral and the jaw should stay relaxed.
associated with head side-bending (Table 6.6). The contralateral scapula is initially passively
The inability to prevent these compensation strat- positioned in upward rotation ± elevation to
egies during active side-bending identifies UCM. unload any myofascial restriction. The scapula is
During the attempt to dissociate these compen- actively held against the wall for support and
sations from independent low cervical side- feedback (Figure 6.73). Some persons may need
bending (face in the frontal plane), the person to passively support their contralateral shoulder
trate and try too hard.
The identification of UCM during low cervical
side-bending and lateral tilt needs to be assessed
on both sides. Note the direction that the side-
bending cannot be controlled (i.e. does the rota-
tion or chin poke during side-bending occur to the
left or the right). It may be unilateral or bilateral.
The assessment of restricted motion is reliable
only if any compensations/UCM are either
actively or passively controlled. When compensa-
tions are eliminated, a lack of end range of low
cervical side-bending identifies ‘real’ restriction,
which may be due to either a myofascial or articu-
lar restriction or both combined. The uncon-
trolled cervical side-bending of the head may also
be associated with a myofascial restriction holding
the scapula in depression or downward rotation
caused by inefficiency of the stability function of
the scapula-trunk muscles (serratus anterior and
middle and lower trapezius).

If some other movement (e.g. a small amount of thoracic

flexion) is observed during a motor control (dissociation)
test of upper cervical side-bend, do not score this as
uncontrolled upper cervical side-bend. The thoracic
flexion motor control tests will identify if the observed
cervical side-bend UCM is only positive if uncontrolled
upper cervical side-bend is demonstrated. Figure 6.73 Correction standing with wall support and
shoulder girdle unloaded
286
girdle with their other hand at the elbow (like a As control improves and symptoms decrease,
sling), or use the armrest of a chair to maintain the person should begin to actively control the
the unloaded shoulder girdle, or use taping in scapula position supported on the wall during
order to prevent the contralateral scalenes and the neck side-bending dissociation. The person
levator scapula from generating increased tension should eventually progress to active control of the
and adding to the myofascial restriction. unsupported shoulder girdle off the wall while
The person monitors upper cervical side-bend training neck side-bending dissociation exercises.
control by palpating the C0–3 transverse and The person should self-monitor the control of
spinous processes. The person can also use their upper cervical side-bend UCM with a variety of
hand to provide manual fixation and support for feedback options (T41.3). There should be no
the upper cervical spine if necessary. The person provocation of any symptoms within the range
is then instructed to actively tilt the head through that the side-bend UCM can be controlled.
the available range of lower cervical side-bend by Once the pattern of dissociation feels familiar
tilting the head at the base of the neck while it should be integrated into various functional
preventing side-bending in the upper cervical postures and positions. T41.4 illustrates some
spine. As the ear drops towards the shoulder the retraining options.
chin should move towards the same side.
287
T41.1 Assessment and rating of low threshold recruitment efficiency of the Lower Neck Lean Test
LOWER NECK LEAN TEST
ASSESSMENT
Control point:
• prevent upper cervical: side-bend, rotation
• prevent lower cervical flexion
• prevent scapular elevation
Movement challenge: low cervical side-bend (sitting)
Benchmark range: low cervical side-bend through full available from the midline with plane of the face in the frontal
plane
RATING OF LOW THRESHOLD RECRUITMENT EFFICIENCY FOR CONTROL OF DIRECTION

or or
• Able to prevent UCM into the test direction • Looks easy, and in the opinion of the assessor,
Correct dissociation pattern of movement is performed with confidence
Prevent low cervical UCM into: • Feels easy, and the subject has sufficient
• upper cervical side-bend awareness of the movement pattern that they
• upper cervical extension confidently prevent UCM into the test
• low cervical rotation direction
Prevent scapula UCM into: • The pattern of dissociation is smooth during
• elevation concentric and eccentric movement
and move low cervical side-bend • Does not (consistently) use end-range
• Dissociate movement through the benchmark movement into the opposite direction to
range of: full end-range 15º low cervical prevent the UCM
side-bend past midline (face in frontal plane) • No extra feedback needed (tactile, visual or
If there is more available range than the verbal cueing)
benchmark standard, only the benchmark • Without external support or unloading
range needs to be actively controlled • Relaxed natural breathing (even if not ideal
• Without holding breath (though it is – so long as natural pattern does not change)
acceptable to use an alternate breathing • No fatigue
strategy)
• Control during eccentric phase
• Control during concentric phase
from the Lower Neck Lean Test
LOWER NECK LEAN TEST
Site Direction To the (L) To the (R) position
Upper cervical • Rotation ! ! Visual observation Observe in a mirror or directly
• Extension ! ! watch the movement
Low cervical • Flexion ! ! Cueing and verbal Listen to feedback from
Scapula • Elevation ! !
T41.4 Functional positions for retraining upper cervical side-bend control

288
Cervical stability dysfunction

summary
(Table 6.7)
Table 6.7 Summary and rating of cervical tests

Test of stability control (site and direction) Rating (✓✓ or ✓✗ or ✗✗) and rationale
SITE: LOW CERVICAL DIRECTION: FLEXION CLINICAL PRIORITY !

Occiput lift test
Thoracic flexion test
Overhead arm lift test
SITE: UPPER CERVICAL DIRECTION: FLEXION CLINICAL PRIORITY !

Forward head lean test
Arm extension test
SITE: UPPER CERVICAL DIRECTION: EXTENSION CLINICAL PRIORITY !

Backward head lift test
Horizontal retraction test
SITE: MID-CERVICAL DIRECTION: TRANSLATION CLINICAL PRIORITY !

(DURING EXTENSION)
Head back hinge test
Chin lift hinge test
SITE: CERVICAL DIRECTION: SIDE-BEND CLINICAL PRIORITY !

Head turn test (L) (R)
SITE: CERVICAL DIRECTION: ROTATION CLINICAL PRIORITY !

Head tilt test (L) (R)
SITE: LOW CERVICAL DIRECTION: SIDE-BEND CLINICAL PRIORITY !

Upper neck tilt test (L) (R)
SITE: UPPER CERVICAL DIRECTION: SIDE-BEND CLINICAL PRIORITY !

Lower neck lean test (L) (R)
289
REFERENCES
Amevo, B., Aprill, C., Bogduk, N., 1992. reduced electromyographic activity mechanical neck disorders. Spine 29,
Abnormal instantaneous axes of of the deep cervical flexor muscles 1541–1548.
rotation in patients with neck pain. during performance of the Johnston, V., Jull, G., Darnell, R.,
Spine 54 (2), 213–217. craniocervical flexion test. Spine 29, Jimmieson, N.L., Souvlis, T., Jull, G.,
Butler, D., 2000. The sensitive nervous 2108–2114. et al., 2008b. Alterations in cervical
system. NOI Publications, Adelaide, Falla, D., Jull, G., Hodges, P., Vicenzino, muscle activity in functional and
Australia. B., 2006. An endurance-strength stressful tasks in female office
Caldwell, C., Sahrmann, S., Van, D., training regime is effective in workers with neck pain. European
2007. Use of a movement system reducing myoelectric manifestations Journal of Applied Physiology 103
impairment diagnosis for physical of cervical flexor muscle fatigue in (3), 253–264.
therapy in the management of a females with chronic neck pain. Johnston, V., Jull, G., Souvlis T.,
patient with shoulder pain. Journal Clinical Neurophysiology 117, Jimmieson, N.L., 2008a. Neck
of Orthopaedic and Sports Physical 828–837. movements and muscle activity
Therpay 37 (9), 551–563. Falla, D., Jull, G., Russell, T., Vicenzino, characteristics in office workers with
Cheng, J.S., Liu, F., Komistek, R.D., B., Hodges, P., 2007. Effect of neck neck pain. Spine 33 (5), 555–563.
Mahfouz, M.R., Sharma, A., Glaser, exercise on sitting posture in patients Jull, G., Kristjansson, E., Dall’Alba, P.,
D., 2007. Comparison of cervical with chronic neck pain. Physical 2004. Impairment in the cervical
spine kinematics using a Therapy 87, 408–417. flexors: a comparison of whiplash
fluoroscopic model for adjacent Fernández-de-las-Peñas, C., Falla, D., and insidious onset neck pain
segment degeneration. Invited Arendt-Nielsen, L., Farina, D., 2008. patients. Manual Therapy 9, 89–94.
submission from the Joint Section Cervical muscle co-activation in Jull, G., Sterling, M., Falla, D., Treleaven,
on Disorders of the Spine and isometric contractions is enhanced J., O’Leary, S., 2008. Whiplash,
Peripheral Nerves, March 2007. in chronic tension-type headache headache and neck pain. Elsevier,
Journal of Neurosurgery, Spine 7 (5), patients. Cephalalgia 28 (7), Edinburgh.
509–513. 744–751.
Jull, G., Trott, P., Potter, H., Zito, G.,
Comerford, M.J., Mottram, S.L., 2011. Fernández-de-las-Peñas, C., Pérez-de-
Niere, K., Shirley, D., et al., 2002. A
Diagnosis of uncontrolled Heredia, M., Molero-Sánchez, A.,
randomized controlled trial of
movement, subgroup classification Miangolarra-Page, J.C., 2007.
exercise and manipulative therapy
and motor control retraining of the Performance of the craniocervical
for cervicogenic headache. Spine 27,
neck. Kinetic Control, UK. flexion test, forward head posture,
1835–1843.
and headache clinical parameters in
Dall’Alba, P.T., Sterling, M.M., Treleaven, Kapandji, I.A., 1982. The physiology of
patients with chronic tension-type
J.M., Edwards, S.L., Jull, G.A., 2001. the joints, 5th edn. Vol 3. The trunk
headache: a pilot study. Journal of
Cervical range of motion and vertebral column. Churchill
Orthopaedic and Sports Physical
discriminates between asymptomatic Livingstone, Edinburgh.
Therapy 37 (2), 33–39.
persons and those with whiplash. Kapreli, E., Vourazanis, E., Strimpakos,
Spine 26 (19), 2090–2094. Fritz, J.M., Brennan, G.P., 2007.
Preliminary examination of a N., 2008. Neck pain causes
Dvorak, J., Froehlich, D., Penning, L., proposed treatment-based respiratory dysfunction. Medical
Baumgartner, H., Panjabi, M.M., classification system for patients Hypotheses 70 (5), 1009–1013.
1998. Functional radiographic receiving physical therapy Kjellman, G.V., Skargren, E.I., Oberg,
diagnosis of the cervical spine: interventions for neck pain. Physical B.E., 1999. A critical analysis of
flexion/extension. Spine 13, Therapy 87 (5), 513–524. randomised clinical trials on neck
748–755. pain and treatment efficiency. A
Grip, H., Sundelin, G., Gerdle, B.,
Falla, D., Farina, D., 2007. Neural and Karlsson, J.S., 2008. Cervical helical review of the literature. Scandinavian
muscular factors associated with axis characteristics and its center of Journal of Rehabilitation Medicine
motor impairment in neck pain. rotation during active head and 31, 139–152.
Current Rheumatology Reports 9 upper arm movements – Lindman, R., Eriksson, A., Thornell,
(6), 497–502. comparisons of whiplash-associated L.E., 1991a. Fiber type composition
Falla, D., Bilenkij, G., Jull, G., 2004b. disorders, non-specific neck pain and of the human female trapezius
Patients with chronic neck pain asymptomatic individuals. Journal of muscle: enzyme – histochemical
demonstrate altered patterns of Biomechanics doi:10.1016/j. characteristics. American Journal of
muscle activation during jbiomech.2008.07.005. Anatomy 190 (4), 385–392.
performance of a functional Gross, A.R., Hoving, J.L., Haines, T.A., Lindman, R., Hagberg, M., Karl-Axis, A.,
upper limb task. Spine 29, Goldsmith, C.H., Kay, T., Aker, P., Soderlund, K., Hultman, E.,
1436–1440. et al., 2004. Cervical, Overview Thornell, L.E., 1991b. Changes in
Falla, D., Jull, G., Hodges, P., 2004a. Group. A Cochrane review of muscle morphology in chronic
Patients with neck pain demonstrate manipulation and mobilization for trapezius myalgia. Scandinavian
290
Journal of Work, Environment and Panjabi, M.M., 1992. The stabilising Neck and shoulder muscle
Health 17 (5), 347–355. system of the spine. Part II. Neutral recruitment patterns. Manual
McDonnell, M.K., Sahrmann, S.A., Van zone and instability hypothesis. Therapy 10, 270–280.
Dillen, L., 2005. A specific exercise Journal of Spinal Disorders 5 (4), Szeto, G.P.Y., Straker, L., O’Sullivan, P.,
program and modification of 390–397. 2005b. A comparison of
postural alignment for treatment of Sahrmann, S.A., 2002. Diagnosis symptomatic and asymptomatic
cervicogenic headache: a case report. and treatment of movement office workers performing
Journal of Orthopaedic and Sports impairment syndromes. Mosby, monotonous keyboard work. 2:
Physical Therapy 35, 3–15. St Louis, MO. Neck and shoulder kinematics.
Miyazaki, M., Hong, S.W., Yoon, S.H., Shacklock, M., 2005. Clinical Manual Therapy 10, 281–291.
Zou, J., Tow, B., Alanay, A., et al., neurodynamics: a new system of Szeto, G.P., Straker, L.M., O’Sullivan,
2008. Kinematic analysis of the neuromusculoskeletal treatment. P.B., 2008. Neck-shoulder muscle
relationship between the grade of Butterworth Heinmann, Edinburgh. activity in general and task-specific
disc degeneration and motion unit Singer, K.P., Fitzgerald, D., Milne, N., resting postures of symptomatic
of the cervical spine. Spine 33 (2), 1993. Neck retraction exercises and computer users with chronic neck
187–193. cervical disk disease. MPAA pain. Doi:10.1016/j.
Mottram, S.L., 2003. Dynamic stability Conference proceedings, Australia. math.2008.05.001.
of the scapula. In: Beeton, K.S. (Eds), Sterling, M., Jull, G., Vicenzino, B., Van Dillen, L.R., McDonnell, M.K.,
Manual therapy masterclasses – the Kenardy, J., Darnell, R., 2003. Susco, T.M., Sahrmann, S.A., 2007.
peripheral joints. Churchill Development of motor system The immediate effect of passive
Livingstone, Edinburgh. dysfunction following whiplash scapular elevation on symptoms
Nederhand, M.J., Hermens, H.J., injury. Pain 103 (1–2), 65–73. with active neck rotation in patients
IJzerman, M.J., Turk, D.C., Zilvold, Sterling, M., Jull, G., Vicenzino, B., with neck pain. Clinical Journal of
G., 2002. Cervical muscle Kenardy, J., Darnell, R., 2005. Pain 23 (8), 641–647.
dysfunction in chronic whiplash- Physical and psychological Verhagen, A.P., Scholten-Peeters, G.G.,
associated disorder grade 2: the factors predict outcome following de Bie, R.A., Bierma-Zeinstra, S.M.,
relevance of the trauma. Spine 27 whiplash injury. Pain 114 (1–2), 2004. Conservative treatments for
(10), 1056–1061. 141–148. whiplash. Cochrane Database Syst.
Nederhand, M.J., Ijzerman, M.J., Straker, L.M., O’Sullivan, P.B., Smith, Rev. 1, CD003338.
Hermens, H., Baten, C.T., Zilvold, G., A.J., Perry, M.C., 2008. Relationships White, 3rd., A.A., Johnson, R.M.,
2000. Cervical muscle dysfunction in between prolonged neck/shoulder Panjabi, M.M., Southwick, W.O.,
the chronic whiplash associated pain and sitting spinal posture in 1975. Biomechanical analysis of
disorder grade II (WAD-II). Spine 25 male and female adolescents. clinical stability in the cervical spine.
(15), 1938–1943. Manual Therapy, doi:10.1016/j. Clinical Orthopaedics and Related
O’Leary, S., Jull, G., Kim, M., Vicenzino, math.2008.04.004. Research (109), 85–96.
B., 2007. Cranio-cervical flexor Szeto, G.P.Y., Straker, L., O’Sullivan, P., Yip, C.H., Chiu, T.T., Poon, A.T., 2008.
muscle impairment at maximal, 2005a. A comparison of The relationship between head
moderate, and low loads is a feature symptomatic and asymptomatic posture and severity and disability of
of neck pain. Manual Therapy 12, office workers performing patients with neck pain. Manual
34–39. monotonous keyboard work. 1: Therapy 13 (2), 148–154.
291
CHAPTER 7
THE THORACIC SPINE
Flexion control
T42 Standing: back flattening test 296
T43 Sitting: head hang test 300
T44 Sitting: pelvic tail tuck test 304
T45 Sitting: bilateral forward reach test 308
Extension control
T46 Standing: bilateral overhead reach test 313
T47 Sitting: head raise test 316
T48 Sitting: pelvic tail lift test 319
T49 Standing: bilateral backward reach test 323
Rotation control
T50 Sitting: head turn test 328
T51 Sitting: pelvic twist (swivel chair) test 331
T52 Standing: pelvic side-shift test 334
T53 Standing: one arm wall push test 337
T54 4 point: one arm lift test 340
T55 Side-lying: lateral arm lift test 344
T56 Side-lying: side bridge test 347
Thoracic/rib respiration control

T57 Standing: apical drop + inspiration test 351
T58 Standing: anterior costal lift + expiration test 354
T59 Standing: abdominal hollowing + expiration test 357
Chapter 7
The thoracic spine
that have been developed from the extensive

INTRODUCTION research conducted in the lumbar spine and neck.
This chapter details the assessment of UCM at
The thoracic spine has been the focus of little the thoracic spine and describes retraining
research or review attention compared to the strategies.
lumbar and cervical spine. This may partly be due
to the lower frequency of thoracic spinal pain
syndrome and partly because the thoracic region
is well stabilised by the rib cage and rib articula- DIAGNOSIS OF THE SITE AND
tions to the thoracic vertebrae (Watkins et al DIRECTION OF UCM IN THE
2005). Almost all of the research and review lit- THORACIC SPINE
erature available that is related to the thoracic
spine is based on anatomical and biomechanical
The diagnosis of the site and direction of UCM
analysis of osteoligamentous and myofascial
in the thoracic spine can be identified in terms of
influences on articular function (Edmondston &
the site (being thoracic spine) and the direction of
Singer 1997; Maitland et al 2005). There is a lack
flexion, extension, rotation and respiratory move-
of research and analysis of neurophysiological
ment (Table 7.1).
motor control changes associated with pain and
dysfunction in the thorax.
Linking the site of UCM to symptom
Changes in movement and postural presentation
control in the thoracic spine
A diagnosis of UCM requires evaluation of its
Most of the clinical interventions to address clinical priority. This is based on the relationship
motor control dysfunction of the thoracic spine between the UCM and the presenting symptoms.
are extrapolated from the current research derived The therapist should look for a link between the
from the lumbar spine and cervical spine direction of UCM and the direction of symptom
(Carrière 1996; Lee 1996, 2003; Lee et al 2005). provocation: i) Does the site of UCM relate to the
There are currently no significant studies pub- site or joint that the patient complains of as the
lished measuring uncontrolled movement (UCM) source of symptoms? ii) Does the direction of
in the thoracic spine. Observations of thoracic movement or load testing relate to the direction
UCM are largely anecdotal, and management or position of provocation of symptoms? This
guidelines are based on principles and strategies identifies the clinical priorities.

DOI: 10.1016/B978-0-7295-3907-4.00007-4 293
Table 7.1 Site and direction of UCM in the thorax The site and direction of UCM at the thoracic
spine can link with different clinical presenta-
SITE DIRECTION
tions, and postures and activities which may
aggravate symptoms. The typical assessment find-
Thoracic • Flexion ings in the thoracic spine are identified in Table
• Extension 7.2.
• Rotation The following section will demonstrate the spe-
• Respiratory/ribs
cific procedures for testing for UCM in the tho-
racic spine.
Table 7.2 The site and direction of UCM at the thoracic spine linked with different clinical presentations
SITE AND DIRECTION SYMPTOM PROVOCATIVE MOVEMENTS,

OF UCM PRESENTATION POSTURES AND ACTIVITIES
THORACIC FLEXION UCM • Presents with symptoms in Symptoms provoked by thoracic flexion
Can present as: the posterior chest and/or movements and postures (especially if
• uncontrolled thoracic flexion lateral ribs repetitive or sustained); for example,
(with or without hypermobile • May present with a localised sustained sitting (especially if slouching
flexion range) pain pattern at a desk), bending forwards, driving,
• ± Radicular pain from looking down, reaching forwards
myofascial and articular
structures
THORACIC EXTENSION UCM • Presents with symptoms in Symptoms provoked by thoracic
Can present as: the posterior chest and/or extension movements and postures
• uncontrolled thoracic lateral ribs (especially if repetitive or sustained); for
extension (with or without • May present with a localised example, sustained standing, arching
hypermobile extension range) pain pattern backwards, looking up, reaching
• ± Radicular pain from overhead, reaching backwards
structures
THORACIC ROTATION UCM • Presents with symptoms in Symptoms provoked by thoracic rotation
Can present as: the posterior chest and/or movements and postures (especially if
• uncontrolled thoracic rotation lateral ribs repetitive or sustained); for example,
(with or without hypermobile • May present with a localised twisting to one side, looking over one
rotation range) pain pattern shoulder, reaching forwards or
• unilaterally or bilaterally • ± Radicular pain from backwards or out to the side with one
myofascial and articular arm, throwing, weight bearing on one
structures arm or pushing with one arm
THORACIC/RIBS RESPIRATORY • Presents with symptoms in Symptoms provoked by thoracic or rib
UCM the posterior chest and/or respiratory movements (inspiration or
Can present as: lateral ribs or anterior ribs and expiration); for example, twisting or
• uncontrolled thoracic or rib sternum side-bending to one side, deep
inspiratory or expiratory • May present with a localised inspiration (breath in), full expiration
movement pain pattern (breath out), cough or sneeze, bracing
• unilaterally or bilaterally • ± Radicular pain from ribcage to push, pull or lift a heavy load
structures
294
The thoracic spine Chapter |7|
increased cervical lordosis and a loss of

THORACIC TESTS FOR UCM extensibility of the posterior cervical fascias
and the ligamentum nuchae.
• Scapular restriction of protraction – recruitment
Thoracic flexion control overactivity or postural change may result in
a loss of extensibility of the rhomboids. A
subsequent myofascial restriction of scapular
THORACIC FLEXION CONTROL TESTS protraction may also contribute to
AND FLEXION CONTROL compensatory increases in thoracic flexion
REHABILITATION range.
These flexion control tests assess the extent of

flexion UCM in the thoracic spine and assess the
ability of the dynamic stability system to ade- • Thoracic flexion – the thoracic spine may
quately control flexion load or strain. It is a prior- initiate the movement into flexion and
ity to assess for flexion UCM if the person contribute more to producing forward
complains of or demonstrates flexion-related bending while the lumbar spine and hip
symptoms or disability. The tests that identify contributions start later and contribute less.
dysfunction can also be used to guide and direct At the limit of forward bending, excessive or
rehabilitation strategies. hypermobile range of thoracic flexion may
be observed. During the return to neutral the
thoracic flexion persists and presents as an
Movement faults associated with increased thoracic kyphosis.
thoracic flexion
Relative stiffness (restrictions) Indications to test for thoracic
• Lumbopelvic restriction of flexion – a flexion UCM
lumbopelvic flexion restriction may
contribute to compensatory increases in
thoracic flexion range. This is confirmed with 1. hypermobile thoracic flexion range
manual segmental assessment (e.g. Maitland 2. excessive initiation of bending or leaning
PPIVMs or PAIVMs) of the lumbopelvic forwards with thoracic flexion
joints. There may also be a loss of lumbar- 3. symptoms (pain, discomfort, strain)
dorsal fascia extensibility if a lordotic associated with bending or reaching forwards
posture is exaggerated. with associated thoracic flexion.
• Cervical restriction of flexion – a cervical The person complains of flexion-related symp-
flexion restriction may contribute to toms in the thorax. Under flexion load, the tho-
compensatory increases in thoracic flexion racic spine has greater give into flexion relative to
range. This is not usually associated with the lumbar spine, head and shoulders. The dys-
articular restrictions of flexion. However, a function is confirmed with motor control tests of
chin poke neck posture may have an flexion dissociation.
295
relaxed. The heels are positioned about 20 cm in

Tests of thoracic flexion control front of the wall with the feet at least shoulder
width apart and with the knees slightly flexed
(hip flexors unloaded and wide base of support)
T42 STANDING: BACK FLATTENING TEST
(Figure 7.1). Then, keeping the thoracic spine
(tests for thoracic flexion UCM) and head stationary on the wall, the person is
instructed to roll the pelvis backwards into pos-
This dissociation test assesses the ability to actively terior tilt to flatten the lumbar spine against the
dissociate and control thoracic flexion then wall. The lumbar lordosis should reverse so that
reverse the lumbar lordosis to the back flat posi- the whole lumbar spine is in full contact with the
tion (i.e. flex the lumbar spine and posterior tilt wall (Figure 7.2). There should be no flexion of
the pelvis) while standing against a wall. the thorax, head or shoulders off the wall.
This test should be performed without any extra
feedback (self-palpation, vision, etc.) or cueing
for correction. When feedback is removed for
Test procedure
testing, the therapist should use visual observa-
The person stands with the back of the pelvis, the tion of the head and thorax relative to the wall to
upper thoracic spine and the back of the head determine whether the control of thoracic flexion
resting against a wall with the shoulders and arms is adequate.
Figure 7.1 Start position back flattening test Figure 7.2 Benchmark back flattening test
296
Thoracic flexion UCM

toms in the thoracic spine. The thorax has UCM
into flexion relative to the lumbar spine under
flexion load. The head and thoracic spine start to
flex off the wall before full back flattening and
posterior tilt is achieved. During the attempt to
dissociate the thoracic flexion from independent
posterior pelvic tilt and lumbar flexion, the person
trate and try hard to control the thoracic flexion.


test of thoracic flexion, do not score this as uncontrolled
thoracic flexion. The thoracic rotation motor control tests
uncontrolled. A test for thoracic flexion UCM is only
positive if uncontrolled thoracic flexion is demonstrated.
Rating and diagnosis of thoracic

flexion UCM
(T42.1 and T42.2)
Correction Figure 7.3 Correction start position

If control is poor, retraining is best started by
allowing both the lumbar and thoracic spines to
start in flexion, and then reverse the dysfunction
by unrolling the thoracic spine back up the wall options (T42.3). There should be no provocation
into extension. The person stands with the heels of any symptoms within the range that the flexion
at least shoulder width apart and about 20 cm in UCM can be controlled.
front of a wall with the knees slightly flexed (hip Once segmental unrolling and control of the
flexors unloaded and wide base of support). Rest thoracic flexion improves, the exercise can return
the pelvis against the wall and allow the whole to the original start position. The person stands
spine to slump forwards into flexion, but roll the with the back of the pelvis, the upper thoracic
pelvis backwards into posterior tilt and flatten the spine and the back of the head resting against a
lumbar spine against the wall (Figure 7.3). Once wall. Then, keeping the thoracic spine and head
the pelvis and lumbar spine are in contact with stationary on the wall, the person rolls the pelvis
the wall, slowly lift the head and chest to unroll into posterior tilt to flatten the lumbar spine
the thoracic spine back up the wall (Figure 7.4). against the wall. They should only roll the pelvis
Only move as far as the thoracic extensor muscles into posterior tilt as far as the head and thoracic
can extend the thoracic spine while holding the spine can stay on the wall (Figure 7.5). At the
lumbopelvic region flat on the wall. point in range that the head and thoracic spine
The person should self-monitor the control of begin to flex off the wall, the movement should
thoracic flexion UCM with a variety of feedback stop.
297
T42.1 Assessment and rating of low threshold recruitment efficiency of the Back Flattening Test
from the Back Flattening Test
BACK FLATTENING TEST – STANDING
(WALL) position
Site Direction ✗✗ or ✓✗
(check box) watch the movement
Thoracic Flexion ! Adhesive tape Skin tension for tactile feedback

correction observer
298
Figure 7.4 Correction partial thoracic extension with pelvic Figure 7.5 Correction partial posterior tilt with head and
support in posterior tilt thoracic support
299
head forwards towards the sternum. Do not

T43 SITTING: HEAD HANG TEST allow the sternum or shoulders to drop forwards.
(tests for thoracic flexion UCM) This is independent cervical flexion. Ideally, the
person should have the ability to keep the tho-
This dissociation test assesses the ability to actively racic spine neutral and prevent thoracic flexion
dissociate and control thoracic flexion then lower while independently flexing the cervical spine
the head towards the chest to hang forwards (i.e. region through full flexion so that the chin is
flex the cervical spine) while sitting upright and within 2–3 cm of the upper sternum (Figure 7.7).
unsupported. This test should be performed without any extra
for correction. The therapist should use visual
Test procedure
observation of the head and thorax relative to the
The person should have the ability to actively wall to determine whether the control of thoracic
hang the head forwards towards the sternum flexion is adequate when feedback is removed for
(flexing the cervical spine) while controlling the testing.
thoracic spine and preventing thoracic flexion.
The person sits tall with the feet off the floor and
with the spine and head positioned in the neutral.
Position the head directly over the shoulders The person complains of flexion-related symp-
without chin poke (Figure 7.6). Without letting toms in the thoracic spine. The thorax has UCM
the thoracic spine or shoulders move, lower the into flexion relative to the cervical spine under
Figure 7.6 Start position head hang test Figure 7.7 Benchmark head hang test
300
flexion load. The thoracic spine starts to flex The person stands with the heels at least shoulder
before full cervical flexion (head hanging for- width apart and about 20 cm in front of a wall
wards and chin within 2–3 cm of the sternum) with the knees slightly flexed.
is achieved. During the attempt to dissociate The thoracic spine and the back of the head are
the thoracic flexion from independent cervical supported upright against a wall (Figure 7.8). The
flexion, the person either cannot control the UCM person should monitor the control of thoracic
or has to concentrate and try hard to control the flexion by palpating the sternum or clavicles. Any
thoracic flexion. forward or lowering movement of the sternum or
clavicles indicates uncontrolled thoracic flexion.
The person is instructed to slowly allow the head
Clinical assessment note for direction-specific to flex forwards off the wall. Only allow the head
motor control testing to hang forwards as far as there is no thoracic
flexion (monitored by the hand palpating the
If some other movement (e.g. a small amount of thoracic sternum). Using feedback from palpating the
rotation) is observed during a motor control (dissociation) sternum, the person is trained to control and
prevent thoracic flexion and perform independ-
thoracic flexion. The thoracic rotation motor control tests
ent lower cervical flexion (Figure 7.9).
uncontrolled. A test for thoracic flexion UCM is only The person should self-monitor the control of
positive if uncontrolled thoracic flexion is demonstrated. thoracic flexion UCM with a variety of feedback
options (T43.3). There should be no provocation
of any symptoms within the range that the flexion
Rating and diagnosis of thoracic UCM can be controlled.
Once control of the thoracic flexion improves,
flexion UCM the person should move away from the wall and
(T43.1 and T43.2) the exercise can be performed with self-monitoring
of thoracic flexion control by palpating the
Correction sternum, with the thoracic spine unsupported
(no wall support).
If control is poor, retraining is best started by sup-
porting the thoracic spine against a wall and
flexing the cervical spine through reduced range.
301
T43.1 Assessment and rating of low threshold recruitment efficiency of the Head Hang Test
from the Head Hang Test
HEAD HANG TEST – SITTING
Site Direction ✗✗ or &check✗ position
(check box) Visual observation Observe in a mirror or directly
watch the movement
Thoracic Flexion !
correction observer
302
Figure 7.8 Correction start position on wall Figure 7.9 Correction partial head flexion with thoracic
support on wall
303
thoracic flexion. This also allows the person to

T44 SITTING: PELVIC TAIL TUCK TEST experience and learn the movement pattern that
(tests for thoracic flexion UCM) will be tested.
The person is then instructed to make the spine
This dissociation test assesses the ability to as tall or as long as possible to position the normal
actively dissociate and control thoracic flexion curves in an elongated ‘S’. Position the head
then roll the pelvis backwards (i.e. ‘tail tuck’ or directly over the shoulders without chin poke
posterior pelvic tilt) while sitting upright and (Figure 7.10). Then, without letting the thoracic
unsupported. spine flex (sternum does not lower or move for-
wards), actively roll the pelvis backwards (tuck the
tail under the pelvis) into full available posterior
Test procedure
pelvic tilt. The person is required to produce the
The person should have the ability to actively roll same range of posterior pelvic tilt that the thera-
the pelvis backwards into posterior pelvic tilt pist identified with passive assessment.
while controlling and preventing thoracic flexion. Ideally, the person should have the ability to
The person sits tall with the feet off the floor and dissociate the thoracic spine from posterior pelvic
with the lumbar spine and pelvis positioned tilt as evidenced by the ability to prevent thoracic
in the neutral. The therapist should passively flexion while independently rolling the pelvis
support the thoracic spine and passively roll the backwards (Figure 7.11). There must be no move-
pelvis backwards to assess the available range of ment into thoracic flexion. There should be no
posterior pelvic tilt that is independent of provocation of any symptoms under posterior tilt
Figure 7.10 Start position pelvic tail tuck test Figure 7.11 Benchmark pelvic tail tuck test
304
(flexion) load, so long as the thoracic flexion

testing the therapist should use visual observa-
tion of the thorax relative to the pelvis to deter-
mine whether the control of thoracic flexion is
adequate.

into flexion relative to posterior pelvic tilt under
flexion load. The thoracic spine starts to flex
before full independent posterior pelvic tilt (’tail
tuck’) is achieved. During the attempt to dissoci-
ate the thoracic flexion from independent poster-
ior pelvic tilt, the person either cannot control the
UCM or has to concentrate and try hard to control
the thoracic flexion.


thoracic flexion. The thoracic rotation motor control tests Figure 7.12 Correction partial posterior tilt with thoracic
will identify if the observed unrelated movement is support
against a wall. Then, keeping the thoracic spine

and head stationary on the wall, the person is
Rating and diagnosis of thoracic instructed to roll the pelvis backwards into pos-
flexion UCM terior pelvic tilt (Figure 7.12). It may be useful to
(T44.1 and T44.2) visualise tucking an imaginary tail under the
pelvis. Another visualisation cue is to visualise the
pelvis as a bucket full of water and the thorax as
Correction the handle of the bucket. The aim is to visualise
Retraining is best started by supporting the thor- the ability to tip water out the back of the bucket
acic spine against a wall for increased thoracic but not allow the handle to swing forwards into
support and feedback and posterior tilting the thoracic flexion.
pelvis through reduced range. The person stands If control is poor, it is also recommended that
with the back of the pelvis, the upper thoracic the person use self-palpation to monitor the
spine and the back of the head resting against a correct performance of the exercise. Monitor the
wall with the shoulders and arms relaxed. The control of thoracic flexion by placing one hand
pelvis is positioned in anterior tilt to start on the sternum or clavicles. Monitor lumbopelvic
the training. This can also be performed with the motion by placing the other hand on the sacrum
person sitting on a low stool with the feet on the (Figure 7.13). Without letting the thoracic spine
floor and the thoracic spine and head resting flex (sternum does not lower or move forwards)
305
Figure 7.14 Correction (posterior pelvic tilt followed by

thoracic extension)
Figure 7.13 Correction partial posterior tilt with Figure 7.15 Correction (thoracic extension followed by
self-palpation posterior pelvic tilt)
actively roll the pelvis backwards (tuck the tail body and trunk weight can be supported on
under the pelvis) into full available posterior hands and knees. Position the pelvis in neutral
pelvic tilt. Using feedback from palpating the pelvic tilt and the lumbar spine, the thoracic
sternum, the person is trained to control and spine and head in neutral alignment (the back of
prevent thoracic flexion and perform independ- the head touches an imaginary line connecting
ent posterior pelvic tilt. Only allow posterior the sacrum and mid-thoracic spine). There are
pelvic tilt (tail tuck) as far as there is no thoracic two recruitment reversal strategies that are
flexion (monitored by the hand palpating the appropriate:
sternum). There must be no UCM into thoracic
1. First, actively posterior tilt the pelvis to end
flexion. There should be no provocation of any
range, and then extend the thoracic spine as
symptoms under flexion load, so long as the tho-
far as possible without losing the posterior
racic flexion UCM can be controlled.
tilt (Figure 7.14).
2. The reverse order of this same pattern may
thoracic flexion UCM with a variety of feedback
also be used. That is, first, actively extend the
thoracic spine as far as possible and then
of any symptoms within the range that the flexion
posteriorly tilt the pelvis (Figure 7.15).
If control is very poor, rather than specific dis- When the pattern of this recruitment reversal feels
sociation, for some patients it is easier to initially easy to perform, the person can progress back to
use a recruitment reversal exercise. The upper the sitting dissociation exercise.
306
T44.1 Assessment and rating of low threshold recruitment efficiency of the Pelvic Tail Tuck Test
from the Pelvic Tail Tuck Test
PELVIC TAIL TUCK TEST – SITTING
Site Direction ✗✗ or ✗✓ position
watch the movement
Thoracic Flexion !
correction observer
307
chin poke. Both arms are held at 90° of shoulder

T45 SITTING: BILATERAL FORWARD flexion, with the scapulae relaxed in a neutral
REACH TEST mid-position (Figure 7.16). Then, without letting
(tests for thoracic flexion UCM) the thoracic spine flex (sternum does not lower
or move forwards) or the head to move forwards,
actively reach forwards with both hands into full
available scapular protraction.
dissociate and control thoracic flexion then reach
forwards in front of the body with both arms
dissociate the thoracic spine from scapular pro-
(i.e. bilateral scapular protraction) while sitting
traction as evidenced by the ability to prevent
upright and unsupported.
thoracic flexion while independently reaching
forwards (Figure 7.17). There must be no move-
Test procedure
ment into thoracic flexion. There should be no
The person should have the ability to actively provocation of any symptoms under flexion load,
reach forwards with both arms into full scapular so long as the thoracic flexion UCM can be
protraction while controlling and preventing controlled.
thoracic flexion. The person sits tall with the feet This test should be performed without any
off the floor. The person is then instructed to sit extra feedback (self-palpation, vision, etc.) or
upright with the spine in its neutral normal curves cueing for correction. When feedback is removed
and the head directly over the shoulders without for testing the therapist should use visual
Figure 7.16 Start position bilateral forward reach test Figure 7.17 Benchmark bilateral forward reach test
308
observation of the head and thorax relative to the reaching forwards (scapular protraction) through
shoulders to determine whether the control of reduced range. The person stands with the heels
thoracic flexion is adequate. at least shoulder width apart and about 20 cm in
front of a wall with the knees slightly flexed.
The thoracic spine and the back of the head are
supported upright against a wall. The person
The person complains of flexion-related symp- should monitor the control of thoracic flexion by
toms in the thoracic spine. The thorax has UCM palpating the sternum or clavicles with one hand.
into flexion relative to scapular protraction. The Any forward of lowering movement of the sternum
thoracic spine starts to flex before full independ- or clavicles indicates uncontrolled thoracic
ent scapular protraction (forward reach) is flexion. The person is instructed to slowly reach
achieved. During the attempt to dissociate the forwards with the other arm. Only reach forwards
thoracic flexion from independent scapular pro- as far as there is no thoracic flexion (monitored
traction, the person either cannot control the by the hand palpating the sternum) (Figure 7.18).
UCM or has to concentrate and try hard to control Using feedback from palpating the sternum, the
the thoracic flexion. person is trained to control and prevent thoracic
flexion and perform independent scapular
Clinical assessment note for direction-specific protraction.
motor control testing The person should self-monitor the control of
thoracic flexion UCM with a variety of feedback
If some other movement (e.g. a small amount of thoracic options (T45.3). There should be no provocation
rotation) is observed during a motor control (dissociation) of any symptoms within the range that the flexion
test of thoracic flexion, do not score this as uncontrolled UCM can be controlled.
thoracic flexion. The thoracic rotation motor control tests Once control of the thoracic flexion improves,
the person should reach forwards with both arms
while using the wall for feedback and support of
the thoracic spine (Figure 7.19). Eventually, they
can move away from the wall and the exercise can
Rating and diagnosis of thoracic be performed with the thoracic spine unsup-
ported (no wall support).
flexion uncontrolled movement
(T45.1 and T45.2) Thoracic flexion UCM summary
(Table 7.3)
Correction
If control is poor, retraining is best started by sup-
porting the thoracic spine against a wall and
Table 7.3 Summary and rating of thoracic flexion tests

THORACIC FLEXION !
Standing: back flattening
Sitting: head hang
Sitting: pelvic tail tuck
Sitting: bilateral forward reach
309
T45.1 Assessment and rating of low threshold recruitment efficiency of the Bilateral Forward Reach Test
from the Bilateral Forward Reach Test
BILATERAL FORWARD REACH
TEST – SITTING position
Site Direction ✗✗ or ✗✓
Thoracic Flexion ! Adhesive tape Skin tension for tactile feedback

correction observer
310
Figure 7.18 Correction unilateral forward reach with

thoracic support on wall
Figure 7.19 Correction bilateral forward reach with thoracic
support on wall
311
Thoracic extension control Indications to test for thoracic

extension UCM
EXTENSION CONTROL TESTS AND
1. hypermobile thoracic extension range
EXTENSION CONTROL REHABILITATION 2. excessive initiation of looking up or lifting
with thoracic extension
These extension control tests assess the extent of 3. symptoms (pain, discomfort, strain)
extension UCM in the thoracic spine and assess associated with looking up or reaching
the ability of the dynamic stability system to ade- overhead with associated thoracic extension.
quately control extension load or strain. It is a The person complains of extension-related symp-
priority to assess for extension UCM if the person toms in the thorax. Under extension load, the
complains of or demonstrates extension-related thoracic spine has greater give into extension rela-
symptoms or disability. The tests that identify tive to the lumbar spine, head and shoulders. The
dysfunction can also be used to guide and direct dysfunction is confirmed with motor control tests
rehabilitation strategies. of extension dissociation.
312
instructed to slowly lift both arms into flexion.

Tests of thoracic extension control Without letting the thoracic spine extend (sternum
does not lift or move backwards) or the head
move backwards, the person should be able to
T46 STANDING: BILATERAL OVERHEAD
actively reach overhead with both hands into
REACH TEST end-range shoulder flexion.
(tests for thoracic extension UCM) Ideally, the person should have the ability to
dissociate the thoracic spine from overhead
This dissociation test assesses the ability to actively shoulder flexion as evidenced by the ability to
dissociate and control thoracic extension then prevent thoracic extension while independently
reach overhead with both arms (i.e. bilateral reaching overhead to at least 160° bilateral shoul-
shoulder flexion) while standing upright and der flexion (Figure 7.21). There must be no move-
unsupported. ment into thoracic extension. There should be no
provocation of any symptoms under overhead
load, so long as the thoracic extension UCM can
Test procedure
be controlled.
The subject stands upright with the spine in its This test should be performed without any extra
neutral normal curves, the head directly over the feedback (self-palpation, vision, etc.) or cueing
shoulders without chin poke and with the arms for correction. When feedback is removed for
resting by the side with the shoulders in a neutral testing the therapist should use visual observa-
position (Figure 7.20). The person is then tion of the head and thorax relative to the
Figure 7.20 Start position bilateral overhead reach test Figure 7.21 Benchmark bilateral overhead reach test
313
shoulders to determine whether the control of

thoracic extension is adequate.
Thoracic extension UCM

into extension relative to overhead shoulder
flexion. The thoracic spine starts to extend before
1600 of independent shoulder flexion (overhead
reach) is achieved. During the attempt to dissoci-
ate the thoracic extension from independent
overhead reach, the person either cannot control
the UCM or has to concentrate and try hard to
control the thoracic extension.


test of thoracic extension, do not score this as
uncontrolled thoracic extension. The thoracic rotation
movement is uncontrolled. A test for thoracic extension
UCM is only positive if uncontrolled thoracic extension is
demonstrated.
Rating and diagnosis of thoracic Figure 7.22 Correction partial unilateral overhead reach
extension UCM with thoracic support on wall
(T46.1 and T46.2)

The person is instructed to slowly flex one arm
through range to reach overhead. Only reach
Correction overhead as far as there is no thoracic extension
If control is poor, retraining is best started by sup- (Figure 7.22). Using feedback from the back on
porting the thoracic spine against a wall and the wall (or palpating the sternum), the person is
reaching overhead (shoulder flexion) with unilat- trained to control and prevent thoracic extension
eral arm movement and through reduced range. and perform independent overhead shoulder
The person stands with the thoracic spine and the flexion.
back of the head supported upright against a wall. The person should self-monitor the control of
The person should flatten the lumbar spine thoracic extension UCM with a variety of feed-
against the wall to give additional feedback and back options (T46.3). There should be no provo-
support to the ability to prevent thoracic exten- cation of any symptoms within the range that the
sion. If uncontrolled thoracic extension occurs extension UCM can be controlled.
the person will be aware of the thoracolumbar Once control of the thoracic extension improves,
spine losing contact with the wall (arching into the person should reach overhead with both arms
extension). Alternatively, the person may monitor while using the wall for feedback and support of
the control of thoracic extension by palpating the the thoracic spine. Eventually, they can move
sternum or clavicles with one hand. Any lifting away from the wall and the exercise can be per-
movement of the sternum or clavicles also indi- formed with the thoracic spine unsupported (no
cates uncontrolled thoracic extension. wall support).
314
T46.1 Assessment and rating of low threshold recruitment efficiency of the Bilateral Overhead Reach Test
from the Bilateral Overhead Reach Test
BILATERAL OVERHEAD REACH
TEST – STANDING position
Thoracic Extension ! Adhesive tape Skin tension for tactile feedback

correction observer
315
letting the sternum lift or the thoracic spine

T47 SITTING: HEAD RAISE TEST extend, the person is instructed to move the low
(tests for thoracic extension UCM) cervical spine through extension by raising the
head backwards over the shoulders.
This dissociation test assesses the ability to actively Ideally, the person should have the ability to
dissociate and control thoracic extension then dissociate thoracic extension from low cervical
move the low cervical spine into extension by extension as evidenced by the ability to prevent
raising the head backwards over the shoulders thoracic extension while independently raising
from a flexed position while sitting upright and the head from a flexed position so that the low
unsupported. cervical spine at least reaches the vertical position
(Figure 7.24). There must be no movement into
thoracic extension. There should be no provoca-
Test procedure tion of any symptoms under extension load, so
The person should have the ability to actively long as the thoracic extension UCM can be
extend the low cervical spine while controlling controlled.
and preventing thoracic extension. The person This test should be performed without any extra
sits upright with the feet off the floor and the feedback (self-palpation, vision, etc.) or cueing
spine in its neutral normal curves and the low for correction. The therapist should use visual
cervical spine positioned in flexion by allowing observation of the thorax relative to the head
the head to hang forwards (Figure 7.23). Without to determine whether the control of thoracic
Figure 7.23 Start position head raise test Figure 7.24 Benchmark head raise test
316
extension is adequate when feedback is removed

for testing.

into extension relative to raising the head from a
flexed position. The thoracic spine starts to extend
before low cervical extension reaches vertical.
During the attempt to dissociate the thoracic
extension from independent low cervical exten-
sion (head raise), the person either cannot control
control the thoracic extension.


demonstrated.
Figure 7.25 Correction leaning forward with table support

extension UCM
(T47.1 and T47.2) extension, the person is instructed to slowly
raise the head backwards over the shoulders.
There should be no chin poke and the movement
Correction should be localised to the low cervical spine.
If control is poor, retraining is best started by sup- They are to raise the head only as far as there
porting the thoracic spine with weight bearing is no thoracic extension (Figure 7.25). The
through the arms and raising the head backwards person is trained to control and prevent thoracic
from a flexed position. extension and perform independent low cervical
The person sits at a table and leans forwards to extension.
take weight through the elbows. The scapulae are The person should self-monitor the control of
positioned midway between elevation and depres- thoracic extension UCM with a variety of feed-
sion with the head hanging forwards in neck back options (T47.3). There should be no provo-
flexion. Then the person pushes the chest away cation of any symptoms within the range that the
from the elbows to protract the scapula and use extension UCM can be controlled.
serratus anterior to help support the thorax and Once control of the thoracic extension improves,
control thoracic extension. the exercise can be performed with the thoracic
Without letting the chest drop forwards towards spine unsupported (no weight bearing scapular
the elbows or the sternum lift into thoracic support).
317
T47.1 Assessment and rating of low threshold recruitment efficiency of the Head Raise Test
from the Head Raise Test
HEAD RAISE TEST – SITTING
watch the movement
Thoracic Extension !
correction observer
318
extension. This also allows the person to experi-

T48 SITTING: PELVIC TAIL LIFT TEST ence and learn the movement pattern that will be
(tests for thoracic extension UCM) tested.
The person is then instructed to make the spine
This dissociation test assesses the ability to as tall or as long as possible to position the
actively dissociate and control thoracic extension normal curves in an elongated ‘S’. Position the
then roll the pelvis forwards (i.e. ‘tail lift’ or head directly over the shoulders without chin
anterior pelvic tilt) while sitting upright and poke (Figure 7.26). Then, without letting the tho-
unsupported. racic spine extend (sternum does not lift or move
backwards), actively roll the pelvis forwards (lift
the tail up from the pelvis) into full available
Test procedure anterior pelvic tilt. The person is required to
The person should have the ability to actively roll produce the same range of anterior pelvic tilt that
the pelvis forwards into anterior pelvic tilt while the therapist identified with passive assessment.
controlling and preventing thoracic extension. Ideally, the person should have the ability to
The person sits tall with the feet off the floor and dissociate the thoracic spine from anterior pelvic
with the lumbar spine and pelvis positioned tilt as evidenced by the ability to prevent thoracic
in the neutral. The therapist should passively extension while independently rolling the pelvis
support the thoracic spine and passively roll the forwards (Figure 7.27). There must be no move-
pelvis forwards to assess the available range of ment into thoracic extension. There should be no
anterior pelvic tilt that is independent of thoracic provocation of any symptoms under anterior tilt
Figure 7.26 Start position pelvic tail lift test Figure 7.27 Benchmark pelvic tail lift test
319
(extension) load, so long as the thoracic exten-

sion UCM can be controlled.
observation of the thorax relative to the pelvis to
determine whether the control of thoracic exten-
sion is adequate when feedback is removed for
testing.

into extension relative to anterior pelvic tilt under
extension load. The thoracic spine starts to extend
before full independent anterior pelvic tilt (’tail
lift’) is achieved. During the attempt to dissociate
the thoracic extension from independent anterior
pelvic tilt, the person either cannot control the
the thoracic extension.


uncontrolled thoracic extension. The thoracic rotation Figure 7.28 Correction partial anterior pelvic tilt with
motor control tests will identify if the observed unrelated thoracic support on wall
demonstrated.
against a wall. Then, keeping the thoracic spine
and head stationary on the wall, the person is
Rating and diagnosis of thoracic instructed to roll the pelvis forwards into anterior
extension UCM pelvic tilt (Figure 7.28). It may be useful to visu-
(T48.1 and T48.2) alise lifting an imaginary tail up from behind the
pelvis. Another visualisation cue is to visualise the
pelvis as a bucket full of water and the thorax as
Correction the handle of the bucket. The aim is to visualise
Retraining is best started by supporting the thor- the ability to tip water out the front of the bucket
acic spine against a wall for increased thoracic but not allow the handle to swing backwards into
support and feedback and anterior tilting the thoracic extension.
pelvis through reduced range. The person stands If control is poor, it is also recommended that
with the back of the pelvis, the upper thoracic the person use self-palpation to monitor the
spine and the back of the head resting against a correct performance of the exercise. Monitor the
wall with the shoulders and arms relaxed. The control of thoracic flexion by placing one hand
pelvis is positioned in posterior tilt to start the on the sternum or clavicles. Monitor lumbopelvic
training. This can also be performed with motion by placing the other hand on the sacrum
the person sitting on a low stool with the feet on (Figure 7.29). Without letting the thoracic spine
the floor and the thoracic spine and head resting extend (sternum does not lift or move
320
Figure 7.30 Correction (anterior pelvic tilt followed by

thoracic flexion)
Figure 7.29 Correction partial anterior tilt with

Figure 7.31 Correction (thoracic flexion followed by anterior
self-palpation
pelvic tilt)
backwards), actively roll the pelvis forwards (lift use a recruitment reversal exercise. The upper
the tail up from the pelvis) into full available body and trunk weight can be supported on hands
anterior pelvic tilt. Using feedback from palpat- and knees. Position the pelvis in neutral pelvic tilt
ing the sternum, the person is trained to control and the lumbar spine, the thoracic spine and head
and prevent thoracic extension and perform in neutral alignment (the back of the head touches
independent anterior pelvic tilt. Only allow ante- an imaginary line connecting the sacrum and
rior pelvic tilt (tail lift) as far as there is no mid-thoracic spine). There are two recruitment
thoracic extension (monitored by the hand pal- reversal strategies that are appropriate:
pating the sternum). There must be no UCM
1. Actively anteriorly tilt the pelvis to end
into thoracic extension. There should be no
range, and then flex the thoracic spine as far
provocation of any symptoms under extension
as possible without losing the anterior tilt
load, so long as the thoracic extension UCM
(Figure 7.30).
can be controlled.
2. The reverse order of this same pattern may
also be used. That is, first, actively flex the
thoracic extension UCM with a variety of feed-
thoracic spine as far as possible and then
anteriorly tilt the pelvis (Figure 7.31).
extension UCM can be controlled. When the pattern of this recruitment reversal feels
If control is very poor, rather than specific dis- easy to perform, the person can progress back to
sociation, for some patients it is easier to initially the sitting dissociation exercise.
321
T48.1 Assessment and rating of low threshold recruitment efficiency of the Pelvic Tail Lift Test
from the Pelvic Tail Lift Test
PELVIC TAIL LIFT TEST – SITTING
watch the movement
Thoracic Extension !
correction observer
322
instructed to slowly reach backwards with both

T49 STANDING: BILATERAL BACKWARD arms into shoulder extension. Without letting the
REACH TEST thoracic spine extend (sternum does not lift or
(tests for thoracic extension UCM) move backwards) or the head to move backwards,
they should be able to actively reach backwards
with both hands into shoulder extension.
dissociate and control thoracic extension then
dissociate the thoracic spine from shoulder exten-
reach backwards with both arms (i.e. bilateral
sion as evidenced by the ability to prevent tho-
shoulder extension) while standing upright and
racic extension while independently reaching
unsupported.
backwards to at least 10–15° bilateral shoulder
extension (Figure 7.33). There must be no move-
ment into thoracic extension. There should be no
Test procedure
provocation of any symptoms under shoulder
The subject stands upright with the spine in its extension load, so long as the thoracic extension
neutral normal curves, the head directly over the UCM can be controlled.
shoulders without chin poke and with the arms This test should be performed without any extra
resting by the side with the shoulders in a neutral feedback (self-palpation, vision, etc.) or cueing
position (Figure 7.32). The person is then for correction. The therapist should use visual
Figure 7.32 Start position bilateral reach back test Figure 7.33 Benchmark bilateral reach back test
323
observation of the head and thorax relative to the

shoulders to determine whether the control of
thoracic extension is adequate when feedback is
removed for testing.

into extension relative to bilateral shoulder exten-
sion (reaching backwards). The thoracic spine
starts to extend before 10–15° of independent
shoulder extension is achieved. During the
attempt to dissociate the thoracic extension from
independent reaching backwards, the person
trate and try hard to control the thoracic
extension.


demonstrated. Figure 7.34 Correction unilateral arm extension with
thoracic support on wall

extension UCM (arching into extension). Alternatively, the person
(T49.1 and T49.2) may monitor the control of thoracic extension
by palpating the sternum or clavicles with one
hand. Any lifting movement of the sternum or
Correction clavicles also indicates uncontrolled thoracic
If control is poor, retraining is best started by extension.
supporting the thoracic spine against a wall and The person is instructed to slowly extend one
reaching backwards (shoulder flexion) with uni- arm through range to reach backwards. Only
lateral arm movement and through reduced reach backwards as far as there is no thoracic
range. The person stands with the thoracic spine extension (Figure 7.34). Using feedback from the
and the back of the head supported upright back on the wall (or palpating the sternum), the
against a wall. The person should flatten the person is trained to control and prevent thoracic
lumbar spine against the wall to give additional extension and perform independent overhead
feedback and support to the ability to prevent shoulder extension.
thoracic extension. If uncontrolled thoracic The person should self-monitor the control
extension occurs the person will be aware of the of thoracic extension UCM with a variety of
thoracolumbar spine losing contact with the wall feedback options (T49.3). There should be no
324
T49.1 Assessment and rating of low threshold recruitment efficiency of the Bilateral Backward Reach Test
from the Bilateral Backward Reach Test
BILATERAL BACKWARD REACH
Thoracic Extension ! Adhesive tape Skin tension for tactile feedback

correction observer
325
provocation of any symptoms within the range performed with the thoracic spine unsupported
that the extension UCM can be controlled. (no wall support).
Once control of thoracic extension improves
the person should reach back with both arms
while using a doorway or a pole for feedback and
Thoracic extension UCM summary
support of the thoracic spine. Eventually, they can
move away from the wall and the exercise can be (Table 7.4)
Table 7.4 Summary and rating of thoracic extension tests

THORACIC EXTENSION !
Standing: bilateral overhead reach
Sitting: head backward raise
Sitting: pelvic tail lift
Standing: bilateral backward reach
326
Thoracic rotation control Indications to test for thoracic

rotation UCM
THORACIC ROTATION CONTROL TESTS
1. hypermobile thoracic rotation range
AND ROTATION CONTROL 2. excessive initiation of turning or twisting
REHABILITATION with thoracic rotation
3. symptoms (pain, discomfort, strain)
These rotation control tests assess the extent of associated with turning or twisting with
rotation UCM in the thoracic spine and assess the associated thoracic rotation.
ability of the dynamic stability system to ade- The person complains of rotation-related symp-
quately control rotation load or strain. It is a toms in the thorax. Under rotation load, the tho-
priority to assess for rotation UCM if the person racic spine has greater give into rotation relative to
complains of or demonstrates rotation-related the lumbar spine, head and shoulders. The dys-
symptoms or disability. The tests that identify function is confirmed with motor control tests of
dysfunction can also be used to guide and direct rotation dissociation.
rehabilitation strategies.
327
alignment (Figure 7.35). The person is then

Tests of thoracic rotation control instructed to fully rotate the head by turning to
look over the shoulder, keeping the eyes and the
shoulders horizontal. Without letting the thoracic
T50 SITTING: HEAD TURN TEST
spine rotate or lean to the side, they should be
(tests for thoracic rotation UCM) able to actively turn the head through approxi-
mately 70–80° of rotation.
This dissociation test assesses the ability to actively Ideally, the person should have the ability to
dissociate and control thoracic rotation and turn dissociate the thoracic spine from head rotation
the head by rotating the neck through full range as evidenced by the ability to prevent thoracic
while sitting. During any asymmetrical or non- rotation while independently turning the head to
sagittal trunk or head movement a rotational 70–80° of independent head rotation (Figure
force is transmitted to the thorax. 7.36). There must be no movement into thoracic
rotation. There should be no provocation of any
symptoms under head rotation load, so long as
Test procedure
the thoracic rotation UCM can be controlled.
The person sits upright with feet unsupported This test should be performed without any extra
and with the spine in its neutral normal curves; feedback (self-palpation, vision, etc.) or cueing
the head and neck in neutral alignment with the for correction. The therapist should use visual
scapulae positioned in their neutral mid-range observation of the thorax relative to the head to
Figure 7.35 Start position head turn test Figure 7.36 Benchmark head turn test
328
determine whether the control of thoracic rota-

tion is adequate when feedback is removed for
testing. Assess rotation to both sides separately.
Thoracic rotation UCM

The person complains of rotation-related symp-
into rotation relative to cervical rotation (turning
the head to look over the shoulder). The thoracic
spine starts to rotate (or lean into lateral flexion)
before 70–80° of independent head rotation is
achieved. During the attempt to dissociate the
thoracic rotation from independent head rota-
tion, the person either cannot control the UCM
or has to concentrate and try hard to control the
thoracic rotation.


test of thoracic rotation, do not score this as uncontrolled
thoracic rotation. The thoracic flexion motor control tests
uncontrolled. A test for thoracic rotation UCM is only
positive if uncontrolled thoracic rotation is
demonstrated.
Figure 7.37 Correction partial head rotation with thoracic

support on wall
rotation UCM
(T50.1 and T50.2) look over the shoulder. They are to keep the
occiput in contact with the wall to monitor that
the head turns into rotation (axial movement)
Correction and does not roll (side-bend) into rotation. Both
Retraining is best started by supporting the thor- scapulae should actively maintain symmetrical
acic spine against a wall for increased thoracic contact on the wall and the thorax should not
support and feedback and turning the head move. They are to turn the head only as far as
through reduced range. The person stands with there is no thoracic rotation (Figure 7.37). The
the back of the pelvis, the upper thoracic spine person is trained to control and prevent thoracic
and the back of the head resting against a wall rotation and perform independent cervical
with the shoulders neutral and the arms crossed rotation.
in front of the chest. Both scapulae should contact The person should self-monitor the control of
the wall equally. This can also be performed with thoracic rotation UCM with a variety of feedback
the person sitting on a low stool with the feet on options (T50.3). There should be no provocation
the floor and the thoracic spine and head resting of any symptoms within the range that the rota-
against a wall. Then, without letting the chest turn tion UCM can be controlled.
to follow the head (thoracic rotation) or allowing Once control of thoracic rotation improves, the
the shoulders to drop into lateral flexion, the exercise can be performed with the thoracic spine
person is instructed to slowly turn the head to unsupported (no wall support).
329
T50.1 Assessment and rating of low threshold recruitment efficiency of the Head Turn Test
from the Head Turn Test
HEAD TURN TEST – SITTING
Site Direction Thorax to the Thorax to the position
left (L) right (R)
Thoracic Rotation ! ! Adhesive tape Skin tension for tactile feedback
correction observer
330
alignment. The finger tips touch a table in front

T51 SITTING: PELVIC TWIST (SWIVEL of the body to provide a fixation point to turn the
CHAIR) TEST chair (Figure 7.38). The person is then instructed
(tests for thoracic rotation UCM) to rotate the chair to one side, but keep the upper
thorax, shoulders and head facing the front. The
eyes and the shoulders should maintain a hori-
zontal alignment. Without letting the shoulders
dissociate and control thoracic rotation and turn
and upper chest rotate or lean to the side, they
the pelvis by rotating the pelvis through full range
should be able to actively turn the chair through
while sitting on a swivel chair. During any asym-
approximately 45° of rotation.
metrical or non-sagittal trunk or pelvic move-
ment a rotational force is transmitted to the
dissociate the upper thoracic spine from pelvic
thorax.
rotation as evidenced by the ability to prevent
upper thoracic rotation while independently
Test procedure
turning the chair to 45° of independent pelvic
The person sits upright on a swivel chair (height rotation (Figure 7.39). There must be no move-
adjusted for feet clearance) with feet unsupported ment into thoracic rotation. There should be no
and with the spine in its neutral normal curves; provocation of any symptoms under head rota-
the head and neck in neutral alignment with the tion load, so long as the thoracic rotation UCM
scapulae positioned in their neutral midrange can be controlled.
Figure 7.38 Start position pelvic twist test Figure 7.39 Benchmark pelvic twist test
331
This test should be performed without any extra Rating and diagnosis of thoracic
feedback (self-palpation, vision, etc.) or cueing rotation UCM
observation of the thorax relative to the pelvis to (T51.1 and T51.2)
determine whether the control of thoracic rota-
tion is adequate when feedback is removed for Correction
testing. Assess the pelvic twist to each side
separately. Retraining is best started by supporting the tho-
racic spine with the shoulder girdle by holding
the table with a firmer hand grip (increased fixa-
Thoracic rotation UCM tion for thoracic support) and turning the chair
The person complains of rotation-related symp- through reduced range. The person sits upright on
toms in the thoracic spine. The thorax has UCM a swivel chair (height adjusted for feet clearance)
into rotation relative to pelvic rotation (turning with feet unsupported and the spine in its neutral
the chair to the side). The thoracic spine starts to normal curves. The head and shoulders are posi-
rotate (or lean into lateral flexion) before 45° of tioned in their neutral alignment and the hands
independent chair rotation is achieved. During firmly grip the table to provide a fixation point to
the attempt to dissociate the upper thoracic rota- turn the chair.
tion from independent pelvic rotation, the person Then, without letting the chest turn to follow
either cannot control the UCM or has to concen- the pelvis or the shoulders drop into lateral
trate and try hard to control the thoracic flexion, the person is instructed to slowly turn the
rotation. chair to the side. They are to keep the upper
thorax, shoulders and head facing the front. They
are to turn the chair and pelvis only as far as there
is no upper thoracic rotation. The person is
trained to control and prevent upper thoracic
Clinical assessment note for direction-specific rotation and perform independent pelvic
motor control testing rotation.
If some other movement (e.g. a small amount of thoracic thoracic rotation UCM with a variety of feedback
flexion) is observed during a motor control (dissociation) options (T51.3). There should be no provocation
test of thoracic rotation, do not score this as uncontrolled of any symptoms within the range that the rota-
thoracic rotation. The thoracic flexion motor control tests tion UCM can be controlled.
will identify if the observed unrelated movement is Once control of thoracic rotation improves, the
exercise can be performed with the thoracic spine
demonstrated.
less supported (only finger tips for fixation
support).
332
T51.1 Assessment and rating of low threshold recruitment efficiency of the Pelvic Twist Test
from the Pelvic Twist Test
PELVIC TWIST TEST – SITTING
(SWIVEL CHAIR) position
Site Direction Thorax to the Thorax to the
left (L) right (R)
watch the movement
Thoracic Rotation ! !
correction observer
333
keeping the shoulders level and stationary, they

T52 STANDING: PELVIC SIDE-SHIFT TEST are instructed to side-shift the pelvis laterally to
(tests for thoracic rotation UCM) one side. Without letting the thoracic spine rotate,
lean to the side, or move laterally, the person
This dissociation test assesses the ability to actively should be able to actively side-shift the pelvis at
dissociate and control thoracic rotation and side- least 5 cm (Figure 7.41).
shift the pelvis through full range of lateral pelvic Ideally, the person should have the ability to
shift while standing unsupported. During any dissociate the thoracic spine from lateral pelvic
asymmetrical or non-sagittal trunk or pelvic side-shift as evidenced by the ability to prevent
movement, a rotational force is transmitted to the thoracic rotation or lateral flexion while inde-
thorax. pendently laterally shifting the pelvis to the side.
There must be no movement into thoracic rota-
tion. There should be no provocation of any
Test procedure
symptoms under pelvic side-shift load, so long as
The person stands upright (unsupported), the the thoracic rotation UCM can be controlled.
feet at least shoulder width apart and with the This test should be performed without any extra
knees slightly flexed (hip flexors unloaded and feedback (self-palpation, vision, etc.) or cueing
wide base of support). The arms are crossed in for correction. The therapist should use visual
front of the chest with the shoulders and the observation of the thorax relative to the pelvis to
pelvis level (horizontal) (Figure 7.40). Then, determine whether the control of thoracic
Figure 7.40 Start position pelvic side shift test Figure 7.41 Benchmark pelvic side shift test
334
rotation is adequate when feedback is removed

for testing. Assess side-shift to each side sepa-
rately. There should also be good symmetry to
each side.

into rotation relative to lateral pelvic side-shift.
The thoracic spine starts to rotate (or lean into
lateral flexion) before 5 cm of independent side-
shift is achieved. During the attempt to dissociate
the thoracic rotation from independent pelvic
side-shift, the person either cannot control the
the thoracic rotation.


demonstrated.
Figure 7.42 Correction partial pelvic side shift with thoracic
support on wall
rotation UCM
(T52.1 and T52.2)
shoulders to drop into lateral flexion, the person
is instructed to slowly slide the pelvis laterally on
Correction the wall. Both scapulae should actively maintain
Retraining is best started by supporting the thor- symmetrical contact on the wall and the thorax
acic spine against a wall for increased thoracic should not move. They are to side-shift the pelvis
support and feedback and turning the head only as far as there is no thoracic rotation (Figure
through reduced range. The person stands with 7.42). The person is trained to control and prevent
the back of the pelvis, the upper thoracic spine thoracic rotation and perform independent lateral
and the back of the head resting against a wall pelvic side-shift.
with the shoulders neutral and the arms crossed The person should self-monitor the control of
in front of the chest. Both scapulae should contact thoracic rotation UCM with a variety of feedback
the wall equally. This can also be performed with options (T52.3). There should be no provocation
the person sitting on a low stool with the feet on of any symptoms within the range that the rota-
the floor and the thoracic spine and head resting tion UCM can be controlled.
against a wall. Once control of thoracic rotation improves, the
Then, without letting the chest turn to follow exercise can be performed with the thoracic spine
the pelvis (thoracic rotation) or allowing the unsupported (no wall support).
335
T52.1 Assessment and rating of low threshold recruitment efficiency of the Pelvic Side-Shift Test
from the Pelvic Side-Shift Test
PELVIC SIDE-SHIFT TEST – STANDING
left (L) right (R)
correction observer
336
on the wall at shoulder height and the fingers

T53 STANDING: ONE ARM WALL PUSH vertical (Figure 7.43).
TEST The person is then instructed to lean their body
(tests for thoracic rotation UCM) weight onto the hand and slowly bend the elbow
to lower the forearm to the wall. The forearm
should stay vertically aligned under the hand
(not out to the side). The body should maintain
dissociate and control thoracic rotation and
a straight line from the ankles through the hips
perform a one arm ‘push up’ against a wall while
and back to the head and shoulders as the body
standing. During any unilateral or asymmetrical
leans in towards the wall in the ‘one arm wall
upper limb movement, a rotational force is trans-
push’. Without allowing the thoracic spine to
mitted to the thorax.
rotate or the scapula to ‘wing’ off the thorax, the
person should be able to actively lean in to the
wall and take full weight on the vertical forearm
Test procedure
and then push off the wall to return to the start
The person stands upright facing a wall, with one position.
arm held horizontal (90° shoulder flexion) with Ideally, the person should have the ability to
the wrist extended and the palm facing forwards. dissociate the thoracic spine from unilateral arm
The shoulders are held neutral (midway between loading as evidenced by the ability to prevent
elevation and depression). The body is positioned thoracic rotation while independently perform-
arm’s length from the wall with the palm resting ing the one arm wall push (Figure 7.44). There
Figure 7.43 Start position one arm wall push test Figure 7.44 Benchmark one arm wall push test
337
must be no movement into thoracic rotation. Rating and diagnosis of thoracic

There should be no provocation of any symptoms rotation UCM
under unilateral arm load, so long as the thoracic
rotation UCM can be controlled. (T53.1 and T53.2)
feedback (self-palpation, vision, etc.) or cueing Correction
testing the therapist should use visual observa- Retraining is best started by standing closer to the
tion of the thorax relative to the shoulder and arm wall to reduce body load during the one arm wall
to determine whether the control of thoracic rota- push. The person stands upright facing a wall,
tion is adequate. Assess one arm wall push to each with the palm resting on the wall horizontally in
side separately. Performance to right and left sides front of the shoulder (fingers vertical). The body
should be symmetrical. is positioned less than arm’s length from the wall.
At this point the elbow will be partially flexed.
The person is then instructed to lean their body
Thoracic rotation UCM weight onto the hand and slowly lower the
The person complains of rotation-related symp- forearm to the wall, keeping the forearm vertically
toms in the thoracic spine. The thorax has UCM aligned under the hand. The body should main-
into rotation relative to unilateral arm weight tain a straight line from the ankles to the head.
bearing. The thoracic spine starts to rotate (or the Then, without letting the thoracic spine rotate (or
scapula wings) before the forearm lowers body the scapula ‘wing’ of the thorax), the person is
weight to the wall and pushes off again. During instructed to slowly lower the forearm to the wall.
the attempt to dissociate the thoracic rotation They are to lean in towards the wall only as far as
from independent unilateral arm loading, the there is no thoracic rotation. The person is trained
person either cannot control the UCM or has to to control and prevent thoracic rotation and
concentrate and try hard to control the thoracic perform independent one arm wall push.
rotation. The person should self-monitor the control of
thoracic rotation UCM with a variety of feedback
of any symptoms within the range that the rota-
Clinical assessment note for direction-specific tion UCM can be controlled.
motor control testing Once control of thoracic rotation improves, the
exercise can be performed standing further away
If some other movement (e.g. a small amount of thoracic from the wall (increased body load in unilateral
flexion) is observed during a motor control (dissociation) weight bearing).
demonstrated.
338
T53.1 Assessment and rating of low threshold recruitment efficiency of the One Arm Wall Push Test
from the One Arm Wall Push Test
ONE ARM WALL PUSH TEST – STANDING
(WALL) position
Site Direction Thorax to the Thorax to the
left (L) right (R)
watch the movement
Thoracic Rotation ! !
correction observer
339
weight bearing on one arm and lifting the other

T54 4 POINT: ONE ARM LIFT TEST arm forwards to 150° flexion (Figure 7.47). There
(tests for thoracic rotation UCM) must be no movement into thoracic rotation.
There should be no provocation of any symptoms
This dissociation test assesses the ability to actively under asymmetrical arm load, so long as the thor-
dissociate and control thoracic rotation and acic rotation UCM can be controlled.
actively lift one arm forward of the body while in This test should be performed without any extra
4 point kneeling (hands and knees). During any feedback (self-palpation, vision, etc.) or cueing
unilateral or asymmetrical upper limb move-
ment, a rotational force is transmitted to the
thorax.
Test procedure
The person should have the ability to actively lift
one arm forward of the body while weight bearing
on the other arm and controlling the thoracic
rotation. The person positions themselves in 4
point kneeling (hands and knees) with the spine
and scapulae in neutral (mid-position) alignment
and hands under the shoulders (weight bearing
at 90° of flexion) (Figures 7.45 and 7.46). The
person is then instructed to lean body weight
onto one hand and slowly lift the other arm into
shoulder flexion to reach forwards of the body.
Without allowing the thoracic spine to rotate or
the scapulae to ‘wing’ off the thorax or to hitch
into elevation, the person should be able to
actively reach forwards with the non-weight
bearing arm to 150° flexion while maintaining Figure 7.46 Start position one arm lift test (front view)
weight bearing control with the other (weight
bearing) arm.
dissociate the thoracic spine from asymmetrical
shoulder loading as evidenced by the ability to
prevent thoracic rotation while independently
Figure 7.45 Start position one arm lift test (lateral view) Figure 7.47 Benchmark one arm lift test
340

observation of the thorax relative to the shoulders
to determine whether the control of thoracic rota-
tion is adequate when feedback is removed for
testing. Assess the unilateral arm lift to each side
separately. Performance to right and left sides
should be symmetrical.

into rotation relative to asymmetrical arm loading.
The thoracic spine starts to rotate (or the scapula
wings or elevates on the thorax) before the arm
lifts forwards to 150° flexion while weight bearing
on the other arm. During the attempt to dissoci-
ate the thoracic rotation from independent asym-
metrical arm loading, the person either cannot
Figure 7.48 Correction lateral weight shift
hard to control the thoracic rotation.
Clinical assessment note for direction-specific scapulae in neutral (mid-position) alignment and
motor control testing hands under the shoulders (weight bearing at 90°
of flexion). Then, without allowing the thoracic
If some other movement (e.g. a small amount of thoracic spine to rotate, the person is instructed to slowly
flexion) is observed during a motor control (dissociation) lean body weight laterally onto one hand but not
test of thoracic rotation, do not score this as uncontrolled to shift full weight onto that hand. The other arm
thoracic rotation. The thoracic flexion motor control tests maintains some partial weight bearing load.
They are to shift weight laterally only as far as
there is no thoracic rotation. The person is trained
demonstrated. to control and prevent thoracic rotation and
perform independent partial weight transfer from
one arm to the other (Figure 7.48).
An alternative progression is to start in a
push-up position off elbows and knees (Figure
7.49). Keep the scapula and chest in mid-position
Rating and diagnosis of thoracic and slowly shift upper body weight onto one arm
rotation UCM (Figure 7.50) only so far as there is thoracic rota-
(T54.1 and T54.2) tion can be controlled.
thoracic rotation UCM with a variety of feedback
Correction options (T54.3). There should be no provocation
Retraining is best started by controlling thoracic of any symptoms within the range that the rota-
rotation during weight shift movement without tion UCM can be controlled.
full weight transfer to one arm. Once control of thoracic rotation improves, the
The person positions themselves in 4 point exercise can be performed with full weight trans-
kneeling (hands and knees) with the spine and fer and one arm lift into flexion.
341
Figure 7.49 Correction – push up position off elbows: start

position
Figure 7.50 Correction – lateral weight shift off elbows
342
T54.1 Assessment and rating of low threshold recruitment efficiency of the One Arm Lift Test
from the One Arm Lift Test
ONE ARM LIFT TEST – 4 POINT KNEELING
left (L) right (R)
correction observer
343
person is instructed to maintain the neutral tho-

T55 SIDE-LYING: LATERAL ARM LIFT TEST racic position and lift the uppermost arm back-
(tests for thoracic rotation UCM) wards (towards the ceiling in the axial plane).
This movement is often referred to as ‘horizontal
This dissociation test assesses the ability to actively abduction’ when performed in standing.
dissociate and control thoracic rotation and lift Ideally, the person should have the ability to
one arm laterally backwards (unilateral horizon- dissociate the thoracic spine from unilateral
tal abduction in the axial plane) while side-lying. shoulder ‘horizontal’ abduction, as evidenced
During any unilateral or asymmetrical upper limb by the ability to prevent thoracic rotation while
movement, a rotational force is transmitted to the independently lifting the arm backwards. The
thorax. scapula should independently retract and the arm
should be able to lift backwards to the vertical
position (abduction in the axial plane) without
Test procedure
any thoracic rotation following the arm move-
The person lies on one side with the hips and ment (Figure 7.52). There should be no provoca-
knees flexed and the spine in neutral alignment. tion of any symptoms under asymmetrical arm
The pelvis, thorax and head should be positioned load, so long as the thoracic rotation UCM can
in neutral rotation (all facing forwards). The be controlled.
uppermost (top) arm should be held horizontal This test should be performed without any extra
to the floor in 90° of flexion (Figure 7.51). The feedback (self-palpation, vision, etc.) or cueing
Figure 7.51 Start position lateral arm lift test Figure 7.52 Benchmark lateral arm lift test
344
for correction. The therapist should use visual Rating and diagnosis of thoracic
observation of the thorax relative to the shoulder rotation UCM
to determine whether the control of thoracic rota-
tion is adequate when feedback is removed for (T55.1 and T55.2)
testing. Assess the lateral arm lift to each side
separately. Performance to right and left sides Correction
should be symmetrical.
Retraining is best started by supporting the thor-
acic spine against a wall for increased thoracic
Thoracic rotation UCM support and feedback and lifting the arm through
The person complains of rotation-related symp- reduced range. The person lies on one side on the
toms in the thoracic spine. The thorax has UCM floor, with the hips and knees flexed and the spine
into rotation relative to asymmetrical arm loading. in neutral alignment and the back supported flat
The thoracic spine starts to rotate before the arm against a wall. The pelvis, thorax and head should
lifts backwards in the axial plane (abduction to be positioned in neutral rotation (all facing for-
the vertical position). During the attempt to dis- wards). The uppermost (top) arm should be held
sociate the thoracic rotation from independent horizontal to the floor in 90° of flexion.
unilateral arm abduction, the person either Using the wall for support and feedback, the
cannot control the UCM or has to concentrate person is instructed to maintain the neutral thor-
and try hard to control the thoracic rotation. acic position and lift the uppermost arm back-
wards (towards the ceiling in the axial plane).
They are to lift the arm only as far as there is no
Clinical assessment note for direction-specific thoracic rotation. The person is trained to control
motor control testing and prevent thoracic rotation and perform inde-
pendent lateral arm lift.
If some other movement (e.g. a small amount of thoracic The person should self-monitor the control of
flexion) is observed during a motor control (dissociation) thoracic rotation UCM with a variety of feedback
test of thoracic rotation, do not score this as uncontrolled options (T55.3). There should be no provocation
thoracic rotation. The thoracic flexion motor control tests of any symptoms within the range that the rota-
will identify if the observed unrelated movement is tion UCM can be controlled.
uncontrolled. A test for thoracic rotation UCM is only Once control of thoracic rotation improves, the
exercise can be performed with the thoracic spine
demonstrated.
unsupported (no wall support).
345
T55.1 Assessment and rating of low threshold recruitment efficiency of the Lateral Arm Lift Test
from the Lateral Arm Lift Test
LATERAL ARM LIFT TEST – SIDE-LYING
left (L) right (R)
346
(Figure 7.54). There should be no provocation of

T56 SIDE-LYING: SIDE BRIDGE TEST any symptoms under unilateral shoulder abduc-
(tests for thoracic rotation UCM) tion in weight bearing, so long as the thoracic
rotation UCM can be controlled.
This dissociation test assesses the ability to actively This test should be performed without any extra
dissociate and control thoracic rotation and feedback (self-palpation, vision, etc.) or cueing
weight bear laterally on one arm in a ‘side bridge’ for correction. When feedback is removed for
or ‘side plank’ position (unilateral abduction) testing the therapist should use visual observa-
while side-lying. During any unilateral or asym- tion of the thorax relative to the shoulder to deter-
metrical upper limb movement, a rotational force mine whether the control of thoracic rotation is
is transmitted to the thorax. adequate. Assess the side bridge to each side sepa-
rately. Performance to right and left sides should
be symmetrical.
Test procedure
The person lies on one side with the spine in
neutral alignment and the legs straight (in line The person complains of rotation-related symp-
with the trunk). The pelvis, thorax and head toms in the thoracic spine. The thorax has UCM
should be positioned in neutral rotation (all into rotation relative to unilateral weight bearing
facing forwards). Body weight is supported on the shoulder abduction. The thoracic spine starts to
lowermost (underneath) elbow with that elbow rotate before body weight is supported at 90°
positioned under the shoulder and the forearm shoulder abduction in the side plank position.
facing forwards. The uppermost (top) hand rests During the attempt to dissociate the thoracic rota-
on the lateral pelvis (Figure 7.53). The person is tion from independent unilateral weight bearing
instructed to maintain the neutral thoracic posi- abduction, the person either cannot control the
tion and lift the pelvis and hips (away from the UCM or has to concentrate and try hard to control
floor) so that the head, spine and legs are all in the thoracic rotation.
the same line. Body weight is supported between
the feet and the weight bearing elbow. The weight Clinical assessment note for direction-specific
bearing shoulder should be at 90° of abduction. motor control testing
This movement is often referred to as a ‘side
bridge’ or a ‘side plank’. If some other movement (e.g. a small amount of thoracic
Ideally, the person should have the ability to flexion) is observed during a motor control (dissociation)
dissociate the thoracic spine from weight bearing test of thoracic rotation, do not score this as uncontrolled
unilateral shoulder abduction as evidenced by the thoracic rotation. The thoracic flexion motor control tests
ability to support body weight and prevent tho-
racic rotation (and scapular winging) while inde- positive if uncontrolled thoracic rotation is demonstrated.
pendently lifting the pelvis into a ‘side bridge’
Figure 7.53 Start position side bridge test Figure 7.54 Benchmark side bridge test
347
Rating and diagnosis of thoracic options (T56.3). There should be no provocation

rotation UCM of any symptoms within the range that the rota-
tion UCM can be controlled.
(T56.1 and T56.2) If control is very poor, the uppermost (top)
hand can be used for support and balance by
Correction contact with the floor. Once control of thoracic
rotation improves, the exercise can be performed
Retraining is best started using reduced body load with full body load (long lever side-bridge off the
by bending the knees and performing the side feet).
bridge between the knees and the weight bearing
elbow (instead of feet and elbow). The person lies
on one side with the spine in neutral alignment Thoracic rotation UCM summary
and the hips straight (in line with the trunk) but (Table 7.5)
with the knees bent to 90° of flexion. The pelvis,
thorax and head should be positioned in neutral
rotation (all facing forwards). Body weight is sup-
ported on the lowermost (underneath) elbow
with that elbow positioned under the shoulder
and the forearm facing forwards.
Using reduced body load, the person is
instructed to maintain the neutral thoracic posi-
tion and lift the pelvis and hips (away from the
floor) so that the head, spine and thighs are all
in the same line. Body weight is supported
between the knees and the weight bearing elbow
(Figure 7.55). They are to lift the pelvis only as
far as there is no thoracic rotation. The person is
trained to control and prevent thoracic rotation
and perform independent side bridge of the
knees.
thoracic rotation UCM with a variety of feedback Figure 7.55 Correction reduced load side bridge off knees
Table 7.5 Summary and rating of thoracic rotation tests

THORACIC ROTATION !
Thorax to (L) Thorax to (R)
Sitting: head turn
Sitting: pelvic twist (swivel chair)
Standing: pelvic side-shift
Standing: one arm wall push
4 point: one arm lift
Side-lying: lateral arm lift
Side-lying: side bridge
348
T56.1 Assessment and rating of low threshold recruitment efficiency of the Side Bridge Test
from the Side Bridge Test
SIDE BRIDGE TEST – SIDE-LYING
left (L) right (R)
correction observer
349
Thoracic and rib Indications to test for thoracic

respiratory control respiratory UCM
1. hypermobile rib movement
THORACIC AND RIB RESPIRATORY 2. excessive initiation or dominant ribcage
CONTROL TESTS AND RESPIRATORY elevation or depression associated with
CONTROL REHABILITATION either costal, apical or abdominal
movement
These respiratory control tests assess the extent of 3. symptoms (pain, discomfort, strain)
respiratory UCM in the thoracic spine and ribcage associated with inspiration or expiration or
and assess the ability of the dynamic stability rib pain associated with thoracic or ribcage
system to adequately control respiratory load or movement.
strain. It is a priority to assess for respiratory UCM The person complains of respiratory or rib-related
if the person complains of or demonstrates respi- symptoms in the thorax. Under respiratory load,
ratory or ribcage-related symptoms or disability. the thoracic spine and ribcage has greater give into
The tests that identify dysfunction can also be ribcage elevation or depression relative to inspiration
used to guide and direct rehabilitation or expiration. The dysfunction is confirmed with
strategies. motor control tests of respiratory dissociation.
350
takes a relaxed breath in and then is asked to fully

Tests of thoracic and ribcage exhale (breathe out) to ensure that the apical
respiratory control ribcage has been fully depressed (Figure 7.56).
They are then to hold this position as the start
position for the test. Then, keeping the apical
T57 STANDING: APICAL DROP + ribcage held down in depression, the person is
INSPIRATION TEST instructed to slowly start to breathe in (slow
(tests for thoracic respiratory UCM) inspiration). During normal inspiration the
ribcage naturally elevates. However, excessive ele-
This dissociation test assesses the ability to actively vation of the apical ribcage is often associated
dissociate and control apical ribcage elevation with upper thoracic, upper rib, arm pain and neck
then breathe in while standing upright and pain. The ability to control this excessive apical
unsupported. ribcage elevation may be useful in managing
these symptoms.
Test procedure dissociate the apical ribcage elevation from inspi-
The person stands upright with the spine in its ration as evidenced by the ability to prevent apical
neutral normal curves; the head directly over the elevation (from a fully depressed position) while
shoulders and the arms resting by the side with independently breathing in to about 1 2 normal
the shoulders in a neutral position. The person inspiratory volume (Figure 7.57). There must be
Figure 7.56 Start position apical drop + inspiration test Figure 7.57 Benchmark apical drop + inspiration test
351
no movement into apical ribcage elevation. There Rating and diagnosis of thoracic
is usually an observed increase in costal or poste- respiratory UCM
rolateral basal ribcage expansion associated with
correct performance of this test. There should be (T57.1 and T57.2)
no provocation of any symptoms under inspira-
tory effort, so long as the apical elevation UCM Correction
can be controlled.
This test should be performed without any extra Retraining is best started using a reduced amount
feedback (self-palpation, vision, etc.) or cueing of inspiration and self-palpation of the upper
for correction. When feedback is removed for ribcage for feedback. The person stands upright
testing the therapist should use visual observa- with the spine in its neutral normal curves, and
tion of the thorax relative to the respiratory move- palpates the upper ribcage. They take a relaxed
ment to determine whether the control of thoracic breath in and then fully exhale (breathe out) to
respiration is adequate. ensure that the apical ribcage has fully depressed.
Then, keeping the apical ribcage held down in
depression, the person is instructed to slowly start
Thoracic respiratory (apical ribcage to breathe in (slow inspiration). They are to
elevation) UCM breathe in only as far as there is no apical ribcage
elevation. The person is trained to control and
The person complains of respiratory or ribcage- prevent apical elevation and perform independ-
related symptoms in the thorax. The apical ribcage ent inspiration.
has UCM into elevation relative to inspiratory The person should self-monitor the control of
movement. The apical ribcage starts to elevate thoracic respiration UCM with a variety of feed-
before adequate respiratory inspiration is back options (T57.3). There should be no provo-
achieved. During the attempt to dissociate the cation of any symptoms within the range that the
apical ribcage elevation from independent inspi- apical ribcage elevation UCM can be controlled.
ration, the person either cannot control the UCM Once control of apical ribcage elevation
or has to concentrate and try hard to control the improves, the exercise can be performed with
apical ribcage. greater volume of inspiration.


test of thoracic respiration, do not score this as
uncontrolled thoracic respiration. The thoracic rotation
movement is uncontrolled. A test for thoracic respiration
UCM is only positive if uncontrolled thoracic respiration
is demonstrated.
352
T57.1 Assessment and rating of low threshold recruitment efficiency of the Apical Drop + Inspiration Test
from the Apical Drop + Inspiration Test
APICAL DROP + INSPIRATION TEST
Apical ribcage Depression ! Adhesive tape Skin tension for tactile feedback
(Thoracic) (Respiration)
correction observer
353
to hold this position as the start position for the

T58 STANDING: ANTERIOR COSTAL test. Then, keeping the anterior costal ribcage and
LIFT + EXPIRATION TEST sternum held up in elevation, the person is
(tests for thoracic respiratory UCM) instructed to slowly start to breathe out (slow
expiration). During normal expiration the ribcage
naturally depresses. However, excessive depres-
sion of the anterior costal ribcage is often observed
dissociate and control anterior costal ribcage and
associated with lower thoracic, lumbar and pelvic
sternal depression then breathe out while stand-
pain. The ability to control this excessive anterior
ing upright and unsupported.
costal ribcage depression may be useful in man-
aging these symptoms.
Test procedure
dissociate the anterior costal ribcage depression
The person stands upright with the spine in its from expiration as evidenced by the ability to
neutral normal curves and the head directly over prevent anterior costal depression (from a fully
the shoulders. The person is asked to have a elevated position) while independently breathing
relaxed breath out and then fully inhale (breathe out to about 1 2 normal expiratory volume (Figure
in) to ensure that the anterior costal ribcage and 7.59). There must be no movement into anterior
sternum has fully elevated (Figure 7.58). They are costal ribcage depression. There should be no
Figure 7.58 Start position anterior costal lift + expiration

test Figure 7.59 Benchmark anterior costal lift + expiration test
354
provocation of any symptoms under expiratory Rating and diagnosis of thoracic

effort, so long as the anterior costal depression respiratory UCM
This test should be performed without any extra (T58.1 and T58.2)
for correction. When feedback is removed for Correction
testing the therapist should use visual observa-
tion of the thorax relative to the respiratory move- Retraining is best started using a reduced amount
ment to determine whether the control of thoracic of expiration combined with self-palpation of the
respiration is adequate. lower anterior costal ribcage for feedback. The
person stands upright with the spine in its neutral
normal curves, and palpates the anterior costal
Thoracic respiratory (costal ribcage ribcage. They fully inhale (breathe in) and ensure
depression) UCM that the anterior costal ribcage has fully elevated.
Then, keeping the anterior costal ribcage held up
The person complains of respiratory or ribcage- in elevation, the person is instructed to slowly
related symptoms in the thorax. The anterior start to breathe out (slow expiration). They are to
costal ribcage has UCM into depression relative breathe out only as far as there is no anterior
to expiratory movement. The ribcage or thorax costal ribcage depression. The person is trained to
starts to depress before adequate respiratory expi- control and prevent anterior costal depression
ration is achieved. During the attempt to dissoci- and perform independent expiration.
ate the anterior costal ribcage depression from The person should self-monitor the control of
independent expiration, the person either cannot thoracic respiration UCM with a variety of feed-
control the UCM or has to concentrate and try back options (T58.3). There should be no provo-
hard to control the anterior costal ribcage. cation of any symptoms within the range that the
anterior costal ribcage depression UCM can be
controlled.
Clinical assessment note for direction-specific Once control of anterior costal ribcage depres-
motor control testing sion improves, the exercise can be performed with
greater volume of expiration.
is demonstrated.
355
T58.1 Assessment and rating of low threshold recruitment efficiency of the Anterior Costal Lift + Expiration Test
from the Anterior Costal Lift + Expiration Test
ANTERIOR COSTAL LIFT + EXPIRATION
Anterior costal ribcage Elevation ! Adhesive tape Skin tension for tactile feedback
correction observer
356
T59 STANDING: ABDOMINAL

HOLLOWING + EXPIRATION TEST
(tests for thoracic respiratory UCM)

dissociate and control abdominal bracing (bulge)
and lateral basal ribcage depression then breathe
out while standing upright and unsupported.
Test procedure
The person stands upright with the spine in its
neutral normal curves and the head directly over
the shoulders. The person has a relaxed breath
out. They are then instructed to inhale (breathe
in) and ensure that the lateral basal ribcage has
fully elevated. At the same time as inhaling, they
are to ‘hollow’ (pull in) the upper and lower
abdominal wall (Figure 7.60). They are then to
hold this position as the start position for the test.
Keeping the abdominal wall hollowed (pulled in)
and the lateral basal ribcage held up in elevation,
the person is then instructed to slowly start to
breathe out (slow expiration). They are to exhale
without loss of the abdominal hollowing and no
lateral basal ribcage depression.
During normal expiration the ribcage naturally
depresses. However, excessive depression of the
lateral basal ribcage and abdominal bracing is Figure 7.60 Start position abdominal hollowing + expiration
test
often observed associated with lower thoracic and
back pain. The ability to control this excessive
lateral basal ribcage depression and abdominal testing the therapist should use visual observa-
bracing (bulge) may be useful in managing these tion of the abdominal wall and thorax relative to
symptoms. Ideally, the person should have the the respiratory movement to determine whether
ability to dissociate the abdominal bracing and the control of thoracic respiration is adequate.
lateral basal ribcage depression from expiration
as evidenced by the ability to prevent lateral basal Thoracic respiratory (costal ribcage
depression (from a fully elevated position) while
independently breathing out to about 1 2 normal
depression) UCM
expiratory volume (Figure 7.61). The person complains of respiratory or ribcage-
There must be no movement into abdominal related symptoms in the thorax. The lateral basal
bracing or lateral basal ribcage depression. There ribcage has UCM into depression relative to expir-
is usually an observed increase in apical ribcage atory movement. The lateral basal ribcage or
depression associated with correct performance thorax starts to depress and the abdominal wall
of this test. There should be no provocation of bulges out into a bracing action before adequate
any symptoms under expiratory effort, so long respiratory expiration is achieved. During the
as the lateral costal depression UCM can be attempt to dissociate the lateral basal ribcage
controlled. depression from independent expiration, the
This test should be performed without any extra person either cannot control the UCM or has to
feedback (self-palpation, vision, etc.) or cueing concentrate and try hard to control the abdomi-
for correction. When feedback is removed for nal bracing and lateral basal ribcage.
357

respiratory UCM
(T59.1 and T59.2)
Correction
Retraining is best started using a reduced volume
of expiration combined with self-palpation of
the lower lateral basal ribcage for feedback. The
person stands upright with the spine in its neutral
normal curves, and palpates the lateral basal
ribcage. They take a relaxed breath out and then
fully inhale (breathe in) to ensure that the lateral
basal ribcage has fully elevated and concurrently
pull in (hollow) the abdominal wall. Then,
keeping the abdominal hollowing and the lateral
basal ribcage held up in elevation, the person is
instructed to slowly start to breathe out (slow
expiration). They are to breathe out only as far as
there is no loss of the abdominal hollowing or
no lateral basal ribcage depression. The person is
trained to control and prevent lateral basal depres-
sion and perform independent expiration.
thoracic respiration UCM with a variety of feed-
lateral basal ribcage depression UCM can be
controlled.
Figure 7.61 Benchmark abdominal hollowing + expiration Once control of lateral basal ribcage depression
test improves, the exercise can be performed with
greater volume of expiration.


is demonstrated.
358
T59.1 Assessment and rating of low threshold recruitment efficiency of the Abdominal Hollowing + Expiration
Test
from the Abdominal Hollowing + Expiration Test
ABDOMINAL HOLLOWING +
EXPIRATION TEST – STANDING position
Lateral basal ribcage Elevation ! Adhesive tape Skin tension for tactile feedback
correction observer
359
Thoracic respiratory UCM summary

(Table 7.6)
Table 7.6 Summary and rating of thoracic respiratory tests

THORACIC/RIBS RESPIRATORY !
Standing: apical drop + inspiration (prevent apical ribcage elevation)
Standing: anterior costal lift + expiration (prevent anterior costal
ribcage depression)
Standing: abdominal hollowing + expiration (prevent lateral basal
ribcage depression)
REFERENCES
Carrière, B., 1996. Therapeutic exercise Lee, D., 2003. The thorax: an integrated longissimus thoracic during trunk
and self correction. In: Flynn, T.W. approach. In: Diane, G. (Ed.), Lee rotation. Spine 30 (8), 870–876.
(Ed.), The thoracic spine and rib Physiotherapist Corporation. Surrey, Maitland, G., Hengeveld, E., Banks, K.,
cage: musculoskeletal evaluation and Canada. English, K., 2005. Maitland’s
treatment. Butterworth-Heinemann, Lee, D.G., 1996. Rotational stability of vertebral manipulation. Butterworth
Boston. the mid-thoracic spine: assessment Heinemann, Oxford.
Edmondston, S.J., Singer, K.P., 1997. and management. Manual Therapy 1 Watkins 4th, R., Watkins 3rd, R.,
Thoracic spine: anatomical and (5), 234–241. Williams, L., Ahlbrand, S., Garcia, R.,
biomechanical considerations for Lee, L.J., Coppieters, M.W., Hodges, Karamanian, A., et al., 2005. Stability
manual therapy. Manual Therapy 2 P.W., 2005. Differential activation of provided by the sternum and ribcage
(3), 132–143. the thoracic multifidus and in the thoracic spine. Spine 30 (11),
1283–1286.
360
CHAPTER 8
THE SHOULDER GIRDLE
Medial rotation control

T60 Kinetic medial rotation test (KMRT) 372
Lateral rotation control

T61 Kinetic lateral rotation test (KLRT) 378
Shoulder flexion control

T62 Arm flexion test 388
Shoulder abduction control

T63 Arm abduction test 393
Shoulder extension control

T64 Arm extension test 398
Chapter 8
The shoulder girdle
based on movement impairment (Sahrmann

INTRODUCTION 2002; Caldwell et al 2007) encouraged. The con-
sensus statement at a recent scapular summit
The complexity of shoulder girdle dysfunction (Kibler et al 2009) agreed that the observation of
makes diagnosis difficult, with definitions for scapular dyskinesis and clinical tests that alter
common diagnoses, such as impingement and symptoms (UCM in this text) should form the
frozen shoulder, being unclear, inconsistent and basis for the scapular evaluation.
unreliable (Schellingerhout et al 2008). An epi- This chapter sets out to explore the assessment
demiological study examining 1960 people suc- and retraining of UCM in the shoulder. Before
cessfully identified current and past shoulder details of the assessment and retraining of UCM
problems, but was unable to discriminate between in the shoulder region are explained, a brief
discrete shoulder pathologies (Walker-Bone et al review of function, changes in muscle function
2004). Therapy for shoulder girdle pain and dis- and movement and postural control in the region
ability is predominantly concerned with restor- is presented.
ation of optimal movement and function rather
than applying diagnostic labels, with traditional Scapula function and glenohumeral
approaches to clinical diagnosis at the shoulder
joint stability
girdle frequently neglecting to assess dynamic
movement faults, a significant factor associated The ability to control the orientation and move-
with shoulder dysfunction (Lukasiewicz et al ment of the scapula is essential for optimal arm
1999; Ludewig & Cook 2000; Lin et al 2006; Tate function. The bony, capsular and ligamentous
et al 2008). Classification of movement control restraints are minimal at the scapulothoracic
faults at the shoulder girdle is gaining recogni- ‘joint’ so stability is dependent on active muscular
tion, with Kibler & McMullen (2003) describing control. Movement faults and changes in muscle
a clinical classification of scapular dyskinesis function of the scapula are associated with shoul-
(scapular movement control faults). A classifica- der symptoms (Lukasiewicz et al 1999; Ludewig
tion of dysfunction in terms of site and direction & Cook 2000; Lin et al 2006; Roy et al 2008; Tate
of uncontrolled movement (UCM) has been pro- et al 2008).
posed (Mottram 2003; Mottram et al 2009a; The glenohumeral joint has the greatest range
Comerford & Mottram 2011), and diagnosis of motion of any human joint. This mobility is

DOI: 10.1016/B978-0-7295-3907-4.00008-6 363
necessary for upper limb functions, which range pain and pathology. Altered timing (latency) of
from weight bearing to high-speed acceleration electromyographic (EMG) activity has been iden-
and deceleration at the extremes of its range. Sta- tified in muscles of the scapula (Wadsworth &
bility is sacrificed to a significant degree to achieve Bullock-Saxton 1997; Cools et al 2003; Lin et al
this mobility function. The scapula provides the 2005; Falla et al 2007; Moraes et al 2008) and the
base for attachment of muscles that move the glenohumeral joint (Hess et al 2005). Interest-
glenohumeral joint. The scapula should be orien- ingly, muscle function (or dysfunction) has been
tated to optimise the length–tension relationship associated with movement faults; for example,
of these muscles (van der Helm 1994) and decreased serratus anterior activity has been asso-
provides the proximal articular surface of the ciated with an increase in forward tilt of the
glenohumeral joint (glenoid) and orientates scapula (Ludewig & Cook 2000; Lin et al 2005).
the glenoid, to increase the range available to the This literature supports the need for specific
upper limb. The scapula facilitates optimal contact assessment of movement faults so individual
with the humeral head – increasing joint congru- rehabilitation strategies can be implemented.
ency and stability (Saha 1971). Abnormal scapu- Further research is needed to explore the relation-
lar kinematics have been identified in people with ship between movement abnormalities and
multidirectional instability (Ogston & Ludewig symptoms and muscle function.
2007). Full upward rotation of the glenoid
enhances mechanical stability of the joint by
bringing the glenoid fossa directly under the head
of the humerus (Lucas 1973) and prevents Identifying UCM at the
impingement under the subacromial and cora-
shoulder girdle
coacromial arch. Glenohumeral function is
influenced to a large extent by the position and Motion analysis studies have identified abnormal
orientation of the glenoid and hence scapula sta- movements of the scapula which include scapula
bility; however, the glenohumeral joint exhibits a internal rotation (Ludewig & Cook 2000; Nawoc-
number of mechanisms to retain joint congru- zenski et al 2003; Tsai et al 2003; Borstad &
ency during functional movement which include Ludewig 2005; Borstad 2006); scapular down-
passive stability mechanisms and active stability ward rotation (Ludewig & Cook 2000; Tsai et al
mechanisms. Passive stability mechanisms 2003; Lin et al 2006); scapula anterior tilt
include the capsular and ligamentous restraints, (Lukasiewicz et al 1999; Ludewig & Cook 2000;
labrum and mechanisms such as the creation Nawoczenski et al 2003; Borstad & Ludewig 2005;
on negative intra-articular pressure to resist Lin et al 2005; Morrissey 2005); and elevation
translation. (Lukasiewicz et al 1999; Tsai et al 2003; Lin et al
2005). UCM of the glenohumeral joint has been
identified and includes translation (Baeyens et al
Changes in shoulder muscle 2001; Ruediger et al 2002; von Eisenhart-Rothe
et al 2002, Ludewig and Cook 2002) and external
function
rotation (Baeyens et al 2001).
Muscle stiffness is required at the scapula-thoracic In the current literature it is clear that altera-
and glenohumeral to enhance stability. It has tions in dynamic control of the glenohumeral
been shown that moderate levels of muscle con- and scapula-thoracic joints are important factors
traction can significantly increase glenohumeral in shoulder pathology (Ludewig and Cook 2000;
joint stiffness and stability (Huxel et al 2008). A Morrissey 2005; Alexander 2007; Ogston &
non-specific pre-setting action of the rotator cuff Ludewig 2007). Although these studies demon-
and biceps is seen prior to rotation of the shoul- strated clear differences in movement patterns for
der joint, and this recruitment is aimed mainly at symptomatic shoulders, they do not describe test
enhancing the joint ‘stiffness’ and hence its stabil- manoeuvres that could be used specifically to
ity (David et al 2000). A similar action is seen in detect the abnormalities in the clinical environ-
upper trapezius (Wadsworth & Bullock-Saxton ment, therefore neglecting a significant compo-
1997), suggesting it has a pre-setting role at the nent of assessment. This chapter details the
scapula. Evidence suggests that muscle function assessment of UCM at the shoulder region and
around the shoulder girdle can be impaired by describes retraining strategies.
364
The shoulder girdle Chapter |8|
Table 8.1 Site and direction of UCM at the shoulder mechanisms is an important aspect of a compre-
girdle hensive shoulder girdle assessment.
The site and direction of uncontrolled
SITE SCAPULA GLENOHUMERAL movement at the shoulder girdle can be linked
to different clinical presentations of shoulder
Direction • Downward • Anterior translation impingement syndrome and glenohumeral insta-
rotation • Inferior translation bility. Table 8.4 illustrates the clinical guidelines
• Forward tilt • Posterior translation
for impingement and instability.
• Winging • Medial rotation
• Elevation
• Retraction
• Protraction IDENTIFYING SITE AND DIRECTION OF
UCM AT THE SCAPULOTHORACIC AND
GLENOHUMERAL JOINTS
The key principles for assessment and classifica-

DIAGNOSIS OF THE SITE AND tion of UCM are described in Chapter 3. All dis-
sociation tests are performed with the scapula
DIRECTION OF UCM AT THE
and glenohumeral in the neutral training region.
SHOULDER GIRDLE This can be passively positioned by the therapist
prior to each test. The subject needs to clearly
The diagnosis of site and direction of UCM at the understand the test and appropriate facilitation
shoulder girdle can be observed at the scapula in strategies employed, including cognitive aware-
terms of downward rotation, forward tilt, winging ness, tactile, visual and technological feedback,
(internal rotation), elevation, retraction and pro- and proprioceptive input.
traction (abduction) and the glenohumeral joint
in terms of anterior, inferior, posterior translation
Scapula and glenohumeral joint
and medial rotation (Table 8.1).
neutral training region
Linking the site of UCM to symptom The natural resting position of the shoulder girdle
is often displaced from an optimal training posi-
presentation
tion. If there is poor antigravity postural control
A diagnosis of UCM requires evaluation of its the scapula often rests in a downwardly rotated
clinical priority. This is based on the relationship or forward tilted position. If there is a restriction
between the UCM and the presenting symptoms. (e.g. a stiffer pectoralis minor), the scapula will
The therapist should look for a link between the rest in relatively more forward tilt than is ideal.
direction of UCM and the direction of symptom The therapist should passively position the shoul-
provocation: a) Does the site of UCM relate to the der girdle into its ‘neutral training region’ and
site or joint that the patient complains of as the then palpate reference landmarks to ensure
source of symptoms? b) Does the direction of optimal neutral alignment for testing and retrain-
movement or load testing relate to the direction ing movement control.
or position of provocation of symptoms? This As a useful guide to repositioning the scapula
identifies the clinical priorities. in the neutral training region, the therapist stands
The site and direction of UCM at the scapula to the side of the patient’s shoulder and places
and the glenohumeral joint can be linked to dif- the pisiform and ulnar border of one hand on the
ferent clinical presentations and postures and medial side of the patient’s inferior scapular
activities that provoke or produce symptoms angle. The therapist then places the ulnar border
(Table 8.2). of the other hand on the patient’s coracoid with
In a shoulder with signs and symptoms of the hollow of the palm over the humeral head
impingement and instability, control of move- (Figure 8.1). With the fingers of both hands
ment needs to be effective to manage symptoms pointing to the ceiling, the therapist lifts both
and dysfunction. These mechanisms are high- their elbows so that both forearms are in line. The
lighted in Table 8.3 and the assessment of these therapist then gently ‘squeezes’ both hands
365
Table 8.2 The link between the site and direction of UCM at the shoulder and different clinical presentations
SITE AND DIRECTION OF UCM CLINICAL EXAMPLES OF PROVOCATIVE MOVEMENTS,

SYMPTOMS POSTURES AND ACTIVITIES
PRESENTATIONS
SCAPULA • Symptoms of subacromial or Symptoms provoked by arm movements
• Downward rotation coracoacromial impingement; and postures into elevation above 60° (if
• Forward tilt that is, pain at the point of especially sustained or loaded); for
• Winging the shoulder, in the region of example, lifting, reaching forwards,
• Elevation the coracoid and anterior and reaching overhead, pushing or pulling
• Retraction lateral deltoid region with the arm above shoulder height,
• Protraction • ± Referral from myofascial, sustained static postures with the
Can present as: articular and neural structures scapula dropped
• uncontrolled movement of the
scapular into any of these directions
resulting in an increased inferior–
anterior orientation of the glenoid
(IAG)
(± hypermobile range)
GLENOHUMERAL • Symptoms of coracoacromial Symptoms provoked by arm movements
Medial rotation impingement; that is, pain at and postures into forward elevation
Can present as: the point of the shoulder, in above 60° (if especially sustained or
• uncontrolled range of the humerus the region of the coracoid loaded); for example, lifting, reaching
into medial rotation and anterior and lateral forwards, reaching overhead, pushing or
(± hypermobile medial rotation range) deltoid region pulling with the arm above shoulder
• ± Referral from myofascial, height, sustained static postures with
articular and neural structures the scapula dropped
GLENOHUMERAL • Symptoms of glenohumeral Symptoms provoked by arm movements
• Anterior translation instability; that is, pain in the and postures into end range positions
• Inferior translation anterior and posterior (especially if end-range rotation is
• Posterior translation shoulder, at the point of the combined); for example, lifting, reaching
Can present as shoulder and deep axillary forwards, reaching overhead, pushing or
• uncontrolled translation of the pain pulling with the arm above shoulder
humeral head into any of the above • ± Referral from myofascial, height, sustained static postures with
directions (anterior is most common) articular and neural structures the scapula dropped
(± hypermobile translation)
Table 8.3 Normal mechanisms to minimise impingement and instability during arm elevation
IMPINGEMENT INSTABILITY
• Upward rotation of glenoid • Passive capsular and ligamentous restraints
• Glenohumeral lateral rotation timing • Dynamic (active) control of translation
• Inferior humeral head glide • Ideal length and recruitment of glenohumeral rotator muscles
• A stable scapula to provide a biomechanically sound platform for
glenohumeral movement
366
Table 8.4 Clinical guidelines for impingement and instability
IMPINGEMENT INSTABILITY
• Palpable tenderness ++ • Full or hypermobile range
• Mid-range arc or catch of pain • Pain (if any) at the limits of range (often only at stress points)
• Pain on static isolated muscle loading • Symptoms of instability, subluxation, dislocation, clicking,
• Associated weakness/inhibition dysfunction and disability (loss of performance)
• Positive impingement tests • Resisted rotation often pain-free
• Positive manual therapy stress tests to implicate • Good strength (mid-range)
pain-sensitive compression of subacromial or • Positive instability tests
coracoacromial structures • Positive manual therapy stress tests to implicate pain-sensitive
• Movement dysfunction indicates impingement; capsular strain and ligamentous laxity
that is, positive kinetic medial rotation test • Movement dysfunction indicates instability; that is, positive kinetic
(scapula) medial rotation test (glenohumeral)
together so that the acromion rises up, the

humeral head moves backwards and the inferior
scapular angle moves laterally around the chest
wall (Figure 8.2). While the therapist passively
supports the shoulder here, the person is asked to
relax the shoulder and then is asked to use
‘minimal’ effort to actively maintain this position
(Figure 8.3). With the scapula being actively
maintained in this position, the therapist should
palpate a series of landmarks (Box 8.1) and make
any minor adjustments required.
A useful guide is to passively position the shoul-
der and, using visual and palpation feedback, the
person feels the neutral position as a mid-position
between elevation and depression, forward and
backward tilt, upward and downward rotation
and protraction and retraction. They are then
instructed to move away from neutral and actively
return to neutral using this feedback to ensure
accurate repositioning.
Inferior anterior glenoid (IAG)

A common dysfunction pattern seen with loss of
scapula neutral is the orientation of the glenoid
in an inferior anterior direction, termed the infe-
rior anterior glenoid (IAG) (Figure 8.4). This can
be corrected by rotation of the scapula in the
coronal plane – observed by the acromion moving
superiorly while the inferior angle moves laterally
Figure 8.1 Therapist hand position for positioning the (upward rotation of the scapula in the sagittal
scapula ‘neutral’ orientation
plane). The scapula also moves upward and back-
ward (posterior or backward tilt) (Mottram et al
2009b) away from the IAG position.
367
Figure 8.2 Passive positioning into scapula neutral Figure 8.3 Active control of scapula neutral
Box 8.1 Palpation reference guidelines for a neutral shoulder girdle
Palpation guidelines for shoulder girdle • Inferior scapular angle is in contact with ribcage (i.e. no
neutral forward tilt/‘pseudo-winging’).
• Superior-medial corner of scapula is level with T2. • Medial border of scapula is in contract with ribcage (i.e.
• Medial edge of the spine of the scapula is level with T3. no winging).
• Medial border of spine of the scapula is approximately
• Spine of the scapula projects to T4.
5–6 cm lateral from the vertebral spinous processes.
• Inferior scapular angle level with T7.
• No more than 13 of the humeral head should protrude
• Acromion should be higher than the superior-medial
forward of the acromion.
scapular corner, with the spine of the scapula angled
• Scapula must be positioned in neutral alignment prior
upwards (i.e. no downward rotation).
to assessing humeral rotation and the humerus must be
• Plane of the spine of the scapula is orientated between
positioned in neutral alignment to assess forearm
15 and 30° forward of the coronal plane.
position.
• Acromions are level or horizontal.
• Elbow olecranon faces posteriorly and the elbow cubital
• Coracoids are symmetrical. fossa faces anteriorly (differentiate from forearm
• Clavicles are symmetrical and inclined slightly upwards. pronation.
368
Figure 8.4 A. Neutral scapula orientation. B. Scapula inferior – anterior glenoid (IAG)
Segmental translatatory and global testing. Uncontrolled humeral head anterior

range specific UCM translation can be identified in motion testing. In
medial rotation, lateral rotation and extension
When direction-specific UCM is observed at the movements of the shoulder, palpation of the ante-
shoulder, it can present in two ways. The UCM rior prominence of the humeral head is used to
can present as either a segmental translatatory identify excessive anterior translation. The ability
UCM (primarily of the humeral head) or a global to maintain the neutral axis and prevent excessive
range UCM (of either the scapula or the gleno- forward glide of the anterior prominence of the
humeral joint). humeral head during active medial rotation,
lateral rotation and extension is evaluated.
Segmental translatatory UCM
This is a segmental UCM in which the humeral
head appears to ‘glide forwards’ into excessive Global range-specific UCM
anterior, inferior or posterior translatatory dis- A global range-specific UCM demonstrates UCM
placement associated with medial rotation, lateral (± hypermobile range) of the scapula or the gleno-
rotation, flexion, abduction or extension motion humeral joint. This is observed as either excessive
369
or dominant scapular or glenohumeral motion at

the initiation of the movement or hypermobile
range of motion to complete the movement.
A global range specific scapular UCM can be
identified in motion testing. In any functional
movement of the arm, observe or palpate for
uncontrolled scapular:
• downward rotation
• forward tilt
• winging
• elevation
• protraction/abduction
• retraction/adduction.
A global range-specific glenohumeral UCM can be Figure 8.5 Assessment of glenohumeral medial rotation
identified in motion testing. In any functional range with passive stabilisation
movement of the arm, observe or palpate for
uncontrolled glenohumeral medial rotation. movement or glenohumeral anterior
The following section will demonstrate the spe- translation, a significant loss of
cific procedures for testing for UCM in the shoul- glenohumeral medial rotation is often
der girdle. observed. Ideal passive range of medial
rotation is 60°. Loss of medial rotation
range may be due to several reasons:
SHOULDER GIRDLE TESTS FOR UCM
■ Capsular restriction. Capsular shortening
may contribute to a loss of medial
rotation, though this is not the most
Shoulder medial rotation control common cause. If capsular shortening is
present then there is usually a significant
loss of lateral rotation first observed as
OBSERVATION AND ANALYSIS OF less than 90° lateral rotation in
SHOULDER MEDIAL ROTATION abduction.
■ Myofascial restriction. Over-activity,
dominance and relative stiffness of the
Description of ideal pattern glenohumeral lateral rotator muscles: a
While supine or standing, with the shoulder in common presentation-related to the loss
90° of abduction (scapular plane), there is 60° of medial rotation is over-activity and
of medial rotation of the humerus without shortening of the lateral rotator muscles
significant scapula-thoracic movement or gleno- (infraspinatus and teres minor).
humeral anterior translation. Assessment of both the contractile and
The therapist passively stabilises the scapula connective tissue shortening needs to be
and glenohumeral joint and assesses the passive made and appropriate soft tissue work
range of glenohumeral rotation without compen- applied.
sation (Figure 8.5).
■ Co-contraction rigidity. Occasionally, active
medial rotation range at the
glenohumeral joint may be limited by
Movement faults associated with co-contraction rigidity. In the attempt to
glenohumeral medial rotation medially rotate, all glenohumeral muscles
co-contract excessively and seem to
Relative stiffness (restrictions) ‘splint’ the shoulder from achieving full
• Restrictions – reduced glenohumeral medial rotation. This is often a guarding
rotation with the arm abducted. When the response associated with instability or
scapula and humeral head are passively acute pathology or a protective ‘spasm’ in
supported to control scapula-thoracic an acute inflammatory episode.
370
Relative flexibility (potential UCM) the humeral head compensates for a lack
of glenohumeral medial rotation. A
• UCM – compensatory strategies associated with positive test (glenohumeral movement)
restriction of glenohumeral joint medial rotation. has been linked with instability
A variety of compensation strategies for symptoms and risk (Morrissey 2005).
restrictions can be employed to maintain
functional range of motion. If glenohumeral
medial rotation is restricted, compensatory Indications to test for shoulder
movement can be made at both the scapula medial rotation UCM
and the humeral head (Sahrmann 2002;
Morrissey 2005). Observe or palpate for:
■ Uncontrolled scapula forward tilt, downward 1. hypermobile medial rotation range
rotation or elevation. The scapula may 2. discrepancies of shoulder medial rotation
forward tilt, downwardly rotate or elevate range in different positions of arm elevation
to compensate for the loss of medial 3. excessive initiation of scapular compensation
rotation. The accuracy of this palpation during shoulder medial rotation
has been validated with three- 4. excessive glenohumeral translation during
dimensional ultrasound and motion medial rotation
analysis measures (Morrissey et al 2008). 5. symptoms (pain, discomfort, strain)
A positive test (scapula movement) has associated with shoulder medial rotation
been linked with risk of impingement movements.
and symptoms (Morrissey 2005). The test The person complains of rotation-related symp-
is useful for diagnosis, especially for toms in the shoulder. During shoulder medial
impingement, particularly when used rotation load or movements, the scapula or gleno-
with other impingement tests (Morrissey humeral joint has greater ‘give’ or compensation
2005). relative to the trunk or arm. The dysfunction is
■ Uncontrolled glenohumeral translation confirmed with motor control tests of shoulder
control. Excessive anterior translation of medial rotation dissociation.
371
test position is in standing with or without wall

Test of shoulder medial rotation support of the scapula.
control
Rating and diagnosis of shoulder

T60 KINETIC MEDIAL ROTATION
girdle UCM
TEST (KMRT)
(tests for scapula and glenohumeral (T60.1 and T60.2)
These UCMs have been linked to pathology.
UCM) The scapula may forward tilt, downwardly rotate
or elevate to compensate for the loss of medial
This dissociation test assesses the ability to actively rotation. A positive test (scapula UCM) has been
dissociate and control scapula movement and linked with risk of impingement and symptoms
glenohumeral translation during glenohumeral (Morrissey 2005). The test is useful for diagnosis,
medial rotation. especially for impingement, particularly when
used with other impingement tests (Morrissey
Test procedure 2005). Uncontrolled anterior translation of
the humeral head compensates for a lack of
Start supine and with the humerus in 90° abduc- glenohumeral medial rotation. A positive test
tion (hand to the ceiling), and the humerus sup- (glenohumeral UCM) has been linked with insta-
ported in the plane of the scapula. The therapist bility symptoms and risk (Morrissey 2005)
palpates the coracoid and humeral head during (T60.3).
the procedure (Figure 8.6). The accuracy of this
palpation has been measured (Morrissey et al
2008). Medial rotation of the humerus should Correction
occur without compensation at the scapula or With visual, auditory and kinaesthetic cues the
glenohumeral joint. The scapula should not move person becomes familiar with the task of medi-
into forward tilt, downward rotation or elevation ally rotating the glenohumeral joint to 60°
and the humeral head should not translate ante- without scapula movement or glenohumeral
riorly (Morrissey 2005). There should be 60° of translation. Some useful clinical cues are illus-
active medial rotation (Figure 8.7). An alternative trated in Box 8.2.
Figure 8.7 Benchmark kinetic medial rotation test – ideal

Figure 8.6 Start position kinetic medial rotation test movement
372
T60.1 Assessment and rating of low threshold recruitment efficiency of the Kinetic Medial Rotation Test
T60.2 Diagnosis of the site and direction of UCM from the Kinetic Medial Rotation Test
KINETIC MEDIAL ROTATION TEST

Site Direction (L) (R)
Scapula Forward tilt ! !
Downward rotation ! !
Elevation ! !
Glenohumeral Anterior translation ! !
373
T60.3 Relating the site and direction of UCM to impingement and instability
RISK ASSOCIATED WITH THE KINETIC MEDIAL ROTATION TEST

Ideal 60° glenohumeral medial rotation without scapula movement or humeral anterior
translation. No anterior displacement of coracoid or humeral head (Figure 8.7)
Impingement risk Scapular forward tilt, downward rotation or elevation occurs before 60° glenohumeral
medial rotation is achieved. Note anterior displacement of coracoid with (stable) humeral
head ‘tagging along’ in proportion (Figure 8.8)
• Confirm the impingement risk with impingement tests and palpation
Instability risk Humeral head anterior translation occurs before 60° glenohumeral medial rotation is
achieved. Note anterior displacement of humeral head with (stable) coracoid maintaining
stable position (Figure 8.9)
• Confirm the direction(s) of instability with instability tests
Combined impingement Scapular forward tilt, downward rotation or elevation occurs before 60° glenohumeral
and instability risk medial rotation is achieved. However, excessive humeral head anterior translation also
occurs before 60° glenohumeral medial rotation is achieved. Note anterior displacement of
coracoid with the humeral head moving even further forward of the (unstable) coracoid
• Differentiate to determine whether symptoms are primarily due to impingement or
instability
Box 8.2 Useful clinical facilitation and

retraining cues
Cues for facilitation and feedback to

enhance teaching and retraining movement
• Palpate the scapula or glenohumeral joint to monitor
the UCM.
• Imagery of rotating the glenohumeral joint about a
coronal axis (proprioceptive feedback can be given
through olecranon).
• Keep the coracoids open and wide.
• Palpate acromion/coracoid.
• Visualise a string holding the acromion up.
• Unload passively. Figure 8.8 Kinetic medial rotation test uncontrolled scapula
• Tape (proprioceptive skin tension). movement
• Keep same distance between coracoid and ear.
• Keep shoulder blades wide.
An alternative position for retraining the KMRT wall. Only rotate the shoulder forwards as far as
Lean against a wall with the wall supporting the the neutral scapula can be controlled (Figure
shoulder blade position. The upper body has to 8.10). When rotation control on the wall is effi-
turn 15–30° off the wall so that the shoulder cient progress to the same movement unsup-
blade and upper arm can be supported flat on the ported away from the wall (Figure 8.11).
374
Figure 8.9 Kinetic medial rotation test uncontrolled

glenohumeral movement
Figure 8.11 Correction standing – unsupported
Figure 8.10 Correction with wall support
375
Shoulder lateral rotation control

SHOULDER LATERAL ROTATION

This can be observed in standing or supine. While
standing with the humerus by the side in the
scapular plane (elbow forward of the anterior
axillary line) and the elbow flexed to 90° (hand
pointing forwards, palm in) there should be
approximately 60° range of functional lateral
turn out of the arm – at least 45° being gleno-
humeral lateral rotation and about 15° coming
from scapular retraction. The glenohumeral
lateral rotation should be the dominant move-
ment early in the movement with the scapula
contributing later in range.
The therapist assesses the passive range of
glenohumeral lateral rotation. There should be
45° of independent passive lateral rotation. It
should be relatively easy to independently dis- Figure 8.12 Assessment of glenohumeral lateral rotation
sociate the 45° glenohumeral lateral rotation range with passive stabilisation
from the scapular movement (Figure 8.12).
Movement faults associated with Examination of the shoulder ‘quadrant’

test (Maitland et al 2005) would be
glenohumeral lateral rotation positive for a capsular restriction. If at
Scapular retraction initiates or dominates the 90° of arm abduction the lateral rotation
early range of functional arm turn out. This indi- range is normal then the capsule is a very
cates either a restriction (relative stiffness) of unlikely source of restriction.
glenohumeral lateral rotation or compensation ■ Loss of posterior translation of the humerus
(relative flexibility) of scapular retraction. at limit of lateral rotation. At the limit of
active or passive glenohumeral lateral
rotation the capsule tensions anteriorly
Relative stiffness (restriction) and the humeral head is forced to
• Reduced glenohumeral lateral rotation with the translate posteriorly in order to achieve
elbow by side. Functional restrictions of full range (Moseley et al 1992; Wilk et al
glenohumeral lateral rotation are identified 1997). A loss of this posterior translation
with the scapula stabilised and the arm by of the humeral head at the limit of lateral
the side. A significant loss of glenohumeral rotation can significantly reduce the
lateral rotation with the arm by the side is ability to achieve full active or passive
frequently identified. This restriction of lateral rotation at the shoulder when the
functional lateral rotation range may be due arm is by the side. This is identified by a
to several reasons: decreased range of joint play and a
■ Capsular restriction. A capsular restriction restricted end feel on posterior translation
may cause a loss of lateral rotation with of the humeral head at end range lateral
the arm by the side but there will be rotation. Appropriate mobilisation of
significant (if not greater) loss of lateral this articular restriction (e.g. with
rotation with the arm elevated to 90°. glenohumeral accessory anteroposterior
376
glides at the limit of physiological lateral alignment the active lateral rotation
rotations) is often appropriate here. movement returns to normal.
■ Loss of extensibility of myofascial structures. ■ Uncontrolled scapula forward tilt. This is
It may be possible that excessive similar to the above. If the glenoid is
shortening of myofascial structures may orientated antero-inferiorly, lateral
limit lateral rotation range. Pectoralis rotation can be limited. This is confirmed
major and latissimus dorsi may limit by passively positioning the scapula in
lateral rotation with the arm high correct alignment. When the scapula (and
overhead but for lateral rotation to be glenoid) is in neutral alignment the active
limited when the arm is by the side, lateral rotation movement returns to
subscapularis and teres major are likely to normal.
be very short. Clinically, this is ■ Uncontrolled glenohumeral anterior
uncommon but may be associated with a translation. The apparent loss of lateral
prolonged period of immobilisation, rotation may be related to an unstable
surgery and capsular shortening. glenohumeral joint. If the glenohumeral
■ Co-contraction rigidity. Occasionally, active joint has excessive anterior translation
lateral rotation range at the glenohumeral (due to anterior capsular laxity or
joint may be limited by co-contraction instability) then the axis of rotation is
rigidity. This is often a guarding response displaced and normal lateral rotation
associated with instability or acute cannot be achieved. If the humeral head
pathology or protective ‘spasm’ in an is palpated with the shoulder resting at
acute inflammatory episode. end range lateral rotation it is observed to
• UCM – compensatory strategies associated be prominent anteriorly. Upon
with restriction of glenohumeral joint lateral assessment of a posterior translational
rotation. If lateral rotation is restricted, glide in this position, a significantly
different compensation strategies can be increased range of joint play and a lax
seen: soft end feel is identified. This cause of
■ Uncontrolled scapula retraction (scapular dysfunction is confirmed if full lateral
retraction initiating or dominating rotation range returns when the humeral
glenohumeral lateral rotation). This can be head is passively glided posteriorly and
assessed in standing with the arm by the maintained in its neutral position.
side. This is most frequently associated
with a functional loss of glenohumeral Indications to test for shoulder
lateral rotation range and the lateral rotation UCM
development of greater relative flexibility
at the scapulothoracic joint. Instead of
scapular retraction providing extra 1. hypermobile lateral rotation range
movement after the glenohumeral joint 2. discrepancies of shoulder lateral rotation
has completed lateral rotation, scapular range in different positions of arm elevation
retraction increases to compensate for the 3. excessive initiation of scapular compensation
inefficient glenohumeral movement. In during shoulder lateral rotation
extreme cases the recruitment of scapular 4. excessive glenohumeral translation during
retraction even precedes the recruitment lateral rotation
of glenohumeral lateral rotation. 5. symptoms (pain, discomfort, strain)
■ Uncontrolled scapula downward rotation. associated with shoulder lateral rotation
The apparent loss of lateral rotation is movements.
very commonly due to a lack of ability to The person complains of rotation-related symp-
position the glenoid in neutral alignment. toms in the shoulder. During shoulder lateral
If the glenoid is downwardly rotated then rotation load or movements, the scapula or gleno-
lateral rotation can be limited. This is humeral joint has greater ‘give’ or compensation
confirmed by passively positioning the relative to the trunk or arm. The dysfunction is
scapula in correct alignment. When the confirmed with motor control tests of shoulder
scapula (and glenoid) is in neutral lateral rotation dissociation.
377
KLRT Part 1
Test of shoulder lateral rotation
control Start standing, with the elbow by the side in
the scapular plane (elbow forward of the anterior
axillary line) and the elbow flexed to 90°
T61 KINETIC LATERAL ROTATION (hand pointing forwards, palm in (Figure 8.13).
TEST (KLRT) The therapist palpates the corocoid/acromion
(or inferior angle of scapula) and humeral head
(tests for scapula and glenohumeral during the procedure. The person is instructed
UCM) to maintain a neutral position of the scapula
and turn the arm out into lateral rotation. The
This dissociation test assesses the ability to actively scapula should not move into forward tilt,
dissociate and control scapula movement and downward rotation or retraction and the
glenohumeral translation from the glenohumeral humeral head should not translate anteriorly.
lateral rotation. There should be 45° of active lateral rotation of
the humerus without compensation at the
scapula or glenohumeral joint (Figures 8.14
Test procedure and 8.15).
This is a two-part test.
Figure 8.13 Start position kinetic lateral rotation test Figure 8.14 Benchmark kinetic lateral rotation test
378
glenoid in neutral alignment. This is confirmed

by passively positioning the scapula in upward
rotation and observing that when the scapula
(and glenoid) is in correct alignment the active
lateral rotation movement returns to normal
(Figure 8.16).
Glenohumeral UCM
The apparent loss of lateral rotation may be
related to an unstable glenohumeral joint. If
the glenohumeral joint has excessive anterior
translation (due to anterior capsular laxity
or instability) then the axis of rotation is dis-
placed and normal lateral rotation cannot be
achieved. This cause of dysfunction is confirmed
if full lateral rotation range returns when the
humeral head is passively glided posteriorly
and maintained in its correct position (Figure
8.17).
Shoulder girdle control

dysfunction
During active glenohumeral lateral rotation to
45° benchmark range, the subject is unable to
maintain control of either:
• scapula forward tilt, downward rotation or
retraction
Figure 8.15 Kinetic lateral rotation test demonstrating good • glenohumeral anterior translation.
scapula control
KLRT Part 2 Rating and diagnosis of shoulder

Position the person supine, with the elbow by the girdle UCM
side in the scapular plane (elbow forward of the (T61.1 and T61.2)
anterior axillary line) and the elbow flexed to 90° These UCMs may be linked to pathology. A
(hand pointing forwards, palm in). There should positive test for scapula UCM may be linked with
be 45° of active lateral rotation of the humerus risk of impingement and symptoms. The test is
when the scapula is stabilised by lying on it. If useful for diagnosis, especially for impingement,
there is a restriction of lateral rotation in this particularly when used with other impingement
position the therapist must determine if the tests. A positive test of glenohumeral UCM may
restriction is real or if it is the result of uncon- be linked with instability symptoms and risk
trolled scapula or glenohumeral movement. (T61.3).
Differentiation between scapular Correction

and glenohumeral contributions Initial correction can be performed lying in
to apparent restricted range supine with the arm supported by the side.
Active lateral rotation is performed through
Scapular UCM partial range with the scapula stabilised in upward
The apparent loss of lateral rotation is very com- rotation (lying on scapula) and the humeral head
monly due to a lack of ability to position the stabilised in posterior glide (self-palpation)
379
T61.1 Assessment and rating of low threshold recruitment efficiency of the Kinetic Lateral Rotation Test
T61.2 Diagnosis of the site and direction of UCM from the Kinetic Lateral Rotation Test
KINETIC LATERAL ROTATION TEST

Scapula Forward tilt ! !
Downward rotation ! !
Retraction ! !
380
T61.3 Relating the site and direction of UCM to impingement and instability
RISK ASSOCIATED WITH THE KINETIC LATERAL ROTATION TEST

Ideal 45° glenohumeral lateral rotation without scapula movement or humeral anterior translation. No
anterior displacement of coracoid or humeral head (Figure 8.18)
Impingement risk A significant restriction of shoulder lateral rotation is noted (Figure 8.19). Manual passive
repositioning of the scapula in upward rotation and backward tilt (correction of resting position of
excessive downward rotation/forward tilt) results in ability to actively produce the full benchmark
range of 45° lateral rotation (Figure 8.20)
• Confirm scapular control dysfunction by passively positioning the scapula back into downward
rotation and forward tilt and observe a significant reduction in active shoulder lateral rotation
range
• Confirm the impingement risk with impingement tests and palpation
Instability risk A significant restriction of shoulder lateral rotation is noted (Figure 8.21). Manual passive
repositioning of the humeral head into posterior translation with light manual posterior pressure
from two fingers (correction of resting position of excessive anterior translation) results in ability to
actively produce the full benchmark range of 45° lateral rotation (Figure 8.22)
• Confirm glenohumeral translation control dysfunction by passively positioning the humeral
head back into anterior translation and observe a significant reduction in active shoulder lateral
rotation range
• Confirm the direction(s) of instability with instability tests
Figure 8.16 Passive restabilisation of scapula into upward Figure 8.17 Passive restabilisation of humeral head with
rotation to confirm if uncontrolled movement contributes to posterior glide to confirm if uncontrolled movement
restricted functional range contributes to restricted functional range
381
Figure 8.18 Kinetic lateral rotation test – ideal active control
Figure 8.20 Kinetic lateral rotation test (scapular UCM)

– increased lateral rotation with scapular repositioning
Figure 8.19 Kinetic lateral rotation test (scapular UCM)

– restricted lateral rotation with scapular downward rotation
382
Figure 8.21 Kinetic lateral rotation test (humeral UCM) Figure 8.22 Kinetic lateral rotation test (humeral UCM)
– restricted lateral rotation with humeral head forward – increased lateral rotation with humeral head repositioning
displacement
Figure 8.23 Correction partial range lateral rotation with

scapula and glenohumeral support
(Figure 8.23). An alternative position for retrain- Box 8.3 Useful clinical facilitation and
ing the KMLT is to lean against a wall with the retraining cues
wall supporting the shoulder blade position. The
upper body has to turn 15–30° off the wall so Cues for facilitation and feedback to
that the shoulder blade and upper arm can be enhance teaching and retraining movement
supported flat on the wall. Only rotate the shoul- • Palpate the scapula or glenohumeral joint to monitor
der backwards as far as the neutral scapula can be the UCM.
controlled (Figure 8.24). As control improves, the • Imagery of rotating the glenohumeral joint about a
active lateral rotation is performed in standing coronal axis (proprioceptive feedback can be given
with the scapula and humeral head unsupported through olecranon).
(Figure 8.25). With visual, auditory and kinaes- • Keep the coracoids open and wide.
thetic cues the person becomes familiar with the • Palpate acromion/coracoid/inferior angle.
task of laterally rotating the glenohumeral joint • Visualise a string holding the acromion up.
to 45° without scapula movement or gleno- • Unload passively.
humeral translation. Some useful clinical cues are • Tape (proprioceptive skin tension).
illustrated in Box 8.3. • Keep same distance between coracoid and ear.
383
Figure 8.24 Correction with wall support Figure 8.25 Correction partial range lateral rotation with
unsupported shoulder girdle
384
elevation with the scapula relatively stable. This

Shoulder flexion control should occur through approximately the first 90°
of flexion. Medial rotation of the arm should not
be excessive during flexion. Humeral head infe-
rior translation should start in this phase. The
SHOULDER FLEXION second phase is dominated by upward rotation of
the glenoid of the scapula (associated with slight
Description of ideal pattern scapular elevation) with concurrent glenohumeral
rolling into arm elevation. Clavicular rotation is
Throughout arm elevation overhead, the normal necessary for full and appropriate scapular rota-
scapulohumeral rhythm is approximately tion. The head of the humerus should continue
humzzeral: scapula movement of a ratio 2 : 1 or to glide inferiorly on the glenoid during this
3 : 2. During elevation three distinct processes phase. There should not be excessive elevation or
should occur: protraction of the scapula during flexion. After
1. glenohumeral elevation 160° of arm elevation some slight trunk move-
2. upward rotation of the glenoid and slight ment may occur, but this should be minimal and
scapular elevation should only occur towards the end of gleno-
3. slight trunk movement. humeral and scapular movement. Thoracic exten-
Although both glenohumeral and scapular sion occurs during arm flexion and thoracic
movement should occur simultaneously, the first lateral flexion occurs during unilateral arm
phase predominantly consists of glenohumeral flexion. The scapula should not wing during con-
centric or eccentric movement and any protrac-
tion should be minimal. In full arm elevation/
flexion the inferior angle of the scapula should
not protrude any further than 1.5 cm laterally
from the chest wall but should rotate around the
chest wall to reach the mid-axillary line (Figures
8.26 and 8.27).

arm flexion
These faults can be observed with the natural
pattern of thoraco-scapulohumeral motion
through the full range of arm flexion overhead.
Dysfunctions of scapulothoracic
control
• Uncontrolled scapula downward rotation. This
presents as dominance of scapular downward
rotation and/or inefficient upward rotation
and may be observed in several ways:
■ At the initial part of the scapular
movement phase the scapula downwardly
rotates instead of upwardly rotating. This
is observed with medial movement of the
inferior angle before it moves laterally.
■ Reduced upward rotation of the scapula at
the completion of the scapular movement
phase. This is observed as a lack of lateral
Figure 8.26 Shoulder flexion overhead – lateral view movement of scapular inferior angle – it
385
noticeable dominance or shortening of the down-

ward rotators (rhomboids, pectoralis minor and
levator scapula) and poor stabilisation and
control of upward rotation (poor stability func-
tion of trapezius and serratus anterior).
• Uncontrolled scapular elevation (overhead)

– scapular elevation is uncontrolled or initiates
movement during flexion. This is associated
with inefficient lower trapezius activity to
counterbalance the scapular elevators
(particularly rhomboids and levator scapula)
during arm flexion. Elevation of the scapula
is the dominant motion instead of upward
rotation. This is most evident at the limit of
overhead flexion.
• Uncontrolled scapular protraction during flexion.
This is associated with inefficient scapular
stabiliser (middle and lower trapezius)
activity to counterbalance the scapular
protractors (serratus anterior and an
overactive pectoralis minor) during arm
flexion. Protraction (and elevation) of the
scapula is the dominant motion instead of
upward rotation. This is most evident during
eccentric lowering when the scapula is held
forwards in protraction throughout most of
the movement and suddenly ‘flicks’ back in
the last 45° of lowering.
• Uncontrolled scapular winging (prominence of
Figure 8.27 Shoulder flexion overhead – back view the entire medial border of the scapula off the
rib cage):
■ During concentric elevation of the arm
and at rest in static posture: associated
does not reach the mid-axillary line in with an inefficient of serratus anterior.
elevation. This is often associated with ■ During eccentric lowering of the arm:
shortness and relative stiffness in the timing problem associated with the
rhomboids and pectoralis minor (which scapulohumeral muscles not relaxing as
restrict upward rotation) and inefficient quickly as the scapulo-trunk muscles. The
serratus anterior (which cannot upwardly scapulohumeral muscles are relatively
rotate the scapula). stiffer and the glenohumeral muscles
■ During eccentric lowering of the arm and relatively more flexible.
the scapula there is uncontrolled ■ During upper limb weight bearing:
downward rotation of the scapula. This is associated with ‘long’ and inefficient
observed as either the scapula in a medial scapular stabilisers and serratus
downwardly rotated position by 90° anterior.
flexion or the inferior angle travelling • Uncontrolled scapular forward tilt. Observe
medially beyond the ‘normal resting prominence of the inferior angle of the
position’ of the scapula as the arm scapula or protrusion off the lower rib cage,
returns to the side (Mottram et al 2009a). often with concurrent downward rotation of
Uncontrolled downward rotation of the scapula the scapula. This is associated with excessive
is associated with either length or recruitment shortness of pectoralis minor and downward
changes in the scapular rotator muscles. There is rotation of the scapula with a concurrent
386
loss of upward rotation position and poor increased compensatory glenohumeral

control by lower trapezius and serratus inferior translation. Observe deep posterior
anterior. acromial depression or ‘dimple’ instead of a
small skin crease when the arm is in full
elevation and a ‘bulge’ of the humeral head
Dysfunctions of glenohumeral
is in the axilla.
control
• Uncontrolled glenohumeral medial rotation
during arm flexion. During flexion Indications to test for shoulder
uncontrolled medial rotation occurs. As a flexion UCM
rough guide, the arm should be in neutral
rotation (thumb forwards) when the hand
rests by the side, and as the arm flexes it 1. hypermobile flexion range
should stay neutral and not medially rotate. 2. excessive initiation of scapular compensation
Medial rotation is associated with over- during shoulder flexion
activity and dominance of the medial rotator 3. excessive glenohumeral translation during
muscles (pectoralis major or latissimus shoulder flexion
dorsi) or shortness of latissimus dorsi 4. symptoms (pain, discomfort, strain)
resulting in the arm being forced into medial associated with shoulder flexion movements.
rotation to achieve the full overhead The person complains of flexion-related symp-
position. toms in the shoulder. During shoulder flexion
• Uncontrolled glenohumeral inferior translation load or movements, the scapula or glenohumeral
– excessive inferior translational glide of the joint has greater ‘give’ or compensation relative to
humerus during overhead elevation. Inadequate the trunk or arm. The dysfunction is confirmed
upward rotation of the scapula and poor with motor control tests of shoulder flexion
glenohumeral rotation timing often result in dissociation.
387
arm through 90° of shoulder flexion and lower

Test of shoulder flexion control the arm back to the side (Figure 8.29). Ideally, the
scapula should maintain the neutral position and
not elevate during lifting into 90° flexion or drop
T62 ARM FLEXION TEST
into downward rotation, forward tilt or depres-
(tests for scapula and glenohumeral sion during lowering back to the side.
UCM) There should be no winging. The neutral rota-
tion (palm in, thumb up) should be maintained.
This dissociation assesses the ability to actively UCM can be monitored by observation or palpa-
dissociate and control scapula movement and tion: dropping of the acromion (downward rota-
glenohumeral medial rotation during gleno- tion); the coracoid moving inferiorly and the
humeral flexion. inferior angle moving posteriorly (forward tilt);
the medial border of the scapula lifting off the
chest (winging); and hitching of the acromion
Test procedure (elevation).
The subject stands with the arm resting by the
side with the scapula in a neutral position and Rating and diagnosis of shoulder
the glenohumeral joint in neutral rotation (palm girdle UCM
in) (Figure 8.28). The subject is instructed to keep
the scapula in the neutral position and lift the (T62.1 and T62.2)
Figure 8.28 Start position arm flexion test Figure 8.29 Benchmark arm flexion test
388
T62.1 Assessment and rating of low threshold recruitment efficiency of the Arm Flexion Test
T62.2 Diagnosis of the site and direction of UCM from the Arm Flexion Test
ARM FLEXION TEST

Scapula Downward rotation ! !
Forward tilt ! !
Winging ! !
Elevation ! !
Protraction/abduction ! !
Glenohumeral Medial rotation ! !
389
Figure 8.30 Correction with wall support Figure 8.31 Correction arm flexion with self-palpation
Correction Box 8.4 Useful clinical facilitation and

Initial correction can be performed standing with retraining cues
the elbow flexed to reduce the arm lever length
and decrease load and the scapula supported by Cues for facilitation and feedback to
leaning against a wall (Figure 8.30). As control enhance teaching and retraining movement
improves, the arm flexion is performed unsup- • Palpate the scapula or glenohumeral joint to monitor
ported through the partial range that can be con- the UCM.
trolled well with self-palpation. This is eventually • Imagery of lifting the shoulder blade as the arm
progressed throughout the full benchmark range lowers.
with the elbow straight (Figure 8.31). With visual, • Turn the hand (palm in) and follow the thumb
auditory and kinaesthetic cues the person overhead.
becomes familiar with the task of flexing the • Keep the coracoids open and wide.
glenohumeral joint to 90° without scapula move- • Palpate acromion/coracoid/inferior angle.
ment or glenohumeral translation. Some useful • Visualise a string holding the acromion up.
clinical cues are illustrated in Box 8.4. • Unload passively.
• Tape (proprioceptive skin tension).
390
should continue throughout range. Slight thor-

Shoulder abduction control acic lateral flexion occurs during unilateral arm
abduction (Figures 8.32, 8.33, 8.34).
SHOULDER ABDUCTION Movement faults associated with
arm abduction
Description of ideal pattern These faults can be observed with the natural
Observe the natural patterns of thoraco- pattern of thoraco-scapulohumeral motion
scapulohumeral motion through the full range of through the full range of arm abduction
arm abduction overhead in the scapular plane. overhead.
The ideal pattern is similar for flexion (see previ-
ous section) but there are a few points specific Dysfunctions of scapulothoracic
to abduction. Although both glenohumeral and
control
scapula movement should occur simultaneously,
the first phase should predominantly consist of • Uncontrolled scapular downward rotation.
glenohumeral elevation with the scapula rela- This presents as dominance of scapular
tively stable through the first 60° of movement downward rotation and/or inefficient upward
in abduction. During abduction, glenohumeral rotation and is described above in the
lateral rotation is initiated early in this phase and flexion pattern.
Figure 8.33 Shoulder abduction mid-range with

Figure 8.32 Shoulder resting position glenohumeral lateral rotation
391
control
• Uncontrolled glenohumeral rotation – late or
absent glenohumeral lateral rotation during arm
abduction. During abduction the required
lateral rotation movement is absent or late.
The arm should be in neutral rotation
(thumb forwards) when the hand rests
by the side and should actively laterally
rotate the greater tuberosity posteriorly
throughout the range of abduction. As a
rough guide, by 60° the thumb should start
to turn upwards. By at least 120° the thumb
should point to the ceiling and by 180° the
thumb should point posteriorly and the
palms face in towards each other. If the
palms face down to the floor and the
thumbs point forwards at 90° the lateral
rotation timing is late.
• Uncontrolled glenohumeral inferior translation
– excessive inferior translational glide of the
humerus during overhead elevation. Inadequate
upward rotation of the scapula and poor
glenohumeral rotation timing often result in
increased compensatory glenohumeral
inferior translation. Observe deep posterior
acromial dimple instead of a small skin
crease when the arm is in full elevation and
there is a ‘bulge’ of the humeral head in the
Figure 8.34 Shoulder abduction overhead with axilla.
glenohumeral lateral rotation
Indications to test for shoulder

• Uncontrolled scapular elevation (overhead) abduction UCM
– scapular elevation is excessive or initiates
movement during abduction. This presents
more consistently in the full overhead 1. hypermobile abduction rotation range
position (above 140°). With the arms fully 2. excessive initiation of scapular compensation
overhead, when the person is asked to relax during shoulder abduction
their shoulders but keep their hands fully 3. excessive glenohumeral translation during
overhead, the scapula drops from an shoulder abduction
excessively elevated position. 4. symptoms (pain, discomfort, strain)
• Uncontrolled scapular winging (prominence of associated with shoulder abduction
the entire medial border of the scapula off the movements.
rib cage). This presents most consistently The person complains of abduction-related symp-
during eccentric lowering of the arm from toms in the shoulder. During shoulder abduction
overhead. load or movements, the scapula or glenohumeral
• Uncontrolled scapular forward tilt (’tipping’ of joint has greater ‘give’ or compensation relative to
the scapula). This presents most consistently the trunk or arm. The dysfunction is confirmed
during eccentric lowering of the arm from with motor control tests of shoulder abduction
overhead. dissociation.
392
depression during lowering back to the side. The

Test of shoulder abduction control arm should start active lateral rotation through
this range (palm starting to turn forwards should
be maintained (Figure 8.36).
T63 ARM ABDUCTION TEST
(tests for scapula and glenohumeral
UCM)
girdle UCM
This dissociation assesses the ability to actively (T63.1 and T63.2)
dissociate and control scapula movement and
glenohumeral medial rotation during gleno- Correction
humeral flexion. Initial correction can be performed standing with
the elbow flexed to reduce the arm lever length
and decrease load and the scapula supported by
Test procedure
leaning against a wall (Figure 8.37). As control
The subject stands with the arm resting by the improves the arm abduction is performed unsup-
side in neutral rotation (palm in towards the ported through the partial range that can be con-
side) and with the scapula in a neutral position. trolled well with self-palpation (Figure 8.38).
The subject is instructed to keep the scapula in This is eventually progressed throughout the full
the neutral position and lift the arm through 90° benchmark range with the elbow straight.
of shoulder abduction (in the scapula plane) and With visual, auditory and kinaesthetic cues the
lower the arm back to the side (Figure 8.35). person becomes familiar with the task of abduct-
Ideally, the scapula should maintain the neutral ing the glenohumeral joint to 90° without scapula
position and not elevate during lifting into 90° movement or glenohumeral translation. Some
abduction or drop into downward rotation or useful clinical cues are illustrated in Box 8.5.
Figure 8.35 Start position arm abduction test Figure 8.36 Benchmark arm abduction test
393
T63.1 Assessment and rating of low threshold recruitment efficiency of the Arm Abduction Test
T63.2 Diagnosis of the site and direction of UCM from the Arm Abduction Test
ARM ABDUCTION TEST

Forward tilt ! !
Winging ! !
Elevation ! !
Glenohumeral Medial rotation ! !
394
Figure 8.37 Correction with wall support Figure 8.38 Correction arm abduction with self-palpation
Box 8.5 Useful clinical facilitation and retraining cues
Cues for facilitation and feedback to enhance • Keep the coracoids open and wide.
teaching and retraining movement • Palpate acromion/coracoid/inferior angle.
• Palpate the scapula or glenohumeral joint to monitor • Visualise a string holding the acromion up.
the UCM. • Unload passively.
• Imagery of lifting the shoulder blade as the arm lowers. • Tape (proprioceptive skin tension).
• Turn the hand to ensure lateral rotation throughout • Keep same distance between coracoid and ear.
range. • Keep shoulder blades wide.
395
Shoulder extension control

SHOULDER EXTENSION

Observe the natural patterns of thoraco-
scapulohumeral motion through the full range of
arm extension. Although both glenohumeral and
scapula movement should occur simultaneously,
the first phase should predominantly consist of
glenohumeral extension with the scapula rela-
tively stable through the first 15° of movement
in extension. Medial rotation should not be exces-
sive during extension. Some humeral anterior
translation should start in this phase, but should
not be excessive.
The second phase is dominated by retraction of
the scapula. Thoracic flexion occurs towards the
end of bilateral arm extension and thoracic rota-
tion occurs towards the end of unilateral arm
extension.
The scapula should not rotate downwardly or
tilt forwards during concentric or eccentric move-
ment and retraction should occur later in range.
In full extension, no more than one-third of the
anterior humeral head should protrude forward
of the anterior edge of the acromion (Sahrmann Figure 8.39 Shoulder extension
2002). Thoracic movement should not initiate or
dominate arm extension (Figure 8.39).
• Uncontrolled scapular retraction –

Movement faults associated with scapular retraction initiating or dominating
extension glenohumeral extension. This is most
frequently associated with a functional loss
Dysfunction of scapula-thoracic control of extensibility of the posterior shoulder
• Uncontrolled scapular downward rotation. muscle (infraspinatus and teres minor) and
Uncontrolled downward rotation may occur the development of greater relative flexibility
before the end of arm extension. This is at the scapulothoracic joint. Instead of
observed with medial movement of the scapular retraction providing extra movement
inferior angle as the arm moves behind after the glenohumeral joint has completed
midline trunk. This is associated with extension, scapular retraction increases to
either length or recruitment changes in compensate for the inefficient glenohumeral
the scapular rotator muscles. There is movement. In some instances the
noticeable dominance or shortening of the recruitment of scapular retraction is observed
downward rotators (rhomboids, pectoralis before the arm extends past the neutral
minor and levator scapula) and poor midline of the trunk.
stabilisation control of upward rotation • Uncontrolled scapular winging – true
(inefficient function of trapezius and serratus winging of the scapula. Winging is
anterior). observed with prominence of the entire
396
medial border of the scapula lifting off the arm should be in neutral rotation (thumb
rib cage: forwards) when the hand rests by the side,
■ During concentric elevation of the arm and as the arm extends it should stay neutral
and at rest in static posture: associated and not medially rotate. Uncontrolled or
with poor function of serratus anterior. excessive medial rotation is often associated
■ During extension from a flexed position with dominance of the latissimus dorsi.
of the arm: timing problem associated • Uncontrolled glenohumeral anterior translation.
with the scapulohumeral muscles not Uncontrolled anterior translation of the
relaxing as quickly as the scapulothoracic humeral head often develops to compensate
muscles. for a lack of glenohumeral extension or
■ During upper limb weight bearing in restricted glenohumeral lateral rotation
extension (e.g. push off the armrests of a during extension.
chair): associated with inefficient medial
scapular stabilisers and serratus anterior.
• Uncontrolled scapular forward tilt – forward tilt Indications to test for shoulder
of the scapula (or ‘tipping’ of the scapula). extension UCM
Forward tilt is observed as prominence of the Observe or palpate for:
inferior angle of the scapula lifting off the
lower rib cage and often combined with 1. hypermobile extension range
downward rotation of the scapula taking the 2. excessive initiation of scapular compensation
glenoid into an anterior inferior position. during shoulder extension
This is most frequently associated with 3. excessive glenohumeral translation during
excessive shortness of pectoralis minor and shoulder extension
downward rotation of the scapula with a 4. symptoms (pain, discomfort, strain)
concurrent loss of upward rotation position associated with shoulder extension
and poor control by lower trapezius and movements.
serratus anterior; and the development of The person complains of extension-related symp-
greater relative flexibility at the toms in the shoulder. During shoulder extension
scapulothoracic joint. Instead of scapular load or movements, the scapula or glenohumeral
retraction providing extra movement after joint has greater ‘give’ or compensation relative to
the glenohumeral joint has completed the trunk or arm. The dysfunction is confirmed
extension, scapular retraction increases to with motor control tests of shoulder extension
compensate for the inefficient glenohumeral dissociation.
movement.
control
• Uncontrolled glenohumeral medial rotation.
During extension, uncontrolled medial
rotation may occur. As a rough guide, the
397
shoulder extension and return the arm back to

Test of shoulder extension control the side (Figure 8.41). Ideally, the scapula should
maintain the neutral position and not elevate or
forward tilt during extension or drop into down-
T64 ARM EXTENSION TEST
ward rotation or retract during the return back to
(tests for scapula and glenohumeral the side. The glenohumeral joint should not dem-
UCM) onstrate palpable anterior translation. The arm
should increase medial rotation. It should start in
This dissociation test assesses the ability to actively neutral rotation (palm in) and should stay in
dissociate and control scapula movement and neutral rotation throughout this movement.
glenohumeral translation and rotation during
glenohumeral extension.
girdle UCM
Test procedure
(T64.1 and T64.2)
The subject stands with the arm resting by the
side in neutral rotation (palm in towards the
side) and with the scapula in a neutral position Correction
(Figure 8.40). The subject is instructed to keep the Initial correction can be performed standing with
scapula and glenohumeral joint in the neutral the elbow flexed to reduce the arm lever length
position and move the arm through 15° of and decrease load, and with the scapula
Figure 8.40 Start position arm extension test Figure 8.41 Benchmark arm extension test
398
T64.1 Assessment and rating of low threshold recruitment efficiency of the Arm Extension Test
T64.2 Diagnosis of the site and direction of UCM from the Arm Extension Test
ARM EXTENSION TEST

Forward tilt ! !
Winging ! !
Retraction ! !
Medial rotation ! !
399
Figure 8.42 Correction with wall support at corner Figure 8.43 Correction unsupported arm extension with
self-palpation
supported by leaning against the corner of a wall scapula supported against a wall (Figure 8.44)
(Figure 8.42). As control improves, the arm exten- and finally unsupported (Figure 8.45).
sion is performed unsupported through the With visual, auditory and kinaesthetic cues the
partial range that can be controlled well with self- person becomes familiar with the task of extend-
palpation. This is eventually progressed through- ing the glenohumeral joint to 15° without scapula
out the full benchmark range with the elbow movement or glenohumeral translation. Some
straight (Figure 8.43). useful clinical cues are illustrated in Box 8.6.
An alternative progression is to use unilateral
horizontal arm extension, initially with the
400
Figure 8.45 Correction using unsupported horizontal arm

extension
Box 8.6 Useful clinical facilitation and

retraining cues
Cues for facilitation and feedback to

enhance teaching and retraining movement
• Palpate the scapula or glenohumeral joint to monitor
the UCM.
• Imagery of lifting the shoulder blade as the arm
lowers.
• Turn the hand (palm in) and keep palm in.
• Keep the coracoids open and wide.
• Palpate acromion/coracoid/inferior angle.
Figure 8.44 Correction using horizontal arm extension and • Visualise a string holding the acromion up.
wall support
• Unload passively.
• Tape (proprioceptive skin tension).
401
for individual cases and Table 8.5 illustrates some

OTHER USEFUL DISSOCIATION additional dissociation tests.
MOVEMENTS FOR THE SHOULDER At this stage there is no definitive measurement
GIRDLE or consistent peer consensus as to the benchmark
ranges for these dissociation tests of UCM. The
As with all other regions, the principles of dis- authors recommend that if symptoms are associ-
sociation can be applied. The scapula and gleno- ated with these functional movements and the
humeral joint can be maintained in neutral and ability to control (or prevent) the site and direc-
movement occurs above or below or in the same tion of the UCM is poor, then retraining through
region, but in a different direction. Other tests, the range that can be controlled is a useful clinical
and subsequent retraining exercises, can be useful option.
Table 8.5 Potential additional tests for shoulder UCM
TEST (LINKED TO MOVEMENT CHALLENGE CONTROL POINT – OBSERVE FOR

SYMPTOMATIC AND PREVENT UCM (SITE AND
FUNCTION) DIRECTION)
Shoulder overhead reach Arm flexion/abduction 90° to full • Scapula elevation
overhead position (standing) (Figure 8.46) • Glenohumeral inferior translation
• Glenohumeral medial rotation
Shoulder forward reach Protraction of scapula with arm in • Scapula forward tilt
horizontal flexion (standing) (Figure 8.47) • Scapula downward rotation
• Glenohumeral medial rotation
Shoulder press off Shoulder protraction (prone weight • Scapula winging
elbows bearing on elbows) (Figure 8.48) • Scapula forward tilt
Elbow straightening Elbow flexion and extension with the • Glenohumeral anterior translation
upper arm by the side (standing) • Glenohumeral medial rotation
Forearm twist Forearm supination (from a pronated • Scapula retraction
position) with the upper arm by the side • Scapula downward rotation
Neck flexion Cervicothoracic flexion with the arms by • Scapula downward rotation
the side (standing) • Scapula forward tilt
Full head turn Neck rotation with arms by side (sitting) • Scapula elevation (ipsilateral shoulder)
• Scapula retraction (ipsilateral shoulder)
• Scapula forward tilt (ipsilateral shoulder)
• Scapula downward rotation (ipsilateral
shoulder)
Full chest turn Thoracic rotation with arms by side • Scapula retraction (ipsilateral shoulder)
(sitting) • Scapula elevation (ipsilateral shoulder)
• Scapula forward tilt (contralateral shoulder)
• Scapula downward rotation (contralateral
shoulder)
402
Figure 8.46 Correction with overhead arm abduction on Figure 8.47 Correction with horizontal flexion
wall
Figure 8.48 Correction with push-up off elbows
403
UCM AND PRESENTATION WITH Box 8.7 Movement faults related to

impingement of the shoulder
IMPINGEMENT AND INSTABILITY
Impingement assessment priorities
The primary site of UCM needs to be established • Scapula UCM:
with the tests. The UCM can present predomi- – downward rotation
nantly at glenohumeral or scapulothoracic joints. – forward tilt
This can be identified with the kinetic medial – elevation
rotation test. There are characteristic movement – protraction
faults which are related to impingement and – winging.
instability and these are described in Boxes 8.7
• Glenohumeral rotation timing UCM:
and 8.8. The rehabilitation of impingement is
– medial rotation (late or absent lateral rotation
usually targeted at improving dynamic control of during abduction)
the scapula and control of glenohumeral medial – medial rotation (excessive medial rotation during
rotation. The rehabilitation of instability is eccentric flexion).
usually targeted at dynamic control of translation • Glenohumeral inferior translation – restriction:
of the humerus and rotation control of the – restricted or limited inferior humeral head glide
humerus. during abduction.
Correction
Rehabilitation strategies directed at correcting
the movement faults of the shoulder following Box 8.8 Movement faults related to instability
evidence-based assessment, rather than diagnos- of the shoulder
tic category of pathology alone, is gaining recog-
nition as patients may present with a common Instability assessment priorities
diagnostic label but differing kinematic mecha- • Glenohumeral UCM:
nisms. Altering movement patterns can influence – anterior translation
shoulder signs (Caldwell et al 2007; Tate et al – inferior translation
2008), but it is important to establish a clear – posterior translation
diagnosis of the movement faults and from this – medial rotation.
base implement an appropriate rehabilitation Passive:
strategy. – damage or insidious laxity of capsular, ligamentous
Evidence shows physiotherapy does influence and labral restraints.
pain and disability around the shoulder and • Scapula UCM contributing to inappropriate orientation
includes many differing modalities – ultrasound, of the glenoid for optimal glenohumeral stability:
acupuncture, manual therapy, and stretching to – downward rotation
name a few (Ginn et al 1997; Johansson et al – forward tilt
2005; Nawoczenski et al 2006). There is substan- – elevation
tial support for the effectiveness of exercise treat- – protraction
ment programs emphasising scapula retraining – winging.
(Ginn et al 1997; Nawoczenski et al 2006). It is
clear that ‘scapula stabilising’ helps but therapists
need to identify specific motor control deficits of
the scapula. This can only be enhanced with a on the results of testing, the retraining needs to
more thorough understanding of, and assessment be prescriptive.
of, movement faults so therapy can focus on indi-
vidual needs. This can be classified as the diagno-
sis of mechanical shoulder dysfunction based on
Retraining suggestions and options
identifying the site and direction of UCM. The There are many retraining strategies available to
tests have been described in this chapter and, address UCM around the shoulder girdle. Critical
from these strategies for retraining, motor control to success is the patient understanding the move-
of the shoulder girdle can be implemented. Based ment fault and the therapist facilitating the
404
Figure 8.49 Feedback: self-palpation
Figure 8.51 Feedback: tape
appropriate pattern of control. Useful strategies

for the shoulder include:
• palpation of the fault for feedback (e.g.
Figure 8.49)
• shortening the lever (e.g. Figure 8.50)
• tape to enhance control of the movement
fault (e.g. Figure 8.51)
• changing the start position to reduce limb
load against gravity (e.g. Figure 8.52)
• using a wall for feedback and support (e.g.
Figure 8.53).
Useful exercise options for retraining control of
the scapula and glenohumeral joint movement
Figure 8.50 Feedback: short lever are described in Boxes 8.9 and 8.10. Integrating
control into functional tasks is essential. Princi-
ples and strategies to enhance functional integra-
tion are described in Chapter 4.
405
Figure 8.52 Retraining: reducing gravity moment arm Figure 8.53 Feedback: wall support
Box 8.9 Useful retraining exercises for scapular Box 8.10 Useful retraining exercise for
control glenohumeral control
• Dissociate flexion to 90° (Figure 8.54). • Dissociate lateral rotation – standing arm by side
• Dissociate abduction to 90°+ rotation timing (Figure 8.62).
(Figure 8.55). • Dissociate medial rotation – supine arm abducted 90°
• Dissociate medial rotation – supine arm abducted 90° (Figure 8.63).
(Figure 8.56). • Dissociate extension to 15° (Figure 8.64).
• Dissociate lateral rotation – standing arm by side • Dissociate lateral rotation – prone wrist lift
(Figure 8.57). (Figure 8.65).
• Dissociate extension to 15° + rotation timing • Dissociate medial rotation – prone elbow lift
(Figure 8.58). (Figure 8.66).
• Dissociate lateral rotation – prone arm overhead (wrist • Full range overhead movement – flexion and
lift) (Figure 8.59). abduction (Figure 8.67).
• Dissociate medial rotation – prone arm overhead
(elbow lift) (Figure 8.60).
• Full range overhead movement – flexion and
abduction (Figure 8.61).
406
Figure 8.56 Dissociation medial rotation with palpation

feedback of scapula
Figure 8.54 Dissociation flexion with palpation feedback of

scapula
Figure 8.57 Dissociation scapula control with lateral rotation
Figure 8.55 Dissociation abduction with palpation feedback

of scapula
407
Figure 8.60 Dissociation scapula control with medial

rotation overhead
Figure 8.58 Dissociation scapula control with extension
Figure 8.59 Dissociation scapula control with lateral rotation

Figure 8.61 Dissociation scapula control with full range
overhead
overhead flexion or abduction
408
Figure 8.62 Dissociate lateral rotation standing Figure 8.64 Dissociate extension standing
Figure 8.63 Dissociation medial rotation with palpation Figure 8.65 Dissociation lateral rotation overhead with
feedback of humeral head humeral head control
409
Figure 8.66 Dissociation medial rotation overhead with

humeral head control
Figure 8.67 Dissociate full overhead flexion or abduction

with humeral head control
410
Table 8.6 Summary and rating of shoulder girdle tests

SITE DIRECTION CLINICAL PRIORITY !
TEST of stability control RATING (✓✓ or ✓✗ or ✗✗) and rationale
Scapula Downward rotation
Kinetic medial rotation test (L) (R)
Kinetic lateral rotation test
Arm flexion test
Arm abduction test
Arm extension test
Scapula Forward tilt
Arm flexion test
Arm abduction test
Arm extension test
Scapula Winging
Arm flexion test (L) (R)
Arm abduction test
Arm extension test
Scapula Elevation
Arm flexion test
Arm abduction test
Scapula Retraction
Kinetic lateral rotation test (L) (R)
Arm extension test
Scapula Protraction/abduction
Glenohumeral Anterior translation
Arm extension test
Glenohumeral Medial rotation
Arm abduction test
Arm extension test
411
REFERENCES
Alexander, C.M., 2007. Altered control controlled clinical trial of a impingement. Physical Therapy 80,
of the trapezius muscle in subjects treatment for shoulder pain. Physical 276–291.
with non-traumatic shoulder Therapy 77, 802–809. Ludewig, P.M., Cook, T.A., 2002.
instability. Clinical Neurophysiology Hess, S.A., Richardson, C., Darnell, R., Translations of the humerus in
118, 2664–2671. Friis, P., Lisle, D., Myers, P., 2005. persons with shoulder impingement
Baeyens, J., Roy, P.V., Schepper, A.D., Timing of rotator cuff activation symptoms. Journal of Orthopaedic
Declercq, G., Clarijs, J., 2001. during shoulder external rotation in and Sports Physical Therapy 32,
Glenohumeral joint kinematics throwers with and without 248–259.
related to minor anterior instability symptoms of pain. Journal of Lukasiewicz, A.C., McClure, P.,
of the shoulder at the end of the late Orthopaedic and Sports Physical Michener, L., Pratt, N.A., Sennett, B.,
preparatory phase of throwing. Therapy 35 (12), 812–820. 1999. Comparison of 3-dimensional
Clinical Biomechanics 16, 752–757. Huxel, K.C., Swanik, C.B., Swanik, K.A., scapular position and orientation
Borstad, J.D., 2006. Resting position Bartolozzi, A.R., Hillstrom, H.J., between subjects with and without
variables at the shoulder: evidence to Sitler, M.R., et al., 2008. Stiffness shoulder impingement. Journal of
support a posture-impairment regulation and muscle-recruitment Orthopaedic and Sports Physical
association. Physical Therapy 86 (4), strategies of the shoulder in Therapy 29, 574–583.
549–557. response to external rotation Maitland, G., Hengeveld, E., Banks, K.,
Borstad, J.D., Ludewig, P.M., 2005. The perturbations. Journal of Bone and English, K., 2005. Maitland’s
effects of long versus short pectoralis Joint Surgery. American volume 90 vertebral manipulation. Butterworth
minor resting length on scapular (1), 154–162. Heinemann, Oxford.
kinematics in healthy individuals. Johansson, K.M., Adolfsson, L.E., Moseley, J.B., Jobe, F.W., Pink, M., Perry,
Journal of Orthopaedic and Sports Foldevi, M.O., 2005. Effects of J., Tibone, J., 1992. EMG analysis of
Physical Therapy 35, 227–238. acupuncture versus ultrasound in the scapula muscles during a
Caldwell, C., Sahrmann, S., Van Dillen, patients with impingement shoulder rehabilitation program.
L., 2007. Use of a movement system syndrome: randomized clinical trial. American Journal of Sports Medicine
impairment diagnosis for physical Physical Therapy 85, 490–501. 20 (2), 128–134.
therapy in the management of a Kibler, B.W., Ludewig, P.M., McClure, P., Moraes, G.F., Faria, C.D., Teixeira-
patient with shoulder pain. Journal Uhl, T.L., Sciascia, A., 2009. Scapular Salmela, L.F., 2008. Scapular muscle
of Orthopaedic and Sports Physical summit 2009. Journal of recruitment patterns and isokinetic
Therapy 37 (9), 551–563. Orthopaedic and Sports Physical strength ratios of the shoulder
Comerford, M.J., Mottram, S.L., 2011. Therapy 39 (11), A1–A8. rotator muscles in individuals with
Diagnosis, subgroup classification Kibler, W.B., McMullen, J., 2003. and without impingement
and motor control retraining of the Scapular dyskinesis and its relation syndrome. Journal of Shoulder and
shoulder girdle. Kinetic Control, UK. to shoulder pain. Journal of the Elbow Surgery 17, 48S–53S.
Cools, A.M., Witvrouw, E.E., Declercq, American Academy of Orthopedic Morrissey, D., 2005. Development of
G.A., Danneels, L.A., Cambier, D.C., Surgeons 11, 142–151. the kinetic medial rotation test of
2003. Scapular muscle recruitment Lin, J.J., Hanten, W.P., Olson, S.L., the shoulder: a dynamic clinical test
patterns: trapezius muscle latency Roddey, T.S., Soto-quijano, D.A., of shoulder instability and
with and without impingement Lim, H.K., et al., 2005. Functional impingement. PhD thesis, University
symptoms. American Journal of activity characteristics of individuals of London.
Sports Medicine 31, 542–549. with shoulder dysfunctions. Journal Morrissey, D., Morrissey, M.C., Driver,
David, G., Magarey, M., Jones, M.A., of Electromyography and W., King, J.B., Woledge, R.C., 2008.
Dvir, Z., Turker, K.S., Sharpe, M., Kinesiology 15, 576–586. Manual landmark identification and
2000. EMG and strength correlates Lin, J., Hanten, W.P., Olson, S.L., tracking during the medial rotation
of selected shoulder muscles during Roddey, T.S., Soto-quijano, D.A., test of the shoulder: an accuracy
rotations of the glenohumeral joint. Lim, H.K., et al., 2006. Shoulder study using three-dimensional
Clinical Biomechanics 15, 95–102. dysfunction, assessment: self-report ultrasound and motion analysis
Falla, D., Farina, D., Graven-Nielsen, T., and impaired scapular movements. measures. Manual Therapy 13 (6),
2007. Experimental muscle pain Physical Therapy 86, 1065–1074. 529–535.
results in reorganization of Lucas, D., 1973. Biomechanics of the Mottram, S.L., 2003. Dynamic stability
coordination among trapezius shoulder joint. Archives of Surgery of the scapula. In: Beeton, K.S. (Ed.),
muscle subdivisions during repetitive 107, 425–432. Manual therapy masterclasses – the
shoulder flexion. Experimental Brain Ludewig, P.M., Cook, T.M., 2000. peripheral joints. Churchill
Research 178 (3), 385–393. Alterations in shoulder kinematics Livingstone, Edinburgh, pp. 3–17.
Ginn, K.A., Herbert, R.D., Khouw, W., and associated muscle activity in Mottram, S., Warner, M., Chappell, P.,
Lee, R., 1997. A randomized, people with symptoms of shoulder Morrissey, D., Stokes, M., 2009a.
412
Impaired control of scapular rotation shoulder impingement syndrome kinematics. Archives of Physical
during a clinical dissociation test in across different speeds of movement. Medicine and Rehabilitation 84,
people with a history of shoulder Clinical Biomechanics 23 (10), 1000–1005.
pain. 2009 3rd International 1227–1236. van der Helm, F.C.T., 1994. Analysis of
Conference on Movement Ruediger, M.O., von Eisenhart-Rothe, the kinematic and dynamic
Dysfunction, Edinburgh, UK. R.M., Jäger, A., Englmeier, K., Vogl, behaviour of the shoulder
Mottram, S.L., Wolege, R., Morrissey, D., T., Graichen, H., 2002. Relevance of mechanism. Journal of Biomechanics
2009b. Motion analysis study of a arm position and muscle activity on 27 (5), 527–550.
scapular orientation exercise and three-dimensional glenohumeral von Eisenhart-Rothe, R.M., Jäger, A.,
subjects’ ability to learn the translation in patients with traumatic Englmeier, K.H., Vogl, T.J., Graichen,
exercise. Manual Therapy 14 (1), and atraumatic shoulder instability. H., 2002. Relevance of arm position
13–18. American Journal of Sports Medicine and muscle activity on three-
Ogston, J.B., Ludewig, P.M., 2007. 30, 514–522. dimensional glenohumeral
Differences in 3-dimensional Saha, A.K., 1971. Dynamic stability of translation in patients with traumatic
shoulder kinematics between the glenohumeral joint. Acta and atraumatic shoulder instability.
persons with multidirectional Orthopaedica Scaninavica 42, American Journal of Sports Medicine
instability and asymptomatic 491–495. 30 (4), 514–522.
controls. American Journal of Sports Sahrmann, S.A., 2002. Diagnosis and Wadsworth, D.J., Bullock-Saxton, J.E.,
Medicine 35 (8), 1361–1370. treatment of movement impairment 1997. Recruitment patterns of the
Nawoczenski, D.A., Clobes, S.M., Gore, syndromes. Mosby, St Louis. scapular rotator muscles in freestyle
S.L., Neu, J.L., Olsen, J.E., Borstad, Schellingerhout, J.M., Verhagen, P.A., swimmers with subacromial
J.D., et al., 2003. Three-dimensional Thomas, S., Koes, B.W., 2008. Lack impingement. International Journal
shoulder kinematics during a of uniformity in diagnostic labeling of Sports Medicine 18 (8), 618–624.
pressure relief technique and of shoulder pain: time for a different Walker-Bone, K., Palmer, K.T., Reading,
wheelchair transfer. Archives of approach. Manual Therapy 13 (6), I. Coggon, D. Cooper, C., 2004.
Physical Medicine and Rehabilitation 478–483. Prevalence and impact of
84, 1293–1300. Tate, A.R., McClure, P., Kareha, S., Irwin, musculoskeletal disorders of the
Nawoczenski, D.A., Ritter-Soronen, J.M., D., 2008. Effect of the scapula upper limb in the general
Wilson, C.M., Howe, B.A., Ludewig, reposition test on shoulder population. Arthritis and
P.M., 2006. Clinical trial of exercise impingement symptoms and Rheumatism 51, 642–651.
for shoulder pain in chronic spinal elevation in overhead athletes. Wilk, K.E., Arrigo, C.A., Andrews, J.R.,
injury. Physical Therapy 86 (12), Journal of Orthopaedic and Sports 1997. Current concepts: the
1604–1618. Physical Therapy 38 (1), 4–11. stabilizing structures of the
Roy, J.-S., Moffet, H., McFadyen, B.J., Tsai, N.-T., McClure, P.W., Karduna, glenohumeral joint. Journal of
2008. Upper limb motor strategies A.R., 2003. Effects of muscle fatigue Orthopaedic and Sports Physical
in persons with and without on 3-dimensional scapular Therapy 25 (6), 364–379.
413
CHAPTER 9
THE HIP
Flexion control
T65 Standing: vertical trunk single leg 14 squat test 426
T66 Standing: single foot lift test 430
T67 Standing: spinal roll down test 433
T68 Side-lying: single leg abduction test 437
Extension control
T69 Standing: thoracolumbar extension test 442
T70 Standing: single knee lift + anterior tilt test 446
T71 Standing: single knee lift + knee extension test 450
Medial rotation control

T72 Standing: single leg small knee bend test 459
T73 Standing: one leg small knee bend + trunk
rotation away test 463
T74 Side-lying: top leg turnout lift test 467
Lateral rotation/abduction control

T75 Standing: single leg high knee lift test 471
T76 Standing: one leg small knee bend + trunk
rotation towards test 475
T77 4 point: bent knee hip extension test 479
T78 Bridge: single leg lift test 483
Adduction control
T79 Single leg stance: lateral pelvic shift test 488
Forward glide control

T80 Supine: active (vs passive) straight leg raise test 493
T81 Prone: active (vs passive) prone leg lift test 497
T82 Supine: active (vs passive) ‘figure 4’ turnout test 500
Chapter 9
The hip
therapy program to be superior to the exercise

INTRODUCTION therapy program (Hoeksma et al 2004). However,
motor control issues were not specifically identi-
The vast majority of hip pain referred to in the fied or addressed in this paper.
research and clinical literature primarily relates This chapter sets out to explore the assessment
this pain to degenerative osteoarthritis (OA) of the and retraining of uncontrolled movement (UCM)
hip. This pain usually originates from the groin in the hip. Before details of the assessment and
with inconsistent patterns of radiation and referral retraining of UCM in hip region are explained,
of symptoms towards the trochanteric region and a brief review of changes in muscle function
presents with varying degrees of movement restric- and movement and control in the region is
tion and loss of function. Simms (1999) states that presented.
hip pain is usually related to particular move-
ments or sustained positions of the hip joint. Hip Changes in muscle function
pain related to non-degenerative causes is largely
under-reported in the literature. Hip pain from around the hip
non-degenerative causes is often poorly diagnosed Hardcastle & Nade (1985) state that one of the
and frequently attributed to potential lumbar and most consistent markers of hip dysfunction is the
sacroiliac referral mechanisms. lack of lateral control of the hip and pelvis in
A clinical reasoning process is required to single leg stance. Several studies have attempted
differentiate groin, trochanteric and buttock to make links between hip joint pain and altered
pain arising from the hip as opposed to that function of the gluteal muscles. The majority of
arising from the lumbar spine or sacroiliac joint these studies have focused on measuring weak-
(Sahrmann 2002; Lee 2011). Sahrmann (2002) ness during strength tests. Strength deficits are
and Lee (2001) both describe patterns of altered commonly reported. Some studies have evaluated
muscle function (or ‘muscle imbalances’) to clas- changes in muscle size and appearance with pain
sify hip dysfunction. They argue that the presence or altered muscle function. Arokoski et al (2002)
of these patterns of altered muscle function, when showed that subjects with hip osteoarthritis (OA)
linked to painful or dysfunctional hip move- had a decrease in abduction strength by as much
ments, can be used to diagnose and differentiate as 31% compared to controls. The cross-sectional
hip-related pain from lumbar or sacroiliac sources. area (CSA) of the pelvic and thigh muscles,
A study comparing manual therapy (manipula- however, did not show significant differences
tion and mobilisation) with exercise therapy in between the two groups. Those with hip OA dem-
osteoarthritis of the hip showed the manual onstrated a 13% decrease in the CSA of the

DOI: 10.1016/B978-0-7295-3907-4.00009-8 415
gluteals and the adductors on the more severely and pathology results from a variety of biomech-
affected hip as compared to the better hip. Inter- anical mechanisms, which include mechanical
estingly, the decrease in CSA in the abductor and impingement, rotational strain and instability.
adductor muscles was not a direct indicator of Lewis et al (2007) developed a biomechanical
muscle strength deficits. model that found that decreased force contribu-
Robinson et al (2005) presented a series of tions from the gluteal muscles (during hip exten-
eight case reports of subjects with hip pain. All sion) and decreased iliopsoas force (during hip
cases presented with a decrease of CSA in the flexion) resulted in an increase in anterior hip
piriformis, gemelli inferior, obturator externus or loading. They also reported that the hip loading
a combination of one or more of these muscles. was greater if the hip was positioned in extension
Grimaldi et al (2009) evaluated changes in to initiate these movements.
gluteus maximus and tensor fasciae latae (TFL) Sahrmann (2002) describes clinical tests to
muscle volumes in subjects with unilateral hip palpate for the presence of excessive or uncon-
joint pathology. Twelve subjects with hip joint trolled femoral head anterior glide during hip
pain ranging from labral pathology to advanced flexion and hip extension movements. Sahrmann
OA were evaluated by magnetic resonance (2002) postulates that the development of exces-
imaging (MRI), in order to achieve a volume sive hip medial rotation leads to abnormal
measurement, and compared to 12 control sub- loading on the anterior hip structures, which in
jects. The MRI evaluation of gluteus maximus turn results in hip pain and pathology. Levinger
identified two functionally differentiated com- et al (2007) demonstrate excessive and uncon-
partments within gluteus maximus: an upper trolled hip medial rotation during a single leg
(superficial lateral) compartment (UGM) and a squat. Lewis et al (2007) report that the hip dem-
lower (deep medial) compartment (LGM). Their onstrates increased medial rotation if the ilio-
results demonstrated the LGM had a significant psoas force decreases and the TFL force increases,
decrease in volume related to pain and OA while and that this ‘imbalance’ produces an excessive
the TFL and UGM, which insert into the iliotibial increase in anterior hip loading.
band, both maintained muscle bulk in the pres- Mechanical dysfunctions of the hip commonly
ence of OA hip pain. Findings such as this suggest present as combinations of impingement, insta-
that assessment of gross strength deficits per se bility and rotational strain dysfunctions – all of
may not adequately identify hip dysfunction. which can develop into degenerative conditions.
Variations in the timing and sequencing of Motor control dysfunction within the hip local
activation of various hip muscles have been and global musculature contributes significantly
reported by several authors. Many authors (Janda to insidious onset, chronicity and recurrence of
1983; Long et al 1993; Sahrmann 2002) report these hip problems. When symptoms arise from
changes in the neuromuscular coordination mechanical dysfunction in the regional tissues,
between TFL and gluteus medius (GMD). They consistent patterns of altered motor recruitment
demonstrate increased activity, earlier recruit- are evident. These recruitment patterns present as
ment and loss of extensibility in TFL in some motor control inhibition of muscle function and
subjects. During a prone hip extension movement motor imbalance. This chapter details the assess-
a delay in the activation of GMD or failure to ment of UCM at the hip region and describes
maintain efficient holding tension in inner range retraining strategies.
has been reported (Janda 1983; Richardson &
Sims 1991; Bullock-Saxton et al 1994; Sahrmann
2002; Lehman et al 2004).
DIAGNOSIS OF THE SITE AND
DIRECTION OF UCM IN THE HIP
UCM at the hip
Abnormal control of femoral translation and The diagnosis of the site and direction of UCM at
femoral rotation has been linked to anterior hip the hip can be identified in terms of the site (being
pain and pathologies of the labrum and associ- hip) and the direction of medial rotation, lateral
ated hip capsule and anterior muscles (Sahrmann rotation, flexion, extension and forwards glide
2002; Lee 2001; Shindle et al 2006; Lewis et al (Box 9.1). As with all UCM, the motor control
2007). The authors postulate that tissue loading deficit can present as uncontrolled translational
416
The hip Chapter |9|
segmental translatatory UCM or a global range-

Box 9.1 Direction of UCM in the hip
specific UCM.
• Flexion
• Extension Segmental translatatory UCM
• Medial rotation A segmental UCM occurs when the femoral head
• Lateral rotation/abduction appears to ‘glide forwards’ into excessive anterior
• Adduction or anteroinferior translatatory displacement asso-
• Forward glide ciated with flexion, extension or lateral rotation/
abduction motion testing.
A segmental translatatory femoral forwards glide
movement (e.g. forwards glide) or uncontrolled UCM (uncontrolled femoral head anterior trans-
range of functional movement (e.g. hip flexion) lation) can be identified in motion testing in
(Sahrmann 2002). several ways:
• In sagittal plane movements (flexion or
Linking the site of UCM to symptom extension), palpation of the trochanter
during passive hip movement is used to
presentation identify the location of the neutral axis of
A diagnosis of UCM requires evaluation of its hip motion. The ability to maintain the
clinical priority. This is based on the relationship neutral axis and prevent excessive forwards
between the UCM and the presenting symptoms. glide of the trochanter during active
The therapist should look for a link between the unassisted flexion or extension is compared
direction of UCM and the direction of symptom with the passive evaluation.
provocation: a) Does the site of UCM relate to the • In axial plane movements (lateral rotation
site or joint that the patient complains of as the and abduction), palpation of the anterior
source of symptoms? b) Does the direction of prominence of the femoral head during
movement or load testing relate to the direction passive movement with manual stabilisation
or position of provocation of symptoms? This is used to identify the location of the neutral
identifies the clinical priorities. axis of hip motion. The ability to maintain
The site and direction of UCM at the hip can the neutral axis and prevent excessive
be linked with different clinical presentations and forwards glide of the anterior prominence of
postures and activities that provoke or produce the femoral head during active unassisted
symptoms (Table 9.1). lateral rotation and abduction is compared
with the passive evaluation.
IDENTIFYING SITE AND DIRECTION Global range-specific UCM

OF UCM AT THE HIP A global range-specific UCM demonstrates
uncontrolled motion (±hypermobile range)
The key principles for assessment and classifica- into hip flexion or into hip extension. This is
tion of UCM are described in Chapter 3. All dis- observed as either excessive or dominant hip
sociation tests are performed with the hip in a motion at the initiation of the movement or
mid-range neutral training region. However, this hypermobile range of hip motion to complete the
may be closer to end range but not at end range movement.
(e.g. close to extension while attempting to A global range-specific hip flexion UCM can be
prevent flexion). identified in motion testing in several ways:
• Observe or palpate excessive or hypermobile
Segmental translatatory and global range of hip flexion. During the test
movement, the therapist relies on visual
range-specific uncontrolled motion
observation or manual palpation to
When direction-specific, uncontrolled motion is identify if the subject cannot control
observed at the hip, it can present in two ways. (prevent or eliminate) additional hip
The uncontrolled motion can present as either a flexion. The subject demonstrates an
417
Table 9.1 The link between the site and direction of UCM at the hip and different clinical presentations
SITE AND DIRECTION SYMPTOM PRESENTATION PROVOCATIVE MOVEMENTS,

OF UCM POSTURES AND ACTIVITIES
HIP FLEXION UCM • Presents with symptoms in the groin, Symptoms provoked by hip flexion
Can present as: lateral hip (trochanteric region) or movements and postures (especially if
• uncontrolled hip flexion (with or posterior lateral buttock repetitive or sustained); for example,
without hypermobile range) • May present with a segmental sustained sitting (especially if leaning
• uncontrolled forward glide of the localised pain pattern forwards at a desk), bending
femoral head (segmental anterior • ± Radicular pain from myofascial and forwards, driving, squatting, knee lift
translation) during open chain articular structures activities (e.g. stair climbing and
hip flexion walking up hills)
• unilaterally or bilaterally
HIP EXTENSION UCM • Presents with symptoms in the groin, Symptoms provoked by hip extension
• uncontrolled hip extension (with posterior lateral buttock repetitive or sustained); for example,
or without hypermobile range) • May present with a segmental sustained standing arching
• uncontrolled forward glide of the localised pain pattern backwards, lifting, lying prone,
femoral head (segmental anterior • ± Radicular pain from myofascial and walking or running (especially down
translation) during hip extension articular structures hills)
• unilaterally or bilaterally
HIP ROTATION UCM • Presents with symptoms in the groin, Symptoms provoked by hip rotation
• uncontrolled hip medial rotation posterior lateral buttock repetitive or sustained); for example,
or lateral rotation/abduction • May present with a segmental sustained standing (especially if
(with or without hypermobile localised pain pattern weight shift onto leg in adduction
range) • ± Radicular pain from myofascial and and medial rotation), jumping or
• uncontrolled forward glide of the articular structures stepping down onto one leg,
femoral head (segmental anterior sustained sitting (especially if
translation) during hip lateral cross-legged), bending forwards or
rotation squatting with knees jammed
• unilaterally or bilaterally together
HIP ADDUCTION UCM • Presents with symptoms in the groin, Symptoms provoked by hip adduction
• uncontrolled hip adduction (with posterior lateral buttock repetitive or sustained); for example,
or without hypermobile range) • May present with a segmental sustained sitting (especially if legs
• uncontrolled forward glide of the localised pain pattern are crossed), sustained standing
femoral head (segmental anterior • ± Radicular pain from myofascial and (especially if weight shift onto leg in
translation) during hip adduction articular structures adduction), stepping down onto one
• unilaterally or bilaterally leg
inability to prevent movement into further thoracolumbar flexion or lower leg flexion
hip flexion when instructed to prevent when instructed to do so.
flexion. • Place a long piece of adhesive strapping tape
• Observe or palpate that during a functional across the posterior hip (e.g. from the
multi-joint movement into flexion, hip posterior superior iliac spine (PSIS) to the
flexion dominates the initiation of the upper portion of the posterior thigh), with
movement pattern. The subject demonstrates the hip positioned in an extension position
an inability to reverse this pattern. They relevant to the specific test. By skin
cannot easily initiate the movement with tensioning from the lowermost attachment
418
The hip Chapter |9|
(below) to the uppermost attachment, if the the movement pattern. The subject
subject cannot prevent or control hip flexion, demonstrates an inability to reverse this
the tape pulls off the skin when uncontrolled pattern. They cannot easily initiate the
flexion motion is produced. movement with thoracolumbar rotation
A global range-specific hip extension UCM or lower leg rotation when instructed to
can be identified in motion testing in several do so.
ways: • Place a long piece of adhesive strapping tape
across the lateral hip (e.g. from the posterior
iliac crest to the medial portion of the
range of hip extension. During the test
anterior thigh) with the hip positioned in a
movement, the therapist relies on visual
lateral rotation position relevant to the
observation or manual palpation to identify
specific test. By skin tensioning from the
if the subject cannot control (prevent or
lowermost attachment (below) to the
eliminate) additional hip extension. The
uppermost attachment, if the subject cannot
subject demonstrates an inability to prevent
prevent or control hip medial rotation, the
movement into further hip extension when
tape pulls off the skin when uncontrolled
instructed to prevent extension.
motion is produced.
• Observe or palpate that during a
functional multi-joint movement into A global range-specific hip lateral rotation/
extension, hip extension dominates the abduction UCM can be identified in motion testing
initiation of the movement pattern. The in several ways:
subject demonstrates an inability to reverse
this pattern. They cannot easily initiate the
range of hip lateral rotation or abduction.
movement with thoracolumbar extension or
During the test movement, the therapist
lower leg extension when instructed to do
relies on visual observation or manual
so.
palpation to identify if the subject cannot
• Place a long piece of adhesive strapping tape
control (prevent or eliminate) additional hip
across the anterior hip (e.g. from the anterior
lateral rotation or abduction. The subject
superior iliac spine (ASIS) to the upper
demonstrates an inability to prevent
portion of the anterior thigh) with the hip
movement into further hip lateral rotation/
positioned in a flexion position relevant to
abduction when instructed to prevent this
the specific test. By skin tensioning from the
movement.
lowermost attachment (below) to the
• Observe or palpate that during a functional
uppermost attachment, if the subject cannot
multi-joint movement into rotation, hip
prevent or control hip extension, the tape
lateral rotation or abduction dominates the
pulls off the skin when uncontrolled
initiation of the movement pattern.
extension motion is produced.
The subject demonstrates an inability
A global range-specific hip medial rotation UCM to reverse this pattern. They cannot easily
can be identified in motion testing in several initiate the movement with thoracolumbar
ways: rotation or lower leg rotation when
• Observe or palpate excessive or hypermobile instructed to do so.
range of hip medial rotation. During the • Place a long piece of adhesive strapping tape
test movement, the therapist relies on across the medial hip (e.g. from the inguinal
visual observation or manual palpation to ligament and anterior iliac crest to the lateral
identify if the subject cannot control portion of the posterior thigh) with the hip
(prevent or eliminate) additional hip medial positioned in a medial rotation and
rotation. The subject demonstrates an adduction position (relevant to the specific
inability to prevent movement into further test). By skin tensioning from the lowermost
hip medial rotation when instructed to attachment (below) to the uppermost
prevent rotation. attachment, if the subject cannot prevent or
• Observe or palpate that during a functional control hip lateral rotation and abduction,
multi-joint movement into rotation, hip the tape pulls off the skin when uncontrolled
medial rotation dominates the initiation of motion is produced.
419
Occasionally, both segmental translatatory for- prevent hip medial rotation (dissociation), the
wards glide and global range-specific dysfunc- hip demonstrates UCM into either:
tions can present together. • global hip medial rotation – uncontrolled
medial rotation during active unilateral
Examples lower leg movement or thoracolumbar
rotation dissociation tests
Hip flexion UCM
or
The patient complains of flexion-related symp-
• segmental hip forwards glide – uncontrolled
toms in the hip region (groin, lateral hip or pos-
segmental anterior translation of the femoral
terolateral buttock). The hip demonstrates UCM
head during active hip medial rotation.
into flexion relative to the lower leg or thoracolum-
bar spine under flexion load. During a motor Hip lateral rotation/abduction UCM
control test of active lower leg or thoracolumbar
flexion where the instruction is to prevent hip The patient complains of rotation-related symp-
flexion (dissociation), the hip demonstrates UCM toms in the hip region (lateral hip or posterola-
into either: teral buttock ± groin). The hip demonstrates
• global hip flexion – uncontrolled flexion UCM into lateral rotation or abduction relative to
during active lower leg flexion or the lower leg or thoracolumbar spine under rota-
thoracolumbar flexion dissociation tests tion load. During a motor control test of active
lower leg or thoracolumbar rotation where the
or instruction is to prevent hip lateral rotation and
• segmental hip forwards glide – uncontrolled abduction (dissociation), the hip demonstrates
segmental anterior translation of the femoral UCM into either:
head during active hip flexion. • global hip lateral rotation/abduction –
uncontrolled lateral rotation or abduction
Hip extension UCM during active unilateral lower leg movement
The patient complains of extension-related symp- or thoracolumbar rotation dissociation tests
toms in the hip region (groin, lateral hip or pos- or
terolateral buttock). The hip demonstrates UCM • segmental hip forwards glide – uncontrolled
into extension relative to the lower leg or thoraco- segmental anterior translation of the femoral
lumbar spine under extension load. During a head during active hip lateral rotation/
motor control test of active lower leg or thoraco- abduction or ‘turnout’ movements.
lumbar extension where the instruction is to
prevent hip extension (dissociation), the hip Hip adduction UCM
demonstrates UCM into either:
The patient complains of adduction-related
• global hip extension – uncontrolled extension symptoms in the hip region (groin, lateral hip or
during active lower leg extension or posterolateral buttock). The hip demonstrates
thoracolumbar extension dissociation tests UCM into adduction relative to the lower leg or
or thoracolumbar spine under rotation load. During
• segmental hip forwards glide – uncontrolled a motor control test of active lower leg weight
segmental anterior translation of the femoral bearing or thoracolumbar side-bend where the
head during active hip extension. instruction is to prevent hip adduction (dissocia-
tion), the hip demonstrates UCM into either:
Hip medial rotation UCM • global hip adduction – uncontrolled medial
rotation during active unilateral lower leg
The patient complains of rotation-related symp-
weight bearing or thoracolumbar side-bend
toms in the hip region (groin, lateral hip or pos-
dissociation tests
terolateral buttock). The hip demonstrates UCM
into medial rotation relative to the lower leg or or
thoracolumbar spine under rotation load. During • segmental hip forwards glide – uncontrolled
a motor control test of active lower leg or thora- segmental anterior translation of the femoral
columbar rotation where the instruction is to head during active adduction rotation.
420
The hip Chapter |9|
HIP TESTS FOR UCM
Hip sagittal motion control

SAGITTAL HIP FLEXION AND BENDING
Several functional movement patterns can iden-

tify movement faults associated with hip flexion.
These include observing and analysing the rela-
tive hip contributions to:
1. natural or ‘automatic’ forwards bending
2. natural rocking backwards on to hips in 4
point kneeling
3. supine passive hip flexion
4. natural small knee bend.
Description of ideal pattern of

forwards bending
The subject is instructed to stand with the feet in
a natural stance and bend forwards in a normal
relaxed pattern. Ideally, there should be even
flexion throughout the lumbar and thoracic
regions with the hips flexing to approximately to
70°. The spinal flexion and hip flexion should
occur concurrently. The fingertips should reach Figure 9.1 Ideal pattern of forward bending
the floor without the need to bend the knees
(Figure 9.1).
There should be good symmetry of movement
without any lateral deviation, tilt or rotation of
flexion to compensate for the lack of ankle
the trunk or pelvis. The pelvis and hips should
mobility. Gastrocnemius extensibility can be
lead the return to standing with the spine unroll-
tested passively and dynamically with
ing on the way back to the upright posture.
manual muscle extensibility examination
and restrictions of talocrural joint
Movement faults associated with dorsiflexion can be confirmed with manual
assessment of joint mobility.
hip UCM in forwards bending
Relative stiffness (restrictions) Relative flexibility (potential UCM)
• Thoracolumbar restriction of flexion: thoracic or • Hip flexion: the hip may initiate the
lumbar flexion restriction may also movement into flexion; contribute more to
contribute to compensatory increases in hip producing forward bending while the
flexion range. This is confirmed with manual thoracolumbar contributions start later and
assessment of hip flexion range. contribute less. At the limit of forwards
• Gastrocnemius or talocrural joint restriction of bending, excessive or hypermobile range of
ankle dorsiflexion: the ankle lacks normal hip flexion may be observed. During the
range of dorsiflexion in standing forwards return to neutral the hip flexion persists and
bending. The hip frequently may increase unrolls late.
421

• Hip flexion: the hip may initiate the
movement into flexion; contribute more to
producing rocking backwards while the
thoracolumbar contributions start later and
contribute less. Greater than 120° of hip
flexion range is observed during backward
rocking before any posterior pelvic tilt or
lumbar flexion is produced. The person can
almost sit back onto their heels using
excessive hip flexion while maintaining a
straight lumbar spine.
Figure 9.2 Ideal pattern of backward rocking

Description of ideal pattern of
supine passive hip flexion
With the person lying supine, place one hand
Description of ideal pattern of under the lumbar lordosis to monitor pelvic tilt.
backward rocking (hands and knees Flex one hip and knee up in the neutral sagittal
4 point kneeling) plane. Ideally, the person should have 120° of hip
flexion independently of pelvic tilt and spinal
With the subject on hands and knees and the motion. After 120° hip flexion the pelvis should
spine and pelvis in neutral alignment, place the start to tilt posteriorly and the spine should start
knees hip width apart. The subject is instructed to to flex. Greater than 120° of hip flexion range
rock backwards towards their heels. Monitor before any posterior pelvic tilt or lumbar flexion
pelvic motion with one hand placed on the is produced, indicates excessive relative hip
sacrum to identify the point of initiation of pos- flexion.
terior pelvic tilt. This point identifies the limit of
hip flexion range as the posterior hip structures
are tensioned and pull the pelvis into posterior Description of ideal pattern of
tilt. Ideally, the person should have the ability to small knee bend (SKB)
dissociate the lumbar spine and pelvis from hip
flexion as evidenced by 120° of hip flexion during The person stands upright with the feet hip width
backward rocking while preventing lumbar apart (heels approximately 10–15 cm apart) with
flexion or posterior pelvic tilt (Figure 9.2). After the inside borders of the feet parallel (not turned
120° hip flexion the pelvis should start to tilt out) and the 2nd metatarsal aligned along the
posteriorly and the spine should start to flex as ‘neutral line’ of weight transfer (a line that is 10°
the pelvis moves towards the heels. lateral to the sagittal plane). Perform a bilateral
small knee bend (SKB) by flexing at the knees and
dorsiflexing the ankles while keeping the heels on
Movement faults associated with the floor. Hold the knee out over the foot to ori-
hip UCM in backward rocking entate the line of the femur out over the 2nd toe
(on the ‘neutral line’) (Figure 9.3).
Relative stiffness (restrictions) The knees are to bend as far as the heels can
• Thoracolumbar restriction of flexion: thoracic or stay on the floor and correct rotational alignment
lumbar flexion restriction may also is maintained. Ideally, the trunk should stay verti-
contribute to compensatory increases in hip cal (as if sliding down a wall) and the knees flex
flexion range. Soleus extensibility can be so that a vertical plumb line dropped from the
tested passively and dynamically with front of the knees should fall 3–8 cm past the
manual muscle extensibility examination, longest toes, without any hip medial rotation or
and restrictions of talocrural joint midfoot pronation (Figure 9.4). Body weight
dorsiflexion can be confirmed with manual should stay equally distributed on each foot and
assessent of joint mobility. there should be no lateral shift of the pelvis.
422
The hip Chapter |9|
Figure 9.3 Ideal small knee bend front view Figure 9.4 Ideal small knee bend side view
Sagittal movement faults associated on correct rotational alignment the knees do

with hip UCM in the SKB not move sufficiently past the toes.

• Knee and ankle restriction of flexion/dorsiflexion:
a restriction of ankle dorsiflexion or knee Hip and lower quadrant sagittal
flexion may contribute to compensatory alignment evaluation
increases in hip flexion range. This is
confirmed with manual assessment of hip
flexion range. • Stand in neutral foot alignment with correct
tibial rotational alignment (2nd metatarsal
on the neutral line of weight transfer).
Relative flexibility (potential UCM) • Perform a SKB (in weight bearing, flex the
• Hip flexion: the natural pattern of movement knees and dorsiflex the ankles while keeping
is that the hips initiate the movement and both heels on the floor).
contribute more to producing the SKB while • Control femoral rotational alignment
the ankle and knee contributions start later (femurs of neutral line of weight transfer).
and contribute less. Observe that the trunk • Knee bend as far as the heels can stay on the
leans forwards into hip flexion. With a SKB floor.
423
Figure 9.5 Sagittal alignment group 2 – hip flexion

dysfunction: excessive hip flexion relative to limited knee and
ankle movement
Figure 9.6 Sagittal alignment group 3 – lower leg flexion
dysfunction: limited hip flexion relative to excessive knee and
ankle movement
• Observe the relative sagittal alignment of
hip, knee and ankle in the natural pattern
(without cueing and alignment correction). the toes. Hip flexion significantly decreases.
The subject cannot correct the pattern or
finds it very difficult to correct. The trunk is
often inclined backwards to maintain
IDEAL SAGITTAL ALIGNMENT balance.
Sagittal alignment can be classified into one of
The long axis of the femur and the 2nd metatarsal three groups:
are both aligned to the lower limb neutral line (a 1. Ideal (Figure 9.4):
line 10° lateral to the sagittal plane) (Figure 9.4). a. plumb line dropped from the front of
knee falls between 3 and 8 cm in front
of toes.
Dysfunction
2. Hip flexion dysfunction (Figure 9.5):
• With a SKB on correct alignment the knees a. plumb line dropped from the front of
do not move sufficiently past the toes. The the knee falls less than 3 cm in front of
knee alignment is less than 3 cm past the the toes
toe. It is common for the knees to only b. relatively restricted knee flexion and ankle
move as far as the metatarsal heads. To dorsiflexion
maintain functional ability to bend down, c. relatively excessive or uncontrolled hip
hip flexion significantly increases as flexion
uncontrolled compensation. The subject d. the trunk leans forwards from vertical
cannot correct the pattern or finds it very (more hip flexion than ideal) to keep
difficult to correct. Many do not realise that the centre of mass balanced over the
the hips are ‘hanging out the back’ and often midfoot.
believe that the trunk is vertical when it is 3. Lower leg flexion dysfunction (Figure 9.6):
obviously inclined forwards. a. plumb line dropped from the front of
• With a SKB on correct alignment the knees the knee falls more than 8 cm in front of
do not move sufficiently past the toes. The the toes
knee alignment is greater than 8 cm past b. relatively restricted hip flexion
424
The hip Chapter |9|
c. relatively excessive or uncontrolled hip The tests that identify dysfunction can also be
flexion and ankle dorsiflexion used to guide and direct rehabilitation strategies.
d. the trunk leans backwards from vertical
(more hip extension than ideal) to keep
Indications to test for hip
the centre of mass balanced over the
midfoot. flexion UCM
1. hypermobile hip flexion range
2. excessive initiation of bending or leaning
HIP FLEXION CONTROL TESTS AND forwards with hip flexion
FLEXION CONTROL REHABILITATION 3. symptoms (pain, discomfort, strain)
associated with bending or leaning forwards
These flexion control tests assess the extent of or sustained hip flexion postures.
flexion UCM in the hip and assess the ability of The person complains of flexion-related symp-
the dynamic stability system to adequately control toms in the hip. Under flexion load, the hip has
flexion load or strain. It is a priority to assess for greater give into flexion relative to the trunk and
flexion UCM if the patient complains of or dem- lower leg. The dysfunction is confirmed with
onstrates flexion-related symptoms or disability. motor control tests of flexion dissociation.
425
Hip flexion control tests
T65 STANDING: VERTICAL TRUNK

SINGLE LEG 1 4 SQUAT TEST
(tests for hip flexion UCM)

dissociate and control hip flexion and perform a
single leg 1 4 squat – small knee bend (SKB) by
flexing the knee and dorsiflexing the ankle while
in single leg standing.
Test procedure
The person stands with the feet hip width apart
(heels approximately 10–15 cm apart) with the
inside borders of the feet parallel (not turned
out). The upper body should be vertical and the
weight balanced over the midfoot. The person is
asked to shift full weight onto one foot and lift
the other foot just clear of the floor. In this posi-
tion, the person is standing on one leg with the
2nd metatarsal aligned along the ‘neutral line’ of
weight transfer (a line that is 10° lateral to the
sagittal plane). The pelvis should be level and the
trunk upright (vertical). There should be no
lateral deviation, tilt or rotation of the trunk or
pelvis. The head, sternum and pubic symphysis Figure 9.7 Start position vertical trunk single leg 1
4 squat
should be vertically aligned above the inside edge test
of the stance foot with the shoulders level in an
upright posture (Figure 9.7).
From this start position, the person then per-
forms a single leg small knee bend (SKB) by This test should be performed without any
flexing at the knee and dorsiflexing the ankle feedback (self-palpation, vision, etc.) or cueing
while keeping the heel on the floor. The body for correction. When feedback is removed for
weight should be on the heel, not the ball, of the testing the therapist should use visual observa-
foot and the trunk kept vertical (as if sliding the tion of the femur and trunk to determine whether
back down a wall). Do not lean the trunk for- the control of hip flexion is adequate. Assess both
wards. Hold the knee out over the foot to orien- legs separately.
tate the line of the femur out over the 2nd toe (on
the ‘neutral line’) (Figures 9.8 and 9.9). The trunk
Hip flexion UCM
should stay vertical (as if sliding down a wall) and
the knee should move past the toes. If a plumb The person complains of pain in the hip (groin
line were dropped from the front of the knee it impingement, lateral trochanteric or posterola-
should fall between 3 and 8 cm in front of the teral buttock pain) associated with hip flexion
longest toe. Ideally, there should be approxi- activities. During the vertical trunk 1 4 squat test,
mately 3–8 cm of independent SKB past the toes, the hip demonstrates UCM into flexion (the
without any forwards lean of the trunk or poste- trunk leans forwards and the hips move back-
rior shift of the hips and pelvis into increased hip wards into excessive hip flexion) before the knee
flexion. reaches 3–8 cm past the toes. Under weight
426
The hip Chapter |9|
Figure 9.8 Benchmark vertical trunk single leg 1

4 squat test Figure 9.9 Benchmark vertical trunk single leg 1
4 squat test
side view front view
bearing knee flexion and ankle dorsiflexion, the

hip has UCM into flexion relative to the knee and
ankle. Hip flexion control is poor if the subject
is unable to prevent or resist the excessive hip If some other movement (e.g. a small amount of rotation)
flexion. is observed during a motor control (dissociation) test of
The uncontrolled hip flexion is often associated flexion control, do not score this as uncontrolled flexion.
with inefficiency of the stability function of the The rotation motor control tests will identify whether the
gluteal extensor muscles (especially deep gluteus observed movement is uncontrolled. A test for hip flexion
maximus) which provide isometric or eccentric UCM is only positive if uncontrolled hip flexion is
control of hip flexion. During the attempt to dis- demonstrated.
sociate the hip flexion from knee flexion and
ankle dorsiflexion, the person either cannot
hard to control the hip flexion. The movement Rating and diagnosis of hip
must be assessed on both sides. If hip flexion
flexion UCM
UCM presents bilaterally, one side may be better
or worse than the other. (T65.1 and T65.2)
427
Correction the trunk vertical on the wall and the knee should
Initial retraining is best started with the trunk sup- move past the toes. Only slide down the wall as
ported against a wall. The person stands with the far as the trunk can stay on the wall and do not
back against a wall and the feet hip width apart lean forwards into increased hip flexion (Figure
(heels approximately 10–15 cm apart) with the 9.11). At the point in range that the trunk starts
inside borders of the feet parallel. The person is to lean forwards into hip flexion or the knee
asked to stand upright with the upper body verti- moves medially to allow compensation at the
cal and the weight balanced over the midfoot. The foot and ankle, the movement should stop and
heels should be approximately 5–10 cm from the return to the start position. The person should
wall. The pelvis should be level and the trunk self-monitor the hip and trunk alignment and
upright (vertical against the wall) (Figure 9.10). If control hip flexion UCM with a variety of feed-
control is poor, perform a SKB by sliding the trunk back options (T65.3). There should be no provo-
down the wall to a 1 4 squat position. The person cation of any symptoms within the range that the
should keep the back on the wall and weight bal- hip flexion UCM can be controlled.
anced equally on both feet. Only slide down the As the ability to control hip flexion and for-
wall as far as the trunk can stay on the wall and do wards lean of the trunk gets easier and the pattern
not lean forwards into increased hip flexion. of dissociation feels less unnatural, the exercise
As control improves, the person is instructed to can be progressed to performing this same move-
shift their weight to stand on one leg and perform ment unsupported, without the wall, in single leg
a single leg SKB to the 1 4 squat position. Keep stance.
Figure 9.10 Correction bilateral small knee bend with wall Figure 9.11 Correction unilateral small knee bend with wall
support support
428
The hip Chapter |9|
T65.1 Assessment and rating of low threshold recruitment efficiency of the Vertical Trunk Single Leg 1
4 Squat
Test
VERTICAL TRUNK SINGLE LEG 1/4 SQUAT – STANDING
Control point:
• prevent hip flexion
Movement challenge: unilateral knee flexion and ankle dorsiflexion (standing)
Benchmark range: knee flexion 3–8 cm past toes with trunk upright

or or
Prevent hip UCM into: • Feels easy, and the subject has sufficient
• flexion awareness of the movement pattern that they
and move single leg knee flexion and ankle confidently prevent UCM into the test
dorsiflexion direction
• Dissociate movement through the benchmark • The pattern of dissociation is smooth during
range of: knee flexion to 3–8 cm past toes concentric and eccentric movement
with trunk upright in 1/4 squat • Does not (consistently) use end-range
If there is more available range than the movement into the opposite direction to
benchmark standard, only the benchmark prevent the UCM
range needs to be actively controlled • No extra feedback needed (tactile, visual or
• Without holding breath (though it is verbal cueing)
acceptable to use an alternate breathing • Without external support or unloading
strategy) • Relaxed natural breathing (even if not ideal –
• Control during eccentric phase so long as natural pattern does not change)
• Control during concentric phase • No fatigue
from the Vertical Trunk Single Leg 1 4 Squat Test
VERTICAL TRUNK SINGLE LEG 1
4 SQUAT Self-palpation Palpation monitoring of joint
Site Direction (L) leg (R) leg Visual observation Observe in a mirror or directly
Hip Flexion ! ! Adhesive tape Skin tension for tactile feedback

correction observer
429
by more than 2 cm indicates uncontrolled hip

T66 STANDING: SINGLE FOOT LIFT TEST flexion.
(tests for hip flexion UCM) As soon as any movement indicating a loss of
control into increased hip flexion is observed, the
This dissociation test assesses the ability to actively movement must stop and return back to the start
dissociate and control hip flexion in single leg position. The unilateral single foot lift (non-
standing and maintain weight bearing hip control weight bearing hip flexion) must be independent
in a small knee bend (SKB) position and perform of any hip flexion on the weight bearing stance
hip flexion on the other leg. leg. This test should be performed without any
feedback (self-palpation, vision, flexicurve, etc.)
or cueing for correction. The therapist should use
Test procedure visual observation of the pelvis and leg to deter-
The person should stand upright with the upper mine whether the control of hip flexion is ade-
body vertical, the weight balanced over the feet quate when feedback is removed for testing.
and the pelvis centred over the heels (Figure Assess both sides.
9.12). The person is instructed to shift full weight
onto one leg and, keeping the shoulders and
Hip flexion UCM
pelvis level, slowly lift the other foot off the floor
to 90° hip flexion (Figure 9.13). There should be The person complains of pain in the hip (groin
no increase in hip flexion on the weight bearing impingement, lateral trochanteric or posterola-
stance leg. Movement of the buttocks backwards teral buttock pain) associated with hip flexion
Figure 9.12 Start position single foot lift test Figure 9.13 Benchmark single foot lift test
430
The hip Chapter |9|
activities. During the single foot lift test, the

weight bearing hip demonstrates UCM into
flexion (the trunk leans forwards and the hips flex
moving the buttocks backwards as the foot lifts).
The hip has UCM into flexion relative to the con-
tralateral hip flexion. Hip flexion control is poor
if the subject is unable to prevent or resist the
increased hip flexion on the stance leg.
The uncontrolled hip flexion is often associated
with inefficiency of the stability function of the
gluteal extensor muscles (especially deep gluteus
maximus), which provide isometric or eccentric
control of hip flexion. During the attempt to dis-
sociate the weight bearing hip flexion from con-
tralateral hip flexion, the person either cannot
hard to control the hip flexion. The movement
must be assessed on both sides. If hip flexion
or worse than the other.

If some other movement (e.g. a small amount of rotation)

is observed during a motor control (dissociation) test of
flexion control, do not score this as uncontrolled flexion.
The rotation motor control tests will identify whether the
observed movement is uncontrolled. A test for hip flexion
UCM is only positive if uncontrolled hip flexion is
Figure 9.14 Correction partial range with wall support
demonstrated.
The shoulders and pelvis should stay level. The

Rating and diagnosis of hip person should then slowly lift the other foot 15–
flexion UCM 20 cm off the floor (as if stepping up onto a step)
(T66.1 and T66.2) (Figure 9.14). There should be no increase in hip
flexion on the weight bearing stance leg. Only lift
the foot as far as the trunk can stay on the wall
Correction and do not lean forwards into increased hip
Initial retraining is best started with the trunk flexion.
supported against a wall. The person stands with The person should self-monitor the hip and
the back against a wall, the feet hip width apart trunk alignment and control hip flexion UCM
and the weight balanced over the feet. The heels with a variety of feedback options (T66.3). There
should be approximately 5–10 cm from the wall. should be no provocation of any symptoms
The pelvis should be level and the trunk upright within the range that the hip flexion UCM can be
(vertical against the wall). The person should be controlled.
instructed to perform a SKB by sliding the trunk As the ability to control hip flexion and for-
down the wall to a 1 4 squat position with weight wards lean of the trunk gets easier and the pattern
balanced equally on both feet. This is followed by of dissociation feels less unnatural, the exercise
a shift of full weight onto one leg, allowing the can be progressed to performing this same move-
pelvis and shoulders to move laterally to keep ment unsupported, without the wall, in single leg
body weight centred over the weight bearing foot. stance.
431
T66.1 Assessment and rating of low threshold recruitment efficiency of the Single Foot Lift Test
SINGLE FOOT LIFT – STANDING
Control point:
• prevent hip flexion (weight bearing leg)
Movement challenge: contralateral hip flexion (standing)
Benchmark range: lift contralateral foot 15–20 cm

or or
and move contralateral hip flexion confidently prevent UCM into the test
• Dissociate movement through the benchmark direction
range of: contralateral foot lift to 90° hip • The pattern of dissociation is smooth during
flexion concentric and eccentric movement
If there is more available range than the • Does not (consistently) use end-range
range needs to be actively controlled prevent the UCM
• Without holding breath (though it is • No extra feedback needed (tactile, visual or
acceptable to use an alternate breathing verbal cueing)
strategy) • Without external support or unloading
• Control during eccentric phase • Relaxed natural breathing (even if not ideal –
• Control during concentric phase so long as natural pattern does not change)
• No fatigue
from the Single Foot Lift Test
SINGLE FOOT LIFT TEST – STANDING
Site Direction (L) leg (R) leg position
(check box) (check box) Visual observation Observe in a mirror or directly
watch the movement
Hip Flexion ! !
432
The hip Chapter |9|
pelvis backwards (posterior pelvic tilt) to flatten

T67 STANDING: SPINAL ROLL DOWN TEST the back onto the wall. The person should
(tests for hip flexion UCM) monitor that they can feel the sacrum flattened
against the wall. They should then continue to
This dissociation test assesses the ability to actively flex the spine by slowly letting the head and chest
dissociate and control hip flexion and perform drop towards the pelvis. The spine should unroll
spinal flexion by rolling the spine down into into flexion, but the pelvis and sacrum should
flexion while standing. stay firmly flattened against the wall.
The person should have the ability to dissociate
the hip flexion from spinal flexion as evidenced
Test procedure
by preventing the pelvis rolling off the wall, while
The person stands with pelvis and upper back rolling the spine down from the wall into spinal
supported against the wall, the feet at least shoul- flexion. Ideally, the person should be able to roll
der width apart and the knees slightly flexed (hip down into full spinal flexion and maintain the
flexors unloaded and wide base of support). The pelvis posteriorly tilted against the wall (Figure
heels are positioned about 15–20 cm in front of 9.16). There should be no forwards pelvic tilt off
the wall (Figure 9.15). Then, they are instructed the wall (i.e. hip flexion) as the spine rolls for-
to actively lower the sternum towards the pelvis wards off the wall into spinal flexion. The spinal
by flexing the thoracic spine while rolling the flexion must be independent of any hip flexion
Figure 9.15 Start position spinal roll down test Figure 9.16 Benchmark spinal roll down test
433
or movement of the pelvis. Note any uncontrolled unloaded and wide base of support). If control is
hip flexion under spinal flexion load. This test poor, the heels are initially positioned about 30–
should be performed without any feedback (self- 40 cm in front of the wall. Then they are instructed
palpation, vision, etc.) or cueing for correction. to actively lower the sternum towards the pelvis
The therapist should use visual observation of the by flexing the thoracic spine while rolling the
femur and pelvis to determine whether the control pelvis backwards (posterior pelvic tilt) to flatten
of hip flexion is adequate. the back onto the wall. The person should
monitor that they can feel the sacrum flattened
against the wall. Only roll the spine down off the
Hip flexion UCM
wall through partial flexion range (Figure 9.17).
The person complains of pain in the hip (groin Ensure that the sacrum and upper pelvis can stay
impingement, lateral trochanteric or lateral firmly in contact with the wall and not roll for-
buttock pain) associated with hip flexion activi- wards into increased hip flexion.
ties. During the spinal roll down test, the hip As control improves, the person is instructed to
demonstrates UCM into flexion (the pelvis rolls shift their feet closer to the wall and to increase
forwards off the wall to follow the spinal roll the range of spinal roll down. At the point
down). The hip has UCM into flexion relative to in range that the pelvis starts to roll forwards
the spine. Hip flexion control is poor if the subject into hip flexion the movement should stop and
is unable to prevent or resist the excessive hip return to the start position. The person should
flexion or the top of the pelvis rolling forwards
off the wall.
The uncontrolled hip flexion is often associated
gluteal extensor muscles (especially deep gluteus
control of hip flexion. During the attempt to dis-
sociate the hip flexion from spinal flexion, the
person either cannot control the UCM or has to
concentrate and try hard to control the hip
flexion.


flexion control, do not score this as uncontrolled flexion.
The rotation motor control tests will identify whether the
observed movement is uncontrolled. A test for hip flexion
UCM is only positive if uncontrolled hip flexion is
demonstrated.
Rating and diagnosis of hip

flexion UCM
(T67.1 and T67.2)
Correction
Retraining is best started with the trunk supported
against a wall, the feet at least shoulder width
apart and the knees slightly flexed (hip flexors Figure 9.17 Correction partial roll down with wall support
434
The hip Chapter |9|
self-monitor the hip and pelvis alignment and As the ability to control hip flexion and for-
control hip flexion UCM with a variety of feed- wards lean of the trunk gets easier and the pattern
back options (T67.3). There should be no provo- of dissociation feels less unnatural, the exercise
cation of any symptoms within the range that the can be progressed to performing this same move-
hip flexion UCM can be controlled. ment unsupported, without the wall.
435
T67.1 Assessment and rating of low threshold recruitment efficiency of the Spinal Roll Down Test
SPINAL ROLL DOWN – STANDING (WALL)
Control point:
Movement challenge: spinal flexion (standing – wall)
Benchmark range: independent full range spinal flexion without pelvic or hip movement

or or
and move spinal flexion confidently prevent UCM into the test
range of: full end range spinal flexion with • The pattern of dissociation is smooth during
sacrum flat on wall concentric and eccentric movement
• No fatigue
from the Spinal Roll Down Test
SPINAL ROLL DOWN TEST – STANDING
Site Direction position
watch the movement
Hip Flexion !
436
The hip Chapter |9|
Hip flexion UCM

T68 SIDE-LYING: SINGLE LEG
ABDUCTION TEST The person complains of flexion-related symp-
toms in the hip. During the single leg abduction
(tests for hip flexion UCM) test, the leg moves forwards of the body (hip
flexion UCM) before the abduction reaches 35°
This dissociation test assesses the ability to actively above horizontal). Under unilateral hip loading,
dissociate and control hip flexion and perform a the hip has UCM into flexion.
single leg hip abduction and lateral rotation. The uncontrolled hip flexion is often associated
Test procedure gluteal extensor muscles (especially deep gluteus
The person lies on one side with uppermost (top) control of hip flexion. During the attempt to dis-
leg extended in line with the trunk and the other sociate the hip flexion from spinal flexion, the
(bottom leg) hip flexed to 45° and the knees person either cannot control the UCM or has to
flexed to 90° (Figure 9.18). The pelvis should be concentrate and try hard to control the hip
positioned in neutral rotation. The person is flexion. The movement must be assessed on both
instructed to maintain the neutral pelvis position sides. If hip flexion UCM presents bilaterally, one
and turn the uppermost foot outwards (hip lateral side may be better or worse than the other.
rotation). Then they should slowly lift the upper-
most leg vertically up and out to the side while
keeping the leg and foot turned out into lateral
rotation. Ideally, the top leg should be able to
maintain the hip extension and turnout and lift
into at least 35° (above horizontal) of hip abduc-
tion and lateral rotation (Figure 9.19) and return,
without associated loss of neutral extension into
any flexion of the hip.
The unilateral hip abduction must be inde-
pendent of any hip flexion. Note any excessive
hip flexion under hip abduction load. This test
palpation, vision, flexicurve, etc.) or cueing for
correction. The therapist should use visual obser-
vation of the pelvis to determine whether the
control of hip flexion is adequate when feedback
is removed for testing. Assess both sides.
Figure 9.18 Start position single leg abduction test Figure 9.19 Benchmark single leg abduction test
437
to lift the top leg up and out to the side. Hold this
position, and lift the heel of the top foot 2–3 cm
away from the bottom heel. Ensure that, as the
If some other movement (e.g. a small amount of rotation) heel lifts, the leg does not move forwards into hip
is observed during a motor control (dissociation) test of flexion. At the point in range that the hip starts
flexion control, do not score this as uncontrolled flexion. to lose control of flexion, the movement should
The rotation motor control tests will identify whether the stop. The hip position is restabilised (lift the knee
observed movement is uncontrolled. A test for hip flexion and keep the heel down), then hold this position
UCM is only positive if uncontrolled hip flexion is for a few seconds and return to the start
demonstrated. position.
pendent of any hip flexion. The person should
self-monitor the hip alignment and control
flexion UCM with a variety of feedback options
Rating and diagnosis of hip (T68.3). There should be no provocation of any
flexion UCM symptoms within the range that the rotation
(T68.1 and T68.2) UCM can be controlled.
As the ability to control hip flexion gets easier
and the pattern of dissociation feels less unnatu-
Correction ral, the exercise can be progressed to performing
If control is poor, retraining can initially begin the hip abduction and lateral rotation with the
with reduced leg load. With the person side-lying leg fully extended.
and the hips extended to neutral (0° extension),
the knees flexed to 60° and the feet together, the
Hip flexion UCM summary
pelvis should be positioned in neutral rotation.
Keeping the heels together the person is instructed (Table 9.2)
Table 9.2 Summary and rating of hip flexion tests

HIP FLEXION !
TEST RATING (✓✓ or ✓✗ or ✗✗ ) and rationale
Standing: vertical trunk single leg 1

4 squat
Standing: single foot lift
Standing: spinal roll down
Side-lying: single leg abduction
438
The hip Chapter |9|
T68.1 Assessment and rating of low threshold recruitment efficiency of the Single Leg Abduction Test
SINGLE LEG ABDUCTION TEST – SIDE-LYING
Control point:
Movement challenge: unilateral hip abduction and lateral rotation (side-lying)
Benchmark range: 35° independent hip abduction and lateral rotation without compensation

or or
• medial flexion awareness of the movement pattern that they
and move hip abduction and lateral rotation confidently prevent UCM into the test
(turnout) direction
range of: 35° hip abduction and lateral concentric and eccentric movement
rotation • Does not (consistently) use end-range
from the Single Leg Abduction Test
SINGLE LEG ABDUCTION TEST – STANDING
watch the movement
Hip Flexion ! !
439
lumbar spine remains in neutral and the

Hip extension control thigh adducted to the midline, the knee is
passively extended to unload tension from
Movement faults associated with rectus femoris. If rectus femoris is one of the
hip extension short hip flexors, the hip is able to extend
further and the leg drops closer to the table
The modified Thomas test can be used to further
(Figure 9.22).
identify the origin and nature of movement faults
• Tensor fasciae latae and iliotibial band. From
associated with hip extension.
the lowered position (leg hanging above the
table) while the lumbar spine remains in
Modified Thomas test neutral and the knee flexed to 80°, the thigh
The person sits on the end of a plinth or table, is passively abducted to unload tension from
holds onto one knee and rolls backwards onto the iliotibial band. If the iliotibial band is
their back keeping both legs flexed. With the one of the short hip flexors, the hip is able
lower thoracic spine and sacrum flat on the table, to extend further and the leg drops closer to
the subject pulls one knee up towards the chest the table (Figure 9.23).
until the lumbar spine flattens onto the table, but • Anterior capsule or (iliacus). From the lowered
not so far that the sacrum rolls off the table into position (leg hanging above the table) while
lumbopelvic flexion. The subject uses both hands the lumbar spine remains in neutral, the
holding one knee to support this flat back posi- thigh is passively abducted to unload tension
tion. The therapist then passively lowers the test
leg down towards the table (hip extension),
keeping the hip adducted to the midline and knee
flexed to 90° while monitoring maintenance of
the lumbopelvic position (Figures 9.20 and 9.21).
Relative stiffness (restrictions of

hip extension)
If the thigh hangs above horizontal some hip
flexor structure lacks extensibility. Further assess-
ment can differentiate the origin of relative stiff-
ness to short tensor fasciae latae/iliotibial band,
rectus femoris or anterior capsule:
• Rectus femoris. From the lowered position
(leg hanging above the table) while the
Figure 9.20 Modified Thomas test start position Figure 9.21 Modified Thomas test final position
440
The hip Chapter |9|
from the iliotibial band and the knee is

passively extended to unload tension from
rectus femoris. If the anterior capsule is
short, the hip still hangs above the table and
cannot extend fully.

• Excessive hip extension. Unload the myofascial
structures by slightly extending the knee and
abducting the hip. If the thigh hangs more
than 10° below the horizontal there is
excessive range of hip extension with laxity
of the anterior restraints (elongated iliacus
Figure 9.22 Modified Thomas test rectus femoris and anterior hip capsule). If excessive hip
contribution extension is noted it is important to test
further for uncontrolled anterior femoral
head translation (hip forwards glide) as well
as uncontrolled extension.
HIP EXTENSION CONTROL TESTS AND

EXTENSION CONTROL REHABILITATION
These extension control tests assess the amount

of extension UCM in the hip and assess the ability
of the dynamic stability system to adequately
control extension load or strain. It is a priority to
assess for extension UCM if the patient complains
of or demonstrates extension-related symptoms
or disability. The tests that identify dysfunction
can also be used to guide and direct rehabilitation
strategies.

extension UCM
1. hypermobile hip extension range
2. excessive initiation of leaning backwards or
knee extension with hip extension
associated with hip extension or sustained
extension postures.
toms in the hip. Under extension load, the hip
has greater give into extension relative to the trunk
Figure 9.23 Modified Thomas test tensor fasciae latae and lower leg. The dysfunction is confirmed with
– iliotibial band contribution motor control tests of extension dissociation.
441
Hip extension control tests
T69 STANDING: THORACOLUMBAR

EXTENSION TEST
(tests for hip extension UCM)

control hip extension while actively lifting the
sternum up and forwards into thoracolumbar
extension in standing.
Test procedure
The person initially stands tall with the upper
thighs against the edge of a plinth, bench or table
and with the feet as far under the table as balance
can be maintained. Position the head directly
over the shoulders without chin poke. Demon-
strate or manually assist the movement of thora-
columbar extension. The sternum, clavicles and
acromions should all move up and forwards.
There should be no hip extension or forwards
sway of the pelvis (the table provides feedback
and support). The normal anterior pelvic should
be present (with slight concurrent hip flexion)
and all of the lumbar spine and the lower tho-
racic vertebrae should contribute to the thoraco- Figure 9.24 Start position thoracolumbar extension test
lumbar extension initiated from the thoracic
region.
For testing, feedback and the support of the
table are taken away. The person stands tall and
unsupported with legs straight and the lumbar
spine and pelvis positioned in the neutral. The
head is positioned directly over the shoulders
Hip extension UCM
without chin poke (Figure 9.24). Without letting
the lumbopelvic region move into forwards The person complains of extension-related symp-
sway, the person should have the ability to toms in the hip. The hip has UCM into hip exten-
actively lift the sternum and chest up and for- sion and forwards pelvic sway relative to the
wards through the full available range of thora- spine under extension load. During active hip
columbar extension. extension, the hip starts to move into extension
Ideally, the person should have the ability to before achieving thoracolumbar extension. The
prevent hip extension and forwards sway of the upper lumbar spine and thoracic spine may only
pelvis while independently extending the thora- contribute (if at all) to extension at the comple-
columbar region from a position of relaxed tion of hip extension. During the attempt to
flexion through to full extension (Figure 9.25). dissociate the hip extension from independent
The available range of dissociated thoracolumbar thoracolumbar extension (while allowing
extension is small. This test should be performed normal slight anterior pelvic tilt) the person
without any feedback (self-palpation, vision, either cannot control the UCM or has to concen-
tape, etc.) or cueing for correction. trate and try hard.
442
The hip Chapter |9|
Figure 9.25 Benchmark thoracolumbar extension test Figure 9.26 Correction thoracic extension with hip support
extension or forwards sway of the pelvis, the

person actively lifts the chest up and forwards
into thoracolumbar extension only as far as hip
If some other movement (e.g. a small amount of rotation) extension and forwards sway of the pelvis can be
is observed during a motor control (dissociation) test of actively controlled or prevented. The normal
extension control, do not score this as uncontrolled anterior pelvic tilt should be present (with slight
extension. The rotation motor control tests will identify concurrent hip flexion) and all of the lumbar
whether the observed movement is uncontrolled. A test spine and the lower thoracic vertebrae should
for hip extension UCM is only positive if uncontrolled hip contribute to the spinal extension initiated from
extension is demonstrated. the thoracolumbar region.
If control is poor, start retraining with addi-
tional feedback and support. The person stands
Rating and diagnosis of hip with the upper thighs against the edge of a bench
extension UCM or table and with the feet as far under the table
as balance can be maintained. With the table pre-
(T69.1 and T69.2) venting hip extension and forwards sway of the
pelvis, the chest should move up and forwards.
Correction Also, the upper body and trunk weight can be
The person stands tall and unsupported with legs supported by weight bearing through the arms to
straight and the spine, pelvis and hips positioned decrease the load that must be controlled (Figure
in the neutral. Without letting the hips move into 9.26). Train by moving into thoracolumbar
443
extension only as far as the hip extension can be As the ability to control the UCM gets easier,
prevented. and the pattern of dissociation feels less unnatu-
The person should monitor the hip alignment ral, the exercise can be progressed to the unsup-
and control with a variety of feedback options ported position without a bench or table and
(T69.3). There should be no provocation of any then it should be integrated into various func-
symptoms under thoracolumbar extension load, tional postures and positions.
within the range that the hip extension UCM can
be controlled.
444
The hip Chapter |9|
T69.1 Assessment and rating of low threshold recruitment efficiency of the Thoracolumbar Extension Test
THORACOLUMBAR EXTENSION TEST – STANDING
Control point:
• prevent hip extension (forward pelvic sway)
Movement challenge: thoracolumbar extension (standing)
Benchmark range: full available dissociated thoracolumbar extension without compensation

or or
• extension (forward pelvic sway) awareness of the movement pattern that they
and move thoracolumbar extension confidently prevent UCM into the test
range of: full available thoracolumbar • The pattern of dissociation is smooth during
extension concentric and eccentric movement
• No fatigue
from the Thoracolumbar Extension Test
THORACOLUMBAR EXTENSION
Site Direction (L) leg (R) leg
Hip Extension ! ! Adhesive tape Skin tension for tactile feedback

445
should maintain a neutral relaxed shallow lordo-

T70 STANDING: SINGLE KNEE sis (Figure 9.27). The person is then instructed to
LIFT + ANTERIOR TILT TEST hold the hip flexed position (thigh horizontal)
(tests for hip extension UCM) and slowly start to tilt the pelvis forwards (ante-
rior pelvic tilt) and extend the lumbar spine. The
subject should maintain the hip flexed position
This dissociation test assesses the ability to
to prevent any increase in hip extension (lowering
actively dissociate and control hip extension and
of the thigh) as the pelvis tilts and the lumbar
maintain unilateral hip flexion while actively
spine extends.
extending the spine and anteriorly tilting the
Ideally, the pelvis should be able to achieve full
pelvis.
anterior pelvic tilt independently of any hip
extension (keep the thigh horizontal) (Figure
9.28). As soon as any movement indicating a loss
Test procedure
of control into hip extension is observed, or
The person stands on one leg and, keeping the swaying the pelvis forwards to maintain the leg
shoulders and pelvis level, slowly lifts the other position, the movement must stop and return
foot off the ground to lift the thigh to 90° hip back to the start position. Anterior pelvic tilt must
flexion with the lower leg relaxed and the heel be demonstrated with the hip flexion maintained
hanging vertically under the knee. The thigh at 90° (thigh horizontal) and with shoulders and
should be horizontal and the lumbopelvic region pelvis level.
Figure 9.27 Start position single knee lift + anterior tilt test Figure 9.28 Benchmark single knee lift + anterior tilt test
446
The hip Chapter |9|
The anterior pelvic tilt must be independent of Correction

any hip extension. Note any uncontrolled hip If control is poor, initial retraining is best started
extension under pelvic tilt load. This test should in a 1 2 lunge position. The person stands in a
be performed without any feedback (self- shallow 1 2 lunge with the trunk and the rear thigh
palpation, vision, flexicurve, etc.) or cueing for vertical and the front thigh weight bearing and
correction. When feedback is removed for testing held flexed to about 60°. The lumbopelvic region
the therapist should use visual observation of the should maintain a neutral relaxed shallow lordo-
pelvis and leg to determine whether the control sis. If needed, the person can hold onto a table
of hip extension is adequate. Assess both sides. or chair for balance or to support body load. The
person is then instructed to hold the front hip
Hip extension UCM flexed (60°) position and slowly start to tilt the
pelvis forwards (anterior pelvic tilt) and extend
The person complains of pain in the hip (groin the lumbar spine (Figure 9.29).
impingement or lateral buttock pain) associated The person should maintain the hip flexed
with hip extension activities. During the single position to prevent any increase in hip extension
knee lift + anterior tilt test, the person lacks the (lifting the body and straightening up) as the
ability to prevent the thigh from lowering and the pelvis tilts and the lumbar spine extends. They
hip from extending as the pelvis tilts forwards and are to extend the spine and tilt the pelvis only as
the spine extends. The thigh lowers from horizon- far as the front thigh position is maintained
tal before the pelvis achieves full anterior tilt.
Under anterior pelvic tilt loading, the hip has
UCM into extension. Swaying the pelvis forwards
to hold the thigh horizontal is a common substi-
tution strategy for inefficient control.
The uncontrolled hip extension is often associ-
ated with inefficiency of the stability function of
the anterior hip stabilisers (especially iliacus and
pectineus) providing isometric or eccentric
control of hip extension. During the attempt to
dissociate the hip extension from spinal exten-
sion and anterior pelvic tilt, the person either
and try hard to control the hip extension. The
movement must be assessed on both sides. If hip
extension UCM presents bilaterally, one side may


extension control, do not score this as uncontrolled
extension. The rotation motor control tests will identify
whether the observed movement is uncontrolled. A test
for hip extension UCM is only positive if uncontrolled hip
extension is demonstrated.

extension UCM
(T70.1 and T70.2) Figure 9.29 Correction 1
2 lunge plus anterior tilt
447
(monitored with feedback). At the point in range unnatural, the exercise can be progressed to per-
that the body starts to lift or straighten at the front forming this spinal extension in a lower or deeper
hip, the movement should stop. lunge (front thigh horizontal at 90° hip flexion).
The person should self-monitor the hip align- Finally, the exercise is progressed to a non-weight
ment and control extension UCM with a variety bearing exercise position, as in the test position
of feedback options (T70.3). There should be no (i.e. standing upright with the hip held unsup-
provocation of any symptoms withzin the range ported in hip flexion).
As the ability to control hip extension gets
easier and the pattern of dissociation feels less
448
The hip Chapter |9|
T70.1 Assessment and rating of low threshold recruitment efficiency of the Single Knee Lift + Anterior Tilt Test
SINGLE KNEE LIFT + ANTERIOR TILT TEST – STANDING
Control point:
• prevent hip extension
Movement challenge: unilateral hip flexion + spinal extension and anterior pelvic tilt (standing)
Benchmark range: full independent anterior pelvic tilt and maintain 90° hip flexion without compensation of hip extension

or or
• extension awareness of the movement pattern that they
and move spinal extension and anterior pelvic confidently prevent UCM into the test
tilt direction
range of: full anterior pelvic tilt + 90° concentric and eccentric movement
unilateral hip flexion • Does not (consistently) use end-range
from the Single Knee Lift + Anterior Tilt Test
SINGLE KNEE LIFT + ANTERIOR TILT TEST

449
should maintain a neutral relaxed shallow lordo-

T71 STANDING: SINGLE KNEE sis (Figure 9.30). The person is then instructed to
LIFT + KNEE EXTENSION TEST hold the non-weight bearing hip flexed position
(tests for hip extension UCM) (thigh horizontal) and slowly start to straighten
the knee (knee extension). The subject should
maintain the hip flexed position to prevent any
increase in non-weight bearing hip extension
dissociate and control hip extension and main-
(lowering of the thigh) as the knee extends.
tain unilateral hip flexion while actively extend-
Ideally, the knee should be able to straighten to
ing the knee.
within 20° of full extension independently of any
hip extension on the non-weight bearing side
Test procedure
(keep the thigh horizontal) (Figure 9.31). As soon
The person stands on one leg and, keeping the as any movement indicating a loss of control into
shoulders and pelvis level, slowly lifts the other hip extension is observed, or swaying the pelvis
foot off the ground to lift the thigh to 90° of hip forwards to maintain the leg position is noted,
flexion with the lower leg relaxed and the heel the movement must stop and return back to the
hanging vertically under the knee. The thigh start position. Knee extension must be demon-
should be horizontal and the lumbopelvic region strated with the hip flexion maintained at 90°
Figure 9.30 Start position single knee lift + knee extension Figure 9.31 Benchmark single knee lift + knee extension
test test
450
The hip Chapter |9|
(thigh horizontal) and with shoulders and pelvis Correction

level. If control is poor, initial retraining is best started
The knee extension must be independent of with the hip held in less than 90° of hip flexion.
any hip extension. Note any uncontrolled hip The lumbopelvic region should maintain a
extension under knee extension load. This test neutral relaxed shallow lordosis. If needed, the
should be performed without any feedback (self- person can support the back against a wall or
palpation, vision, flexicurve, etc.) or cueing for hold onto a table or chair for balance or to
correction. The therapist should use visual obser- support body load. The person is then instructed
vation of the pelvis and leg to determine whether to stand on one leg and to hold the other hip
the control of hip extension is adequate when flexed to 60° and slowly start to extend the knee
feedback is removed for testing. Assess both sides. (Figure 9.32).
The person should maintain the hip flexed
Hip extension UCM position (at 60°) and prevent any increase in hip
extension (further lowering of the thigh) as the
The person complains of pain in the hip (groin knee extends. They are to extend the knee only as
impingement or lateral buttock pain) associated far as the thigh position is maintained (moni-
with hip extension activities. During the single tored with feedback). At the point in range that
knee lift + knee extension test, the person lacks the thigh starts to lower into increased hip flexion,
the ability to prevent the thigh from lowering the movement should stop.
and the hip from extending as the knee extends.
The thigh lowers from horizontal before the knee
reaches 20° from full extension. Under knee
extension loading, the hip has UCM into
extension.
The uncontrolled hip extension is often associ-
the anterior hip stabilisers (especially iliacus and
pectineus), providing isometric or eccentric
control of hip extension. During the attempt to
dissociate the hip extension from knee extension,
the person either cannot control the UCM or has
to concentrate and try hard to control the hip
extension. The movement must be assessed on
both sides. If hip extension UCM presents bilater-
ally, one side may be better or worse than the
other.


extension control, do not score this as uncontrolled
extension. The rotation motor control tests will identify
whether the observed movement is uncontrolled. A test
for hip extension UCM is only positive if uncontrolled hip
extension is demonstrated.

extension UCM
(T71.1 and T71.2) Figure 9.32 Correction on wall
451
The person should self-monitor the hip align- unnatural, the exercise can be progressed to main-
ment and control extension UCM with a variety taining the thigh horizontal (at 90° hip flexion).
Hip extension UCM summary
As the ability to control hip extension gets
easier and the pattern of dissociation feels less (Table 9.3)
Table 9.3 Summary and rating of hip extension tests

HIP EXTENSION !
Standing: thoracolumbar extension
Standing: single knee lift + anterior tilt
Standing: single knee lift + knee extension
452
The hip Chapter |9|
T71.1 Assessment and rating of low threshold recruitment efficiency of the Single Knee Lift + Knee Extension
Test
SINGLE KNEE LIFT + KNEE EXTENSION TEST – STANDING
Control point:
• prevent hip extension
Movement challenge: unilateral hip flexion + knee extension (standing)
Benchmark range: 20° from full knee extension and maintain 90° hip flexion without compensation of hip extension

or or
• extension awareness of the movement pattern that they
and move knee extension confidently prevent UCM into the test
range of: 20° from full knee extension + 90° • The pattern of dissociation is smooth during
unilateral hip flexion concentric and eccentric movement
• No fatigue
from the Single Knee Lift + Knee Extension Test
SINGLE KNEE LIFT + KNEE EXTENSION

453
Hip rotation control
OBSERVATION AND ANALYSIS OF HIP

ROTATION AND TRUNK TURNING

The subject is instructed to stand with the feet in
a natural stance and shift weight to stand on one
leg by lifting the foot of one leg just clear of the
floor. The subject is instructed to turn to each side
as far as comfortably possible. Ideally, the shoul-
ders and upper body (measured by a line across
both acromions) should be able to turn at least
90° from the stance foot. The pelvis should be
able to turn at least 45° from the stance foot.
Rotation should occur concurrently below the
pelvis (at the ankle, knee, hip) and above the
pelvis (lumbar spine, thoracic spine, scapulae),
with approximately one-half of the contribution
coming from above and one-half from below the
pelvis (Figure 9.33).
There should be good symmetry of movement
without any lateral deviation, tilt or rotation of
the trunk or pelvis. The head, sternum and pubic
symphysis should be aligned above the stance
foot with the shoulders level in an upright posture.
Figure 9.33 Ideal pattern of hip and trunk rotation

Movement faults associated
with hip rotation
Relative stiffness (restrictions) • Restriction of hip medial rotation – the pelvis
lacks 45° of normal range of turning
• Thoracolumbar restriction of rotation – the towards the stance leg (i.e. <45° of pelvis
upper body lacks 45° of normal range of rotation to the right when standing on the
turning towards the stance leg (i.e. <45° right foot). Hip lateral rotation may increase
of upper body rotation to the right when to compensate for the lack of hip medial
standing on the right foot). A thoracolumbar rotation.
rotation restriction may contribute to
compensatory increases in hip rotation Relative flexibility (potential UCM)
range. This is confirmed with motion
assessment and manual segmental joint • Hip medial rotation. The hip may initiate the
assessment (e.g. Maitland PPIVMs or movement into turning, and contribute more
PAIVMs). to producing rotation while the upper body
• Restriction of hip lateral rotation – the pelvis starts later and contributes less. At the limit
lacks 45° of normal range of turning away of turning, excessive or hypermobile range of
from the stance leg (i.e. <45° of pelvis hip rotation may be observed. During the
rotation to the left when standing on the return to neutral, the hip rotation persists
right foot). Hip medial rotation may increase and returns late. Increased range or
to compensate for the lack of hip lateral uncontrolled hip medial rotation is a
rotation. This is a common presentation. common compensation for reduced
454
The hip Chapter |9|
thoracolumbar rotation and reduced hip can be clarified by further assessment of

lateral rotation. stability function for specific muscles and
• Hip lateral rotation. The hip may initiate the determination if muscle active shortening
movement into turning, contribute more to matches joint passive range. This is retrained
producing rotation while the upper body using low threshold (non-fatiguing) active
starts later and contributes less. Excessive or recruitment training in shortened range
hypermobile range of hip rotation may be positions (inner range hold).
observed. During the return to neutral, the • Decreased lateral rotation of hip (common).
hip rotation persists and returns late. This may arise due to shortening of capsule
Increased range or uncontrolled hip lateral or myofascial structures (TFL/ITB).
rotation is a compensation for reduced Differentiate by end feel; also take leg into
thoracolumbar rotation and reduced hip abduction by 5 cm, and if the restricted
medial rotation. range of lateral rotation increased, TFL/ITB is
limiting movement (no change capsule).
Assessment of relative hip Specific muscle length tests can confirm
myofascial shortening. This is best recovered
rotation range using a combination of active inhibitory
Assess relative hip rotation range in hip extension lengthening techniques and passive
(prone). This is where hip rotation is used func- myofascial mobilisation techniques.
tionally. The majority of textbook measurements • Decreased medial rotation of hip. This may
of hip rotation are performed with the hip flexed arise due to shortening of capsule or
to 90° (medial rotation 35–40°, lateral rotation myofascial structures (e.g. piriformis or
45–60°). This is not particularly relevant to the superficial fibres of gluteus maximus).
weight bearing hip where functional loading Differentiate by end feel. Specific muscle
usually occurs in an extended or neutral length tests can confirm myofascial
position. shortening. However, in this hip extended
In a prone position, with the knees together position the piriformis or superficial fibres of
and the hip in neutral based on Craig’s test, assess gluteus maximus are unloaded and could
rotation range. Ideally, there should be 35° of not contribute to decreased medial rotation.
active lateral rotation and 35° of active medial The restriction is more likely to be articular
rotation from neutral. A difference of less than or capsular. This is best recovered using a
10° between medial and lateral rotation is not combination of passive articular and
clinically significant (Sahrmann 2002). capsular mobilisation techniques and active
exercise to maintain mobility.
Movement faults
• Excessive medial rotation of hip (common).
Poor stability function or excessive length of Assessment of rotation
the capsule or lateral rotator stability dysfunction at the hip
muscles (posterior gluteus medius and
intrinsic hip lateral rotators) may be noted. Lower quadrant rotational
This can be clarified by further assessment of alignment evaluation
the stability function for specific muscles,
and determination if muscle active • Stand in natural stance.
shortening matches joint passive range. This • Do a SKB. (In weight bearing, flex the knees
is retrained using low threshold (non- and dorsiflex the ankles while keeping both
fatiguing) active recruitment training in heels on the floor.)
shortened range positions (inner range • Knee bend as far as the heels can stay on the
hold). floor.
• Excessive lateral rotation of hip. Poor stability • Observe the relative rotational alignment of
function or excessive length of the medial hip, knee and foot in the natural pattern
rotator stability muscles (anterior gluteus (without cueing and alignment correction)
medius and minimus) may be noted. This (Figure 9.34).
455
suggesting either a structural or functional

problem:
• Femoral medial rotation indicates a loss of
femoral rotation control (poor stability of
posterior gluteus medius or overactivity of
tensor fasciae latae). Observe that the femur
medially rotates and the long axis of the
femur moves medial to the neutral 10°
sagittal line (and medial to the 2nd
metatarsal).
• Lateral tibial rotation indicates a loss of
tibial rotation control (poor stability of
popliteus and overactivity of tensor fasciae
latae/anterior iliotibial band, superficial
gluteus maximus/posterior iliotibial band or
biceps femoris). Observe that the heel pulls
in or the foot turns out so that the line of
the 2nd metatarsal moves lateral to the
neutral 10° sagittal line and is more than
10° lateral to the sagittal plane (and lateral
to the long axis of the femur).
• Once proximal stability has been lost (loss
of femoral or tibial rotation control) the
rearfoot or midfoot loses functional stability
and the medial longitudinal arch is forced to
collapse. This is often associated with a lack
of closed chain stability control by tibialis
posterior. Observe substitution with
overactivity of the toe flexors.
‘Natural’ (uncorrected) rotational alignment can
Sagittal line (line of gait progression)
be classified into one of four groups:
10° neutral line (line of weight transfer) 1. Ideal (Figure 9.34):
Femur line (line of hip rotation) a. femur and tibia (foot) correctly aligned on
2nd toe line (line of tibial rotation)
the neutral line (=10°).
2. Hip (femoral) medial rotation dysfunction
(Figure 9.35):
Figure 9.34 Ideal rotation (axial) alignment
a. femur aligned inside the neutral line
(<10°)
b. tibia (foot) correctly aligned on the
neutral line (=10°).
3. Tibial lateral rotation dysfunction
Ideal rotational alignment (Figure 9.36):
a. tibia (foot) aligned outside the neutral
The long axis of the femur and the 2nd metatarsal
line (>10°)
are both aligned to the lower limb neutral line (a
b. femur correctly aligned on the neutral line
line 10° lateral to the sagittal plane – starting at
(=10°).
the heel of each foot).
4. Femoral medial rotation + tibial lateral
rotation dysfunction (Figure 9.37):
Dysfunctions a. femur aligned inside the neutral line
The long axis (line) of femur falls medial to (<10°)
the neutral 10° sagittal line or the 2nd metatarsal b. tibia (foot) aligned outside the neutral
aligns lateral to the neutral 10° sagittal line line (>10°).
456
The hip Chapter |9|
Figure 9.35 Rotation (axial) alignment group 2 – hip medial

rotation dysfunction: excessive hip medial rotation (knee
turned in) relative to a neutral foot (tibial) alignment
Figure 9.36 Rotation (axial) alignment group 3 – tibial
lateral rotation dysfunction: excessive tibial lateral rotation
(foot turned out) relative to neutral hip and knee alignment
Correcting neutral rotational
alignment of the small knee
correction can be achieved with ease or only with
bend (SKB) difficulty, or if it cannot be corrected. When cor-
Correct neutral alignment is often required as a recting the SKB to neutral, note if there is a sensa-
start position for many of the dissociation tests tion of strain. This often indicates a site of
for UCM. Correct the foot position (place the feet restriction. Assess that area for articular of myo-
hip width apart with the 2nd metatarsal aligned fascial restrictions.
along the ‘neutral line’ of weight transfer (a line Progress to performing this same movement
that is 10° lateral to the sagittal plane) and without the wall, with both feet. The final pro-
perform a SKB, by flexing the knees and dorsiflex- gression is to perform the SKB unsupported in
ing the ankles while keeping both heels on the single leg stance.
floor (Figure 9.34). Visualise resting the back
against a wall and then bend the knees to slide
the back down the wall. The line of the femur HIP MEDIAL ROTATION CONTROL TESTS
should also be on the 10° neutral line (the
knees should be further apart than the feet). The AND MEDIAL ROTATION CONTROL
trunk should stay vertical and the knees should REHABILITATION
move past the toes.
In weight bearing, with correct alignment, the These rotation control tests assess the extent of
line of the femur should be over and parallel to medial rotation UCM in the hip and assess the
the line of the 2nd metatarsal. Note whether ability of the dynamic stability system to
457
adequately control medial rotation load or strain.

It is a priority to assess for rotation UCM if the
patient complains of or demonstrates medial
rotation-related symptoms or disability. The tests
that identify dysfunction can also be used to
guide and direct rehabilitation strategies.
Indications to test for hip medial

rotation UCM
1. hypermobile hip medial rotation range
2. excessive initiation of turning with hip
medial rotation
associated with turning into hip medial
rotation.
toms in the hip. Under unilateral or rotation
load, the hip has greater give into medial rotation
relative to the trunk or lower leg. The dysfunction
is confirmed with motor control tests of medial
rotation dissociation.
Figure 9.37 Rotation (axial) alignment group 4 – hip medial

rotation dysfunction: excessive hip medial rotation (knee
turned in) as well as tibial lateral rotation dysfunction:
excessive tibial lateral rotation (foot turned out)
458
The hip Chapter |9|
Hip medial rotation control tests
T72 STANDING: SINGLE LEG SKB TEST

(tests for hip medial rotation UCM)

dissociate and control hip medial rotation and
perform a single leg 1 4 squat – SKB by moving
one hip and knee through flexion while in single
leg standing. During any unilateral or asymmetri-
cal lower limb movement, a rotational force is
transmitted to the pelvic and hip region.
Test procedure
out). Stance is upright with the upper body verti-
cal and the weight balanced over the midfoot. The
person is instructed to shift full weight onto one
foot and lift the other foot just clear of the floor.
The person should stand on one leg with the 2nd
metatarsal aligned along the ‘neutral line’ of
weight transfer (a line that is 10° lateral to the
sagittal plane). The pelvis should be level and the
trunk upright (vertical). There should be no
lateral deviation, tilt or rotation of the trunk or
pelvis. The head, sternum and pubic symphysis Figure 9.38 Start position single leg small knee bend test
should be vertically aligned above the inside edge
of the stance foot with the shoulders level in an
upright posture (Figure 9.38).
In this position, the person performs a single rotation or midfoot pronation. Body weight
leg SKB by flexing at the knee and dorsiflexing should stay balanced over the foot and there
the ankle while keeping the heel on the floor. should be no lateral shift of the pelvis. This test
The body weight is kept on the heel, not the ball should be performed without any feedback
of the foot, and the trunk is vertical (as if sliding (self-palpation, vision, etc.) or cueing for correc-
the back down a wall) with no forwards tion. The therapist should use visual observation
lean. The knee is held out over the foot to ori- of the femur and foot to determine whether the
entate the line of the femur out over the 2nd toe control of hip medial rotation is adequate when
(on the ‘neutral line’) (Figure 9.39). The trunk feedback is removed for testing. Assess both legs
should stay vertical and the knees should move separately.
3–8 cm past the toes.
Some people may experience a sensation of a
Hip medial rotation UCM
lack of the required knee bend range. This test
requires that during testing for UCM the knees The person complains of rotation-related symp-
bend to move at least 5 cm past the longest toe toms in the hip. During the single leg SKB the hip
so that the compensation and UCM can be demonstrates UCM into medial rotation (the
identified. knee moves medially) before the knee reaches
Ideally, there should be approximately 3–8 cm 3–8 cm past the toes. As the knee moves medial
of independent SKB, without any hip medial to the foot, the medial longitudinal arch collapses
459


(dissociation) test of medial rotation control, do not score
this as uncontrolled medial rotation. The flexion and
extension motor control tests will identify whether the
observed movement is uncontrolled. A test for hip medial
rotation UCM is only positive if uncontrolled hip medial
rotation is demonstrated.

rotation UCM
(T72.1 and T72.2)
Correction
If control is poor, the uncontrolled hip medial
rotation presents in bilateral weight bearing.
Initial retraining is best started in bilateral stance
with the trunk supported against a wall. The
person stands with the back against a wall and
the feet hip width apart (heels approximately
10–15 cm apart), with the inside borders of the
feet parallel (not turned out) so that the 2nd toe
(both feet) is aligned to the neutral line of weight
transfer. The person should stand upright with
Figure 9.39 Benchmark single leg small knee bend test the upper body vertical and the weight balanced
over the midfoot. The heels should be approxi-
mately 5–10 cm from the wall. The pelvis should
be level and the trunk upright (vertical).
The person is instructed to perform a bilateral
SKB. This is achieved by sliding the trunk down
into midfoot pronation. Under unilateral hip and the wall by flexing at the knees and dorsiflexing
knee weight bearing, the hip has UCM into medial the ankles while keeping the heels down with no
rotation relative to the knee and foot. forwards trunk lean. The person should be
The uncontrolled hip medial rotation is often instructed to keep the knees out over the foot to
associated with inefficiency of the stability func- orientate the line of the femur out over the neutral
tion of the gluteal lateral rotators (especially pos- line (along with the 2nd toe) (Figure 9.40). The
terior gluteus medius and deep gluteus maximus) trunk slides down the wall and the knee flexes
providing isometric or eccentric control of hip only as far as neutral hip rotation can be control-
medial rotation and for popliteus to control rota- led (monitored with feedback). At the point in
tion at the knee. During the attempt to dissociate range that the hip starts to lose control of medial
the hip medial rotation from unilateral leg move- rotation the movement should stop. The hip is
ment, the person either cannot control the UCM restabilised (move the knee out over the 2nd toe)
or has to concentrate and try hard to control the and returns to the start position with control of
hip medial rotation. The movement must be the hip rotation UCM.
assessed on both sides. If hip medial rotation The person should self-monitor the hip
UCM presents bilaterally, one side may be better alignment and control medial rotation UCM
or worse than the other. with a variety of feedback options (T72.3). There
460
The hip Chapter |9|
T72.1 Assessment and rating of low threshold recruitment efficiency of the Single Leg SKB Test
SINGLE LEG SMALL KNEE BEND TEST – STANDING
Control point:
• prevent hip medial rotation
Movement challenge: unilateral hip and knee flexion (standing)
Benchmark range: unilateral knee flexion without compensation

or or
• medial rotation awareness of the movement pattern that they
and move unilateral knee and hip flexion confidently prevent UCM into the test
range of: knee flexion to 3–8 cm past toes • The pattern of dissociation is smooth during
with trunk upright in 1/4 squat concentric and eccentric movement
• No fatigue
from the Single Leg SKB Test
SINGLE LEG SKB TEST – STANDING
watch the movement
Hip Medial rotation ! !
461
Figure 9.40 Partial small knee bend with wall support
should be no provocation of any symptoms is to perform the SKB unsupported in single leg
within the range that the rotation UCM can be stance.
controlled. Note whether correction can be achieved with
As the ability to control hip medial rotation ease or only with difficulty, or if it cannot be cor-
gets easier and the pattern of dissociation feels rected at all. When trying to correct the SKB to
less unnatural, the exercise can be progressed to neutral, note if there is a sensation of ‘strain’. This
performing this same movement without the wall often indicates a site of restriction. Assess that
for support, with both feet. The final progression area for articular or myofascial restrictions.
462
The hip Chapter |9|
T73 STANDING: ONE LEG SKB +

TRUNK ROTATION AWAY TEST
(tests for hip medial rotation UCM)

perform a single leg 1 4 squat – SKB and rotate the
trunk and pelvis away from the stance leg. During
any asymmetrical or non-sagittal trunk move-
ment a rotational force is transmitted to the pelvic
and hip region.
Test procedure
(heels approximately 10–15 cm apart), with the
out). The person is instructed to stand upright
with the upper body vertical and the weight bal-
anced over the midfoot. They then shift full
weight onto one foot and lift the other foot
just clear of the floor. A single leg SKB is then
performed by flexing at the knee and dorsiflexing
the ankle while keeping the heel on the floor.
The person is instructed to keep body weight
on the heel, not the ball of the foot, and
keep the trunk vertical (as if sliding the back
down a wall) without allowing forwards trunk
lean. Hold the knee out over the foot to orientate Figure 9.41 Start position 1 leg small knee bend + trunk
rotation away test
the line of the femur out over the 2nd toe
(on the 10° ‘neutral line’ of weight transfer)
(Figure 9.41).
Hip medial rotation UCM
Then, while standing on one leg, the person is
instructed to rotate the trunk and pelvis away The person complains of rotation-related symp-
from the stance leg (i.e. if standing on the right toms in the hip. During the single leg SKB the
leg, turn the trunk and pelvis to the left). Keep knee moves medially before the knee reaches
the knee aligned to the neutral line. They should 5–10 cm past the toes. During the one leg SKB +
have the ability to actively rotate the trunk and trunk rotation away test, the hip demonstrates
pelvis (hip lateral rotation relative to the pelvis) UCM into medial rotation (the knee moves medi-
without the knee moving medially to follow the ally) before the trunk and pelvis rotation reaches
pelvis. Ideally, there should be approximately 35° 35° lateral rotation away from the stance leg. As
of independent trunk and pelvis rotation (Figure the knee moves medial to the foot, the medial
9.42). As soon as any medial movement of the longitudinal arch collapses into midfoot prona-
knee occurs, the movement must stop and return tion. Under unilateral hip and knee weight
to the start position. This test should be per- bearing, the hip has UCM into medial rotation rela-
formed without any feedback (self-palpation, tive to the knee and foot.
vision, etc.) or cueing for correction. When feed- The uncontrolled hip medial rotation is often
back is removed for testing the therapist should associated with inefficiency of the stability func-
use visual observation of the pelvis to determine tion of the gluteal lateral rotators (especially pos-
whether the control of hip medial rotation is terior gluteus medius and deep gluteus maximus)
adequate. Assess both sides. providing isometric or eccentric control of hip
463
Figure 9.42 Benchmark 1 leg small knee bend + trunk Figure 9.43 Correction partial range with wall support
rotation away test
medial rotation and for popliteus to control rota- Rating and diagnosis of hip
tion at the knee. During the attempt to dissociate rotation UCM
the hip medial rotation from unilateral leg move-
ment, the person either cannot control the UCM (T73.1 and T73.2)
or has to concentrate and try hard to control the
hip medial rotation. The movement must be
assessed on both sides. If hip medial rotation Correction
UCM presents bilaterally, one side may be better The person stands facing the frame of a doorway
or worse than the other. or a corner section of wall, with the toes approxi-
mately 5 cm from the wall/doorframe. They
Clinical assessment note for direction-specific should stand on one leg with the inside border
motor control testing of the foot perpendicular to the wall. The person
first performs a SKB to position the thigh and
If some other movement (e.g. a small amount of flexion trunk against the wall/doorframe. They are then
or extension) is observed during a motor control instructed to turn the trunk and pelvis away from
(dissociation) test of medial rotation control, do not score the stance leg. The wall or doorframe provides
this as uncontrolled medial rotation. The flexion and support and feedback for the subject to monitor
extension motor control tests will identify whether the and control the knee from moving medially
observed movement is uncontrolled. A test for hip medial while the trunk and pelvis laterally rotate (Figure
rotation UCM is only positive if uncontrolled hip medial
9.43). The trunk and pelvis rotate only as far as
rotation is demonstrated.
the thigh position can be controlled (monitored
464
The hip Chapter |9|
with feedback). At the point in range that the variety of feedback options (T73.3). There should
knee moves medially to the neutral line, the be no provocation of any symptoms within the
movement should stop. The hip is restabilised range that the rotation UCM can be controlled.
(move the knee out over the 2nd toe) and returns As the ability to control hip medial rotation
to the start position with control of the hip rota- gets easier and the pattern of dissociation feels
tion UCM. less unnatural, the exercise can be progressed to
The person should self-monitor the hip align- performing this same movement unsupported,
ment and control medial rotation UCM with a without the wall, in single leg stance.
465
T73.1 Assessment and rating of low threshold recruitment efficiency of the One Leg SKB + Trunk Rotation
Away Test
ONE LEG SMALL KNEE BEND + TRUNK ROTATION AWAY TEST – STANDING
Control point:
Movement challenge: unilateral SKB + trunk/pelvis rotation away from stance leg (standing)
Benchmark range: 35° independent trunk/pelvis lateral rotation (unilateral SKB) with knee aligned on the 2nd toe (neutral
line) without compensation of hip medial rotation

or or
and move trunk and pelvis lateral rotation away confidently prevent UCM into the test
from stance leg direction
range of: 35° trunk/pelvis lateral rotation concentric and eccentric movement
• No fatigue
from the One Leg SKB + Trunk Rotation Away Test
ONE LEG SMALL KNEE BEND + TRUNK
ROTATION AWAY TEST – STANDING position
Hip Medial rotation ! ! Adhesive tape Skin tension for tactile feedback
466
The hip Chapter |9|
use visual observation of the pelvis to determine

T74 SIDE-LYING: TOP LEG TURNOUT LIFT whether the control of hip medial rotation is
TEST adequate when feedback is removed for testing.
(tests for hip medial rotation UCM) Assess both sides.
This dissociation test assesses the ability to actively Hip medial rotation UCM
perform a single leg hip abduction and lateral
toms in the hip. During the top leg turnout lift
rotation. During any unilateral or asymmetrical
test, the foot begins to rotate down (hip medial
lower limb movement, a rotational force is trans-
rotation UCM) before the abduction lift reaches
mitted to the pelvic and hip region.
35° above horizontal. Under unilateral hip
loading, the hip has UCM into medial rotation.
Test procedure The uncontrolled hip medial rotation is often
associated with inefficiency of the stability func-
The person lies on one side with uppermost (top)
tion of the gluteal lateral rotators (especially pos-
leg extended in line with the trunk, the other
terior gluteus medius and deep gluteus maximus)
(bottom leg) hip flexed to 45° and the knees
providing isometric or eccentric control of hip
flexed to 90° (Figure 9.44). The pelvis should be
medial rotation. During the attempt to dissociate
positioned in neutral rotation. The person is
the hip medial rotation from unilateral leg
instructed to maintain the neutral pelvis position
and turn the uppermost foot outwards (hip lateral
rotation). Then they should slowly lift the upper-
most leg vertically up and out to the side while
keeping the leg and foot turned out into lateral
rotation. Ideally, the top leg should be able to
maintain the hip extension and turnout and lift
into at least 35° (above horizontal) of hip abduc-
tion and lateral rotation (Figure 9.45) and return,
without associated loss of full turnout into any
medial rotation of the hip.
pendent of any hip medial rotation. Note any
excessive hip medial rotation under hip abduc-
tion load. This test should be performed without
any feedback (self-palpation, vision, flexicurve,
etc.) or cueing for correction. The therapist should
Figure 9.44 Start position top leg turnout lift test Figure 9.45 Benchmark top leg turnout lift test
467
movement, the person either cannot control the medial rotation. At the point in range that the hip
UCM or has to concentrate and try hard to control starts to lose control of rotation, the movement
the hip medial rotation. The movement must be should stop. The hip position is restabilised (lift
assessed on both sides. If hip medial rotation the knee and keep the heel down), then hold this
UCM presents bilaterally, one side may be better position for a few seconds and return to the start
or worse than the other. position.
pendent of any hip medial rotation. The person
Clinical assessment note for direction-specific should self-monitor the hip alignment and
motor control testing control medial rotation UCM with a variety of
feedback options (T74.3). There should be no
If some other movement (e.g. a small amount of flexion provocation of any symptoms within the range
or extension) is observed during a motor control that the rotation UCM can be controlled.
(dissociation) test of medial rotation control, do not score As the ability to control hip medial rotation
this as uncontrolled medial rotation. The flexion and
gets easier and the pattern of dissociation feels
extension motor control tests will identify whether the
observed movement is uncontrolled. A test for hip medial
less unnatural, the exercise can be progressed to
rotation UCM is only positive if uncontrolled hip medial performing the hip abduction and lateral rotation
rotation is demonstrated. with the leg fully extended.
Hip medial rotation UCM summary

Rating and diagnosis of hip (Table 9.4)
rotation UCM
(T74.1 and T74.2)
Correction
If control is poor, retraining can initially begin
with reduced leg load. With the person side-lying
and the hips flexed to 45°, the knees flexed to 90°
and the feet together, the pelvis should be posi-
tioned in neutral rotation. Keeping the heels
together the person is instructed to lift the top leg
up and out to the side (Figure 9.46). Hold this
position, and lift the heel of the top leg 2–3 cm
away from the bottom heel. Ensure that, as the
heel lifts, the knee does not drop down into hip Figure 9.46 Correction partial range turnout short lever
Table 9.4 Summary and rating of hip medial rotation tests

HIP MEDIAL ROTATION !
(L) (R)
Standing: single leg small knee bend
Standing: one leg knee bend + trunk rotation away
Side-lying: top leg turnout lift
468
The hip Chapter |9|
T74.1 Assessment and rating of low threshold recruitment efficiency of the Top Leg Turnout Lift Test
TOP LEG TURNOUT LIFT TEST – SIDE-LYING
Control point:
Movement challenge: unilateral hip abduction and lateral rotation (side-lying)
Benchmark range: 35° independent hip abduction and lateral rotation without compensation

or or
and move hip abduction and lateral rotation confidently prevent UCM into the test
(turnout) direction
range of: 35° hip abduction and lateral concentric and eccentric movement
rotation • Does not (consistently) use end-range
from the Top Leg Turnout Lift Test
TOP LEG TURNOUT LIFT TEST – STANDING
watch the movement
Hip Medial rotation ! !
469
Indications to test for hip lateral

HIP LATERAL ROTATION/ABDUCTION rotation/abduction UCM
CONTROL TESTS AND LATERAL
ROTATION/ABDUCTION CONTROL Observe or palpate for:
REHABILITATION 1. hypermobile hip lateral rotation or
abduction range
These rotation control tests assess the extent 2. excessive initiation of turning with hip
of lateral rotation/abduction UCM in the hip lateral rotation or abduction
and assess the ability of the dynamic stability 3. symptoms (pain, discomfort, strain)
system to adequately control lateral rotation associated with turning into hip lateral
and abduction load or strain. It is a priority to rotation and abduction.
assess for lateral rotation/abduction UCM if the The person complains of rotation-related symp-
patient complains of or demonstrates lateral toms in the hip. Under rotation or unilateral
rotation or abduction-related symptoms or dis- load, the hip has greater give into lateral rotation
ability. The tests that identify dysfunction can or abduction relative to the trunk or lower leg. The
also be used to guide and direct rehabilitation dysfunction is confirmed with motor control tests
strategies. of lateral rotation/abduction dissociation.
470
The hip Chapter |9|
Test procedure
Hip lateral rotation/abduction
control tests The person stands tall and unsupported with
legs straight and the lumbar spine and pelvis
positioned in the neutral (Figure 9.47). The
T75 STANDING: SINGLE LEG HIGH person is instructed to shift weight onto one leg
KNEE LIFT TEST and, keeping the shoulders and pelvis level,
slowly lift the other foot off the ground. Without
(tests for hip lateral rotation/ letting the non-weight bearing hip move into
abduction UCM) lateral rotation or abduction, the person contin-
ues to lift the leg into hip flexion with the lower
This dissociation test assesses the ability to actively leg relaxed and the heel hanging vertically under
dissociate and control hip lateral rotation/ the knee. Ideally, the hip should maintain neutral
abduction and perform at least 90° of unilateral rotation (with no hip lateral rotation) as the hip
hip flexion. During any asymmetrical or non- actively flexes to at least 90° (monitor the flexing
sagittal trunk movement a rotational force is leg). The lumbopelvic region should maintain a
transmitted to the pelvic and hip region. neutral level position (Figure 9.48). As soon as
Figure 9.47 Start position single leg high knee bend lift test Figure 9.48 Benchmark single leg high knee bend lift test
471
any movement indicating a loss of neutral into bilaterally, one side may be better or worse than
hip lateral rotation or abduction is observed, or the other.
hitching the pelvis to lift the leg, the movement
must stop and return to the start position. Hip
flexion to 90° must be demonstrated with the Clinical assessment note for direction-specific
shoulders and pelvis level. motor control testing
The unilateral hip flexion must be independent
of any hip lateral rotation or abduction. Note any
uncontrolled hip lateral rotation or abduction (dissociation) test of lateral rotation/abduction control, do
under non-weight bearing hip flexion load. This not score this as uncontrolled lateral rotation/abduction.
test should be performed without any feedback The flexion and extension motor control tests will identify
(self-palpation, vision, flexicurve, etc.) or cueing if the observed movement is uncontrolled. A test for hip
for correction. When feedback is removed for lateral rotation/abduction UCM is only positive if
testing the therapist should use visual observa- uncontrolled hip lateral rotation or abduction is
tion of the pelvis and leg to determine whether demonstrated.
the control of hip lateral rotation/abduction is
adequate. Assess both sides.
rotation UCM
Hip lateral rotation/abduction UCM
(T75.1 and T75.2)
toms in the hip. During the single leg high knee
lift the hip demonstrates UCM into lateral rota- Correction
tion or abduction before the non-weight bearing If control is poor, initial retraining is best started
hip reaches 90° flexion (thigh horizontal). During with the trunk supported against a wall. The
the single leg high knee lift test, the foot swings person stands with the back against a wall and
in towards the midline (hip lateral rotation UCM) the feet hip width apart (heels approximately
or the thigh turns out into abduction and lateral 10–15 cm apart) with the inside borders of the
rotation before the knee lift reaches 90° (thigh feet parallel. Stand upright with the upper body
horizontal). Under unilateral hip loading, the hip vertical and the weight balanced over the midfoot.
has UCM into lateral rotation or abduction. Hitching The heels should be approximately 5–10 cm
the pelvis to lift the thigh horizontal is not hip from the wall. The pelvis should be level and the
flexion to 90° and is a common substitution trunk upright (vertical). The person is instructed
strategy for inefficient control. Hip flexion to 90° to shift their weight onto one foot and, keeping
must be demonstrated with the shoulders and the shoulders and pelvis level, slowly lift the
pelvis level. other foot off the ground. They are to lift the leg
The uncontrolled hip lateral rotation/abduction only as far as the pelvis stays level and as far as
is often associated with inefficiency of the the foot hangs vertically under the knee (i.e. no
stability function of the gluteal medial rotators hip lateral rotation) and the thigh stays in the
(especially anterior gluteus medius and gluteus midline (i.e. no hip abduction). The hip can lift
minimus) providing isometric or eccentric into flexion only as far as the lateral rotation,
control of hip lateral rotation. Concurrently the abduction and the pelvic position can be control-
deep adductor stabilisers (pectineus and adduc- led (monitored with feedback) (Figure 9.49).
tor brevis) may not provide eccentric control of Initially, the person may only be able to lift the
hip abduction. During the attempt to dissociate leg into 60° or 70° hip flexion before the UCM
the hip lateral rotation/abduction from unilateral is demonstrated. At the point in range that the
leg movement, the person either cannot control foot swings medially (hip lateral rotation), or the
the UCM or has to concentrate and try hard pelvis starts to hitch, the movement should stop.
to control the hip lateral rotation or abduction. The hip and pelvis are restabilised and the leg
The movement must be assessed on both sides. returns to the start position with control of the
If hip lateral rotation/abduction UCM presents hip rotation UCM.
472
The hip Chapter |9|
Figure 9.49 Correction partial range knee lift with support
The person should self-monitor the hip align- As the ability to control hip lateral rotation/
ment and control lateral rotation and abduction abduction gets easier and the pattern of dissocia-
UCM with a variety of feedback options (T75.3). tion feels less unnatural, the exercise can be
There should be no provocation of any symptoms progressed to performing this same movement
within the range that the rotation UCM can be unsupported, without the wall, in single leg
controlled. stance.
473
T75.1 Assessment and rating of low threshold recruitment efficiency of the Single Leg High Knee Lift Test
SINGLE LEG HIGH KNEE LIFT TEST – STANDING
Control point:
• prevent hip lateral rotation/abduction
Movement challenge: unilateral hip flexion (standing)
Benchmark range: 90° independent unilateral hip flexion without compensation of hip lateral rotation or abduction

or or
• lateral rotation/abduction awareness of the movement pattern that they
and move unilateral hip flexion confidently prevent UCM into the test
range of: 90° hip flexion • The pattern of dissociation is smooth during
If there is more available range than the concentric and eccentric movement
benchmark standard, only the benchmark • Does not (consistently) use end-range
range needs to be actively controlled movement into the opposite direction to
• Without holding breath (though it is prevent the UCM
acceptable to use an alternate breathing • No extra feedback needed (tactile, visual or
strategy) verbal cueing)
• Control during eccentric phase • Without external support or unloading
• Control during concentric phase • Relaxed natural breathing (even if not ideal –
so long as natural pattern does not change)
• No fatigue
from the Single Leg High Knee Lift Test
SINGLE LEG HIGH KNEE LIFT
Hip Lateral rotation/ ! ! Adhesive tape Skin tension for tactile feedback
abduction
474
The hip Chapter |9|
T76 STANDING: ONE LEG SKB + TRUNK

ROTATION TOWARDS TEST
(tests for hip lateral rotation/
abduction UCM)

dissociate and control hip lateral rotation/
abduction and perform a single leg 1 4 squat – SKB
and rotate the trunk and pelvis towards the stance
leg. During any asymmetrical or non-sagittal
trunk movement a rotational force is transmitted
to the pelvic and hip region.
Test procedure
out). They should stand upright with the upper
body vertical and the weight balanced over the
midfoot. The person is then instructed to shift full
weight onto one foot and lift the other foot just
clear of the floor. In this position, they should
perform a single leg SKB by flexing at the knee
and dorsiflexing the ankle while keeping the heel
on the floor. They should be instructed to keep
body weight on the heel, not the ball of the foot,
and keep the trunk vertical (as if sliding the back
down a wall) with no trunk forwards lean. The Figure 9.50 Start position 1 leg small knee bend + trunk
rotation towards test
knee should be held out over the foot to orientate
the line of the femur out over the 2nd toe (on the
10° ‘neutral line’ of weight transfer) (Figure 9.50).
Then, while standing on one leg, the person is
instructed to rotate the trunk and pelvis towards The person complains of rotation-related symp-
the stance leg (i.e. if standing on the right leg, turn toms in the hip. During the one leg SKB + trunk
the trunk and pelvis to the right). Keep the knee rotation towards test, the hip demonstrates UCM
aligned to the neutral line. The person should into lateral rotation or abduction (the knee moves
have the ability to actively rotate the trunk and laterally) before the trunk and pelvis rotation
pelvis (hip medial rotation relative to the pelvis) reaches 30° medial rotation towards the stance
without the knee moving laterally to follow the leg. Under unilateral hip and knee weight bearing,
pelvis. Ideally, there should be approximately 30° the hip has UCM into lateral rotation/abduction.
of independent trunk and pelvis rotation (Figure The uncontrolled hip lateral rotation/abduction
9.51). As soon as any lateral movement of the is often associated with inefficiency of the
knee occurs, the movement must stop and return stability function of the gluteal medial rotators
back to the start position. This test should be (especially anterior gluteus medius and gluteus
performed without any feedback (self-palpation, minimus) providing isometric or eccentric control
vision, etc.) or cueing for correction. When feed- of hip lateral rotation. Concurrently the deep
back is removed for testing the therapist should adductor stabilisers (pectineus and adductor
use visual observation of the pelvis to determine brevis) may not provide eccentric control of
whether the control of hip lateral rotation/ hip abduction. During the attempt to dissociate
abduction is adequate. Assess both sides. the hip lateral rotation from unilateral leg
475
Figure 9.52 Correction partial range with wall support

Figure 9.51 Benchmark 1 leg small knee bend + trunk
rotation towards test
movement, the person either cannot control the Rating and diagnosis of hip
UCM or has to concentrate and try hard to control rotation UCM
the hip lateral rotation. The movement must be
assessed on both sides. If hip lateral rotation (T76.1 and T76.2)
or worse than the other. Correction
The person stands facing the frame of a doorway
Clinical assessment note for direction-specific or a corner section of wall, with the toes approxi-
motor control testing mately 5 cm from the wall/doorframe. They
should stand on one leg with the inside border
If some other movement (e.g. a small amount of flexion of the foot perpendicular to the wall. The person
or extension) is observed during a motor control first performs a SKB to position the thigh and
(dissociation) test of lateral rotation/abduction control, do trunk against the wall/doorframe. They are then
not score this as uncontrolled lateral rotation/abduction. instructed to turn the trunk and pelvis towards
The flexion and extension motor control tests will identify the stance leg. The wall or doorframe provides
if the observed movement is uncontrolled. A test for hip support and feedback for the subject to monitor
lateral rotation/abduction UCM is only positive if and control the knee from moving laterally while
uncontrolled hip lateral rotation or abduction is
the trunk and pelvis medially rotate (Figure 9.52).
demonstrated.
The trunk and pelvis rotate only as far as the thigh
476
The hip Chapter |9|
position can be controlled (monitored with feed- There should be no provocation of any symptoms
back). At the point in range that the knee moves within the range that the lateral rotation/
laterally to the neutral line, the movement should abduction UCM can be controlled.
stop. The hip is restabilised and returns to the As the ability to control hip lateral rotation/
start position with control of the hip rotation abduction gets easier and the pattern of dissocia-
UCM. tion feels less unnatural, the exercise can be
The person should self-monitor the hip align- progressed to performing this same movement
ment and control lateral rotation and abduction unsupported, without the wall, in single leg
UCM with a variety of feedback options (T76.3). stance.
477
T76.1 Assessment and rating of low threshold recruitment efficiency of the One Leg SKB + Trunk Rotation
Towards Test
ONE LEG SMALL KNEE BEND + TRUNK ROTATION TOWARDS TEST – STANDING
Control point:
Movement challenge: unilateral SKB + trunk/pelvis rotation toward stance leg (standing)
Benchmark range: 30° independent trunk/pelvis medial rotation (unilateral SKB) with knee aligned on the 2nd toe (neutral
line) without compensation of hip lateral rotation or abduction

or or
and move trunk and pelvis lateral rotation confidently prevent UCM into the test
towards stance leg direction
range of: 30° trunk/pelvis medial rotation concentric and eccentric movement
• No fatigue
from the One Leg SKB + Trunk Rotation Towards
Test FEEDBACK TOOL PROCESS
ONE LEG SKB + TRUNK ROTATION
position
TOWARDS TEST – STANDING
watch the movement
Hip Lateral rotation/ ! !
abduction
478
The hip Chapter |9|
and, keeping that knee flexed to 90°, slowly lift

T77 4 POINT: BENT KNEE HIP EXTENSION that leg into hip extension. The leg should stay in
TEST the sagittal plane and not abduct out to the
(tests for hip lateral rotation/ side. The heel should stay positioned vertically
abduction UCM) above the knee as it lifts into hip extension, and
not swing across the midline into hip lateral rota-
tion. Ideally, the neutral hip rotation should be
This dissociation test assesses the ability to actively maintained until about 0° of hip extension (thigh
dissociate and control hip lateral rotation and horizontal) with the knee held at 90° of flexion.
actively extend one hip (with the knee flexed to The person should have the ability to dissociate
90°) while in 4 point kneeling (hands and knees). the hip lateral rotation/abduction from hip exten-
During any unilateral or asymmetrical lower limb sion as evidenced by preventing hip lateral rota-
movement, a rotational force is transmitted to the tion and abduction, while lifting the bent knee
pelvic and hip region. into hip extension (Figure 9.54). Ideally, the leg
should be able to maintain the flexed knee posi-
tion and lift to 0° (thigh horizontal) of hip exten-
Test procedure
sion without any lateral rotation or abduction of
The person positions themselves in 4 point kneel- the hip. Note any uncontrolled hip lateral rota-
ing (hands and knees) with the lumbar spine and tion or abduction under hip extension load. This
pelvis in neutral alignment (Figure 9.53). The test should be performed without any feedback
person is instructed to shift weight onto one knee (self-palpation, vision, flexicurve, etc.) or cueing
Figure 9.53 Start position bent knee hip extension test Figure 9.54 Benchmark bent knee hip extension test
479
for correction. When feedback is removed for Rating and diagnosis of hip
testing the therapist should use visual observa- rotation UCM
tion of the leg and pelvis to determine whether
the control of hip lateral rotation/abduction is (T77.1 and T77.2)
adequate. Assess both sides.
Correction
Hip lateral rotation/abduction UCM If control is poor, initial retraining is best started
The person complains of rotation-related symp- with reduced knee flexion. The person positions
toms in the hip. During the bent knee hip exten- themselves in 4 point kneeling (hands and knees)
sion test the hip demonstrates UCM into lateral and shifts weight onto one knee. Slowly start to
rotation or abduction before the hip extension lift that leg into hip extension but allow the knee
reaches 0° (thigh horizontal). During the bent to straighten so that it is only flexed to about 20°
knee hip extension test, the foot swings in towards or 30°. The leg should stay in the sagittal plane
the midline (hip lateral rotation UCM) or moves and not abduct out to the side. The heel should
laterally away from the midline (hip abduction) not swing across the midline into hip lateral rota-
before hip extension reaches 0° (thigh horizon- tion. A line from the heel through the 2nd toe
tal). Under unilateral hip loading, the hip has should be vertical (Figure 9.55).
UCM into lateral rotation or abduction. Arching the The unilateral hip extension must be independ-
back or rotating the pelvis to lift the thigh hori- ent of any hip lateral rotation or abduction. The
zontal is not hip extension to 0° and is a common
substitution strategy for inefficient control. Hip
extension to 0° must be demonstrated with the
lumbopelvic compensation.
The uncontrolled hip lateral rotation/abduction
is often associated with inefficiency of the
stability function of the gluteal medial rotators
(especially anterior gluteus medius and gluteus
minimus) providing isometric or eccentric control
of hip lateral rotation. Concurrently the deep
adductor stabilisers (pectineus and adductor
brevis) may not provide eccentric control of hip
abduction. During the attempt to dissociate the
hip lateral rotation and abduction from unilateral
leg movement, the person either cannot control
control the hip lateral rotation/abduction. The
lateral rotation UCM presents bilaterally, one side
may be better or worse than the other.


(dissociation) test of lateral rotation/abduction control, do
not score this as uncontrolled lateral rotation/abduction.
The flexion and extension motor control tests will identify
if the observed movement is uncontrolled. A test for hip
lateral rotation/abduction UCM is only positive if
demonstrated.
Figure 9.55 Correction partial range with knee extension
480
The hip Chapter |9|
hip can lift into extension only as far as the lateral The person should self-monitor the hip align-
rotation, abduction and the pelvic position can ment and control lateral rotation/abduction
be controlled (monitored with feedback). Ini- UCM with a variety of feedback options (T77.3).
tially, the person may only be able to lift the leg There should be no provocation of any symptoms
through minimal range of hip extension before within the range that the rotation UCM can be
the UCM is demonstrated. At the point in range controlled.
that the foot swings medially (hip lateral rota- As the ability to control hip lateral rotation/
tion), the thigh abducts from the midline or the abduction gets easier and the pattern of dissocia-
pelvis starts to move, the movement should stop. tion feels less unnatural, the exercise can be pro-
The hip and pelvis are restabilised and the leg gressed to performing this hip extension through
returns to the start position with control of the increased range of hip extension and, finally, with
hip lateral rotation/abduction UCM. increased knee flexion.
481
T77.1 Assessment and rating of low threshold recruitment efficiency of the Bent Knee Hip Extension Test
BENT KNEE HIP EXTENSION – 4 POINT KNEELING
Control point:
Movement challenge: unilateral hip extension + knee flexion (4 point kneeling)
Benchmark range: 0° independent unilateral hip extension + 90° knee flexion without compensation of hip lateral
rotation/abduction

or or
and move unilateral hip extension + knee flexion confidently prevent UCM into the test
range of: 0° hip extension + 90° knee flexion • The pattern of dissociation is smooth during
• No fatigue
from the Bent Knee Hip Extension Test
BENT KNEE HIP EXTENSION
Hip Lateral rotation/ ! ! Adhesive tape Skin tension for tactile feedback
abduction
482
The hip Chapter |9|
therapist should use visual observation of the

T78 BRIDGE: SINGLE LEG LIFT TEST pelvis to determine whether the control of lum-
(tests for hip lateral rotation/ bopelvic rotation is adequate.
abduction UCM)
This dissociation test assesses the ability to actively The person complains of rotation or abduction
dissociate and control hip lateral rotation/ symptoms in the hip. During the bridge: single
abduction and lift the pelvis into a bridge and leg lift test, the hip adductor/rotator stabilisers are
straighten one leg while in supine lying. During not able to effectively control the hip. The hip has
any unilateral or asymmetrical limb load or UCM into lateral rotation or abduction under
movement, a rotational force is transmitted to the unilateral long lever leg load. The hip begins to
pelvis and hip region. laterally rotate or abduct and the knees move
apart. The person is unable to control hip lateral
Test procedure rotation/abduction.
During the attempt to dissociate the hip lateral
The person lies in crook lying with the heels and rotation/abduction from unilateral leg loading,
knees together (Figure 9.56). Keeping the spine the person either cannot control the UCM or has
in neutral, lift the pelvis just clear (5 cm) of the to concentrate and try hard to control the hip
floor and hold this position. Slowly shift weight lateral rotation/abduction. The movement must
onto one foot and extend the other knee, keeping be assessed on both sides. It may be unilateral or
the knees and thighs side by side. Maintain the bilateral. If hip lateral rotation/abduction UCM
neutral pelvis and hip position and do not allow presents bilaterally, one side may be better or
the knees to move apart. Ideally, the knees should worse than the other.
stay touching side by side. There should be no
change to hip position on the unsupported Clinical assessment note for direction-specific
straight leg. Do not allow the straight leg to later- motor control testing
ally rotate or to abduct laterally away from the
midline (Figure 9.57). Return the foot to the floor If some other movement (e.g. a small amount of flexion
and repeat the movement with the opposite leg. or extension) is observed during a motor control
As soon as any hip lateral rotation or abduction (dissociation) test of lateral rotation/abduction control, do
occurs, the movement must stop and return to the not score this as uncontrolled lateral rotation/abduction.
start position. Do not allow the arms to brace the The flexion and extension motor control tests will identify
trunk by pushing down onto the floor. This test if the observed movement is uncontrolled. A test for hip
lateral rotation/abduction UCM is only positive if
palpation, vision, etc.) or cueing for correction. demonstrated.
When feedback is removed for testing the
Figure 9.56 Start position bridge: single leg lift test Figure 9.57 Benchmark bridge: single leg lift test
483
Rating and diagnosis of hip (crook lying with pelvis resting), with control of
rotation UCM the hip lateral rotation/abduction UCM.
The person should self-monitor the hip align-
(T78.1 and T78.2) ment and control with a variety of feedback
Correction of any symptoms within the range that the rota-
tion UCM can be controlled.
Starting in crook lying with the feet and knees As the ability to control hip lateral rotation/
together, the person lifts the pelvis 5 cm off the abduction gets easier and the pattern of dissocia-
floor while maintaining neutral alignment. Ini- tion feels less unnatural, the exercise can be pro-
tially, the person should be instructed to transfer gressed. The progression is to fully extend the
weight to one foot and only lift the other foot a unweighted leg and alternate right and left knee
few centimetres from the floor. Do not fully extension, keeping the pelvis and hip neutral and
extend the unweighted leg. The person should unsupported during each weight transfer. Make
only lift the unweighted leg as far as hip lateral sure that good control of hip lateral rotation and
rotation and abduction can be controlled (moni- abduction is maintained.
tored by keeping the knees together in the mid-
line). At the point in range that the pelvis and hip
region starts to lose control of lateral rotation or Hip lateral rotation/abduction
abduction, the movement should stop. The hip
position is restabilised, then hold this position
UCM summary
for a few seconds and return to the start position (Table 9.5)
Table 9.5 Summary and rating of hip lateral rotation/abduction tests

HIP LATERAL ROTATION/ABDUCTION !
(L) (R)
Standing: single leg high knee lift
Standing: one leg knee bend + trunk rotation towards
4 point: bent knee hip extension
Bridge: single leg lift
484
The hip Chapter |9|
T78.1 Assessment and rating of low threshold recruitment efficiency of the Bridge: Single Leg Lift Test
BRIDGE: SINGLE LEG LIFT TEST – CROOK LYING
Control point:
Movement challenge: unilateral leg load from an unsupported pelvis (bridge)
Benchmark range: fully extended leg (knees side by side)

or or
and move weight transfer to one leg and confidently prevent UCM into the test
unilateral leg extension direction
range of: full leg extension (knees side by concentric and eccentric movement
side) • Does not (consistently) use end-range
from the Bridge: Single Leg Lift Test
BRIDGE: SINGLE LEG LIFT TEST –
CROOK LYING position
left (L) right (R)
watch the movement
Hip Lateral rotation/ ! !
abduction
(closed chain)
485
Hip adduction control
OBSERVATION AND ANALYSIS OF HIP

ADDUCTION AND WEIGHT TRANSFER

The person is instructed to stand upright, weight
bearing equally on both feet, with the feet 10–
15 cm apart. They are then instructed to shift
their body weight laterally to stand on one leg
by lifting the foot of the other leg just clear of
the floor. Ideally, the pelvis should move laterally
no more than 10 cm, as measured by lateral dis-
placement of the umbilicus (Sahrmann 2002;
Luomajoki et al 2007, 2008). There should be
good symmetry of movement with less than
2 cm of difference in lateral pelvic shift between
sides. The head, sternum and pubic symphysis
should be aligned above the stance foot with
the shoulders level in an upright posture
(Figure 9.58).

lateral weight shift
• Thoracolumbar restriction of side-bend – the Figure 9.58 Ideal weight transfer into hip adduction during
single leg stance
upper body lacks 40° of normal side-
bending range (measured at the sternum
midline) when standing on both feet with
the pelvis stabilised and supported against a
wall. A thoracolumbar side-bend restriction
may contribute to compensatory increases in compensate for the lack of hip medial
lateral pelvic shift and hip adduction range. rotation.
This is confirmed with motion assessment
and manual segmental joint assessment
(e.g. Maitland PPIVMs or PAIVMs). Relative flexibility (potential UCM)
• Restriction of hip lateral rotation – the pelvis • Hip adduction – the hip may initiate the
lacks 45° of normal range of turning away movement into lateral weight transfer and
from the stance leg (i.e. <45° of pelvis contribute more to producing hip adduction
rotation to the left when standing on the while the upper body starts to move laterally
right foot). Hip adduction may increase to later and contributes less. At the limit of
compensate for the lack of hip lateral lateral weight shift, excessive or hypermobile
rotation. range of hip adduction may be observed.
• Restriction of hip medial rotation – the pelvis During the return to neutral, the hip pelvis
lacks 45° of normal range of turning moves back towards the mid-line late.
towards the stance leg (i.e. <45° of pelvis Increased range or uncontrolled hip
rotation to the right when standing on the adduction is a common compensation for
right foot). Hip adduction may increase to reduced thoracolumbar side-bend.
486
The hip Chapter |9|

HIP ADDUCTION CONTROL TESTS AND associated with hip adduction, single leg
ADDUCTION CONTROL REHABILITATION stance or lateral weight transfer.
The person complains of adduction-related symp-
This adduction control test assesses the extent of toms in the hip. Under adduction or single leg
adduction UCM in the hip and assesses the ability stance loading, the hip has greater give into adduc-
of the dynamic stability system to adequately tion relative to the trunk or lower leg. The dysfunc-
control adduction load or strain. It is a priority tion is confirmed with motor control tests of
to assess for adduction UCM if the patient adduction dissociation.
complains of or demonstrates adduction-related
symptoms or disability. The tests that identify
dysfunction can also be used to guide and direct
rehabilitation strategies.

adduction UCM
1. hypermobile hip adduction range
2. excessive initiation of lateral weight shift
with pelvic shift and hip adduction
487
lateral shift of the pelvis and shoulders concur-

Hip adduction control tests rently to maintain the centre of gravity over the
base of support. There should be good symmetry
of lateral pelvic shift between single leg stance on
T79 SINGLE LEG STANCE: LATERAL
the left and right sides.
PELVIC SHIFT TEST The pelvis should not shift laterally further than
(tests for hip adduction UCM) 10 cm. Excessive lateral pelvic shift is demon-
strated by 10 cm of lateral movement of the pelvis
This dissociation test assesses the ability to actively or more than 2 cm of difference between left and
dissociate and control weight bearing hip adduc- right sides in single leg stance (Figure 9.60).
tion in single leg stance. As soon as any movement indicating a loss
of control into hip adduction is observed, the
movement must stop and return back to the start
Test procedure position. This test should be performed without
The person should stand upright with the body any feedback (self-palpation, vision, flexicurve,
vertical and the weight equally balanced over the etc.) or cueing for correction. When feedback
feet and with the feet 10–15 cm apart (Figure is removed for testing the therapist should use
9.59). The person is instructed to shift full weight visual observation of the pelvis and leg to deter-
onto one foot and slowly lift the other foot just mine whether the control of hip adduction is
off the floor. There should be a small amount of adequate. Assess both sides.
Figure 9.59 Start position single leg stance: lateral pelvic Figure 9.60 Benchmark single leg stance: lateral pelvic shift
shift test test
488
The hip Chapter |9|
Hip adduction UCM

The person complains of pain in the hip (groin
impingement, lateral trochanteric or posterola-
teral buttock pain) associated with single leg
stance, lateral weight transfer and hip adduction
activities. During the lateral pelvic shift test, the
weight bearing hip demonstrates UCM into
adduction (excessive or asymmetrical lateral
pelvic displacement) during weight transfer to
single leg stance. The hip has UCM into adduction
during weight transfer. Hip adduction control is
poor if the subject is unable to prevent or resist
excessive hip adduction (lateral pelvic shift of
greater than 10 cm or more than 2 cm of asym-
metry) during single leg stance.
The uncontrolled hip adduction is often associ-
the hip abductor muscles (especially deep gluteus
medius and minimus) which provide isometric
or eccentric control of hip adduction. During the
attempt to minimise or dissociate lateral pelvic
shift during weight transfer, the person either
and try hard to control the hip adduction. The
adduction UCM presents bilaterally, one side may
Clinical assessment note for direction-specific Figure 9.61 Correction – neutral start position on wall

adduction control, do not score this as uncontrolled
adduction. The rotation motor control tests will identify if wall. The pelvis should be level and the trunk
the observed movement is uncontrolled. A test for hip upright (vertical against the wall) (Figure 9.61).
adduction UCM is only positive if uncontrolled hip Using the wall for feedback and support, the
adduction is demonstrated. person should slowly shift full weight onto one
leg and laterally move the pelvis and shoulders
concurrently to keep body weight centred over
the weight bearing foot. Initially, start with partial
Rating and diagnosis of hip weight shift by only lifting the heel (Figure 9.62).
rotation UCM Then, keeping the shoulders and pelvis level,
(T79.1 and T79.2) progress to full weight shift and lift the foot off
the floor (Figure 9.63). If it is difficult to move
the shoulders and pelvis concurrently, initiate the
Correction weight transfer with lateral movement of the
Initial retraining is best started with the trunk shoulders and allow the pelvis to contribute later.
supported against a wall. The person stands with When full weight is on the stance leg the shoul-
the back against a wall and the feet hip width ders and pelvis should be level. There should be
apart and the weight balanced over the feet. The no excessive hip adduction on the weight bearing
heels should be approximately 5–10 cm from the stance leg.
489
The person should self-monitor the hip and dissociation feels less unnatural, the exercise can
trunk alignment and control hip adduction UCM be progressed to performing this same movement
with a variety of feedback options (T79.3). There unsupported, without the wall, in single leg
should be no provocation of any symptoms stance.
within the range that the hip adduction UCM can
be controlled.
Hip adduction UCM summary
As the ability to control hip adduction during
single leg stance gets easier and the pattern of (Table 9.6)
Figure 9.62 Correction – partial weight transfer – heel lift Figure 9.63 Correction – full weight transfer – foot lift
Table 9.6 Summary and rating of hip adduction tests

HIP ADDUCTION !
Single leg stance: lateral pelvic shift
490
The hip Chapter |9|
T79.1 Assessment and rating of low threshold recruitment efficiency of the Lateral Pelvic Shift Test
LATERAL PELVIC SHIFT – SINGLE LEG STANCE
Control point:
• prevent hip adduction (weight bearing leg)
Movement challenge: lateral weight transfer into single leg stance (standing)
Benchmark range: less than 10 cm of pelvis shift and less than 2 cm of asymmetry

or or
• adduction awareness of the movement pattern that they
and move lateral weight transfer into single leg confidently prevent UCM into the test
stance direction
range of: less than 10 cm of lateral pelvic concentric and eccentric movement
shift and less than 2 cm of asymmetry • Does not (consistently) use end-range
from the Lateral Pelvic Shift Test
LATEAL PELVIC SHIFT TEST – STANDING
watch the movement
Hip Adduction ! !
491
Femoral forwards glide (femoral HIP FORWARDS GLIDE CONTROL TESTS

head anterior translation) control AND FORWARDS GLIDE CONTROL
REHABILITATION
Femoral forward glide may be superimposed on
the other uncontrolled hip movements. As such,
its symptoms are not specifically linked to just the These forwards glide (femoral head anterior
forward glide, but rather, are linked to the move- translation) control tests assess the extent of for-
ment that the uncontrolled forward glide is asso- wards glide UCM in the hip and also assess the
ciated with. The femoral head appears to ‘glide ability of the dynamic stability system to ade-
forwards’ into excessive anterior translatatory dis- quately control forwards glide load or strain. It is
placement associated with flexion, extension or a priority to assess for forwards glide UCM if the
lateral rotation/abduction motion testing. patient complains of, or demonstrates, related
A segmental translatatory femoral forwards glide symptoms or disability. The tests that identify
UCM (uncontrolled femoral head anterior trans- dysfunction can also be used to guide and direct
lation) can be identified in motion testing in rehabilitation strategies.
several ways:
• In sagittal plane movements (flexion or Indications to test for hip forwards
extension), palpation of the trochanter glide UCM
during passive movement is used to identify
the location of the neutral axis of hip
motion. The ability to maintain the neutral 1. hypermobile hip anterior translation
axis and prevent excessive forwards glide of 2. symptoms (pain, discomfort, strain)
the trochanter during active unassisted associated with forwards glide (especially
flexion or extension is compared with the clicks or ‘clunks’ felt in the groin during
passive evaluation. open chain leg loading)
• In axial plane movements (lateral rotation 3. the presence of hip flexion, extension or
and abduction), palpation of the anterior rotation symptoms that do not correlate
prominence of the femoral head during with positive tests of UCM for those
passive movement with manual stabilisation directions.
is used to identify the location of the neutral The person complains of related symptoms in the
axis of hip motion. The ability to maintain hip. Under open chain hip movement (especially
the neutral axis and prevent excessive long lever load) the hip has UCM into forwards
forwards glide of the trochanter during active glide. The dysfunction is confirmed with motor
unassisted lateral rotation and abduction is control tests of uncontrolled femoral head ante-
compared with the passive evaluation. rior translation.
492
The hip Chapter |9|
Assess for uncontrolled anterior glide of the

Hip forwards glide control tests femoral head during hip flexion loading. With
the subject supine lying, palpate and monitor the
neutral axis of hip flexion and instruct the subject
T80 SUPINE: ACTIVE (VS PASSIVE)
to actively lift the straight leg to 45°. During an
STRAIGHT LEG RAISE TEST active SLR, while maintaining neutral hip rota-
(tests for hip forwards glide UCM) tion, the axis of rotation of hip flexion should
remain constant (Figure 9.66) (Sahrmann 2002).
This dissociation test assesses the ability to actively During the active SLR the subject should be able
control femoral head forward glide and perform to maintain control of femoral head forward
unilateral hip flexion (straight leg raise). During glide. If the axis of rotation stays constant and
active hip flexion from the extended hip position femoral forward glide is controlled, the pressure
(starting range) there is a biomechanical moment on palpation of the posterior trochanter should
of femoral head anterior translation that should stay the same, or increase very slightly due to
be controlled by co-activation of the hip local slight posterior translation.
stabiliser muscle and the deep anterior hip flexor This test should be performed without any
muscles. feedback (self-palpation, vision, etc.) or cueing
testing the therapist should use palpation and
Test procedure
With the person lying supine and with legs
extended, the therapist palpates posteriorly at the
trochanter through the posterior gluteal muscles
(Figure 9.64). The therapist then passively lifts
the leg through a straight leg raise (SLR) to 45°
(short of hamstring tension) while palpating at
the trochanter to identify the neutral axis of rota-
tion of the hip flexion (Figure 9.65). The neutral
axis is the point at the trochanter where pressure
on the palpating fingers remains constant as the
leg is passively moved through hip flexion
and extension. Ensure that the hip and leg main-
tains a neutral medial–lateral rotation position
throughout the SLR.
Figure 9.64 Start position active straight leg raise test with Figure 9.65 Passive straight leg raise to determine the
therapist palpation for hip forward glide neutral axis of rotation
493
Figure 9.67 Correction with self-palpation with partial range

short lever heel slide
The movement must be assessed on both sides. If

hip forward glide UCM presents bilaterally, one
side may be better or worse than the other.


forward glide control, do not score this as uncontrolled
forward glide. The rotation motor control tests will
identify if the observed movement is uncontrolled. A test
Figure 9.66 Benchmark active straight leg raise test
for hip forward glide UCM is only positive if uncontrolled
hip forward glide is demonstrated.
visual observation of the pelvis and leg to deter-

mine whether the control of femoral forward
glide is adequate. Assess both sides.
rotation UCM
Hip forward glide UCM (T80.1 and T80.2)
The person complains of pain-related symptoms
in the hip (clicks or ‘clunks’ in the groin, groin Correction
pain and impingement or lateral trochanteric/ If control is poor, initial retraining is best started
buttock pain). During open chain hip flexion with reduced leg load. Lying supine with legs
(especially with a long lever load), the hip has extended, the person self-palpates the neutral axis
UCM into forward glide. During the active straight of hip flexion at the trochanter. The first level of
leg raise test, the person lacks the ability to prevent retraining begins with a supported heel slide. The
anterior displacement of the femoral head (moni- person slowly bends the knee and flexes the hip
tored by palpation at the trochanter). Under hip but keeps the heel on the floor. The heel slides
flexion loading, the hip has UCM into femoral along the floor towards the opposite knee (Figure
forward glide. During the attempt to dissociate the 9.67). Ensure that the hip and leg maintain a
hip forward glide from hip flexion, the person neutral medial–lateral rotation position through-
either cannot control the UCM or has to concen- out the movement. They are to slide the heel into
trate and try hard to control the hip forward glide. hip flexion only as far as control of femoral
494
The hip Chapter |9|
forward glide is controlled (monitored with pal-

pation feedback at the trochanter). At the point
in range that the femoral head (trochanter) begins
to displace anteriorly, the movement should stop.
Conscious co-activation of the local stabilisers
of the hip may help some people regain control
of the femoral forward glide UCM more quickly.
A strategy to achieve a non-specific general
co-activation of psoas major and the other hip
local stability muscles can be attempted. This
involves visualising or attempting to ‘pull the
hip into the socket’ or trying to ‘shorten the leg’
at the same time as performing the heel slide or
the active SLR. If this co-activation strategy
Figure 9.68 Correction self-palpation with short lever leg lift
improves the control of the femoral forward glide
(monitored by palpation of the trochanter), or
decreases pain or clicking, it should be used in
conjunction with the correction exercises until If control of femoral forward glide is adequate
control becomes easy. with the heel slide, the progression is to lift the
The person should self-monitor the palpation heel from the floor and continue active hip flexion
of the trochanter and control hip forward glide to 90° with the leg unsupported (Figure 9.68)
UCM with a variety of feedback options (T80.3). and lower the heel to the floor beside the other
There should be no provocation of any symptoms knee. As control improves, the heel is lowered to
within the range that the rotation UCM can be the floor further out into long lever extension,
controlled. progressing eventually to straight leg lowering.
495
T80.1 Assessment and rating of low threshold recruitment efficiency of the Active SLR Test
ACTIVE STRAIGHT LEG RAISE TEST – SUPINE
Control point:
• prevent hip forward glide
Movement challenge: unilateral active SLR (hip flexion) (supine)
Benchmark range: 45° hip flexion (SLR)

or or
• forward glide awareness of the movement pattern that they
and move straight leg raise (hip flexion) confidently prevent UCM into the test
range of: 45° SLR (unilateral hip flexion) • The pattern of dissociation is smooth during
• No fatigue
from the Active SLR Test
ACTIVE SLR TEST – SUPINE
watch the movement
Hip Forward glide ! !
496
The hip Chapter |9|
subject to actively lift the straight leg to 10–15°

T81 PRONE: ACTIVE (VS PASSIVE) hip extension. During an active prone leg lift,
PRONE LEG LIFT TEST while maintaining neutral hip rotation, the axis
(tests for hip forward glide UCM) of rotation of hip extension should stay the same
as the passive test (Figure 9.71). During the active
control femoral head forward glide and perform
unilateral hip extension (prone leg lift). During
active hip extension from the extended hip posi-
tion (end range) there is a biomechanical moment
of femoral head anterior translation that should
be controlled by co-activation of the hip local
stabiliser muscle and the deep posterior hip
extensor muscles.
Test procedure
With the person lying prone and with legs
extended, the therapist palpates the trochanter
laterally (Figure 9.69). The therapist then pas- Figure 9.70 Passive hip extension to determine the neutral
sively lifts the straight leg into 10–15° hip exten- axis of rotation
sion while palpating at the trochanter to identify
the neutral axis of rotation of the hip extension
(Figure 9.70). The neutral axis is the point at the
trochanter where pressure on the palpating fingers
remains constant (or has minimal normal
anterior translation) as the leg is passively
moved through into hip extension and returned.
Ensure that the hip and leg maintain a neutral
medial–lateral rotation position throughout
the movement.
femoral head during hip extension loading. With
the subject lying prone, palpate and monitor the
neutral axis of hip extension and instruct the
Figure 9.69 Start position active prone leg lift test therapist
palpation for hip forward glide Figure 9.71 Benchmark active prone leg lift test
497
prone leg lift, the subject should be able to main-

tain control of femoral head forward glide. If the
femoral forward glide is controlled, the pressure
on palpation of the posterior trochanter should
stay the same as the passive hip extension.
This test should be performed without any
testing the therapist should use palpation and
visual observation of the pelvis and leg to deter-
mine whether the control of femoral forward
glide is adequate. Assess both sides.
Hip forward glide UCM Figure 9.72 Correction with self-palpation with partial rang
in the hip (clicks or ‘clunks’ in the groin, groin
pain and impingement or lateral trochanteric/ with legs extended and with two pillows under
buttock pain). During open chain hip extension the pelvis so that the hips start in 20° of flexion.
(especially with a long lever load), the hip has The person self-palpates the neutral axis of hip
UCM into femoral forward glide. During the active extension at the trochanter and actively lifts the
prone leg lift test, the person lacks the ability to straight leg from 20° of flexion to 0° (leg hori-
prevent anterior displacement of the femoral zontal) (Figure 9.72). Ensure that the hip and leg
head (monitored by palpation at the trochanter). maintains a neutral medial–lateral rotation posi-
During the attempt to dissociate the hip forward tion throughout the movement. They are to lift
glide from hip extension, the person either cannot the leg only as far as control of femoral forward
control the UCM or has to concentrate and try glide is controlled (monitored with palpation
hard to control the hip forward glide. The move- feedback at the trochanter). At the point in range
ment must be assessed on both sides. If hip that the femoral head (trochanter) begins to dis-
forward glide UCM presents bilaterally, one side place anteriorly, the movement should stop.
may be better or worse than the other. Conscious co-activation of the local stabilisers
of the hip may help some people regain control
of the femoral forward glide UCM more quickly.
If some other movement (e.g. a small amount of rotation) local stability muscles can be attempted. This
is observed during a motor control (dissociation) test of involves visualising or attempting to ‘pull the hip
forward glide control, do not score this as uncontrolled into the socket’ or trying to ‘shorten the leg’ at the
forward glide. The rotation motor control tests will same time as performing the prone leg lift. If this
identify if the observed movement is uncontrolled. A test co-activation strategy improves the control of the
for hip forward glide UCM is only positive if uncontrolled femoral forward glide (monitored by palpation
hip forward glide is demonstrated. of the trochanter), or decreases pain or clicking,
it should be used in conjunction with the correc-
tion exercises until control becomes easy.
Rating and diagnosis of hip The person should self-monitor the hip align-
rotation UCM ment and control extension UCM with a variety
(T81.1 and T81.2) of feedback options (T81.3). There should be no
Correction As control improves the pillows are removed so
If control is poor, initial retraining is best started that the prone leg lift is performed from 0° of
in more hip flexion and the leg lifts through a extension to 10–15° hip extension with good
reduced range of extension. The person lies prone control of femoral forward glide.
498
The hip Chapter |9|
T81.1 Assessment and rating of low threshold recruitment efficiency of the Active Prone Leg Lift Test
ACTIVE PRONE LEG LIFT TEST – PRONE
Control point:
Movement challenge: unilateral active prone leg lift (hip extension) (prone)
Benchmark range: 10–15° hip extension

or or
and move prone hip extension confidently prevent UCM into the test
range of: 10–15° unilateral hip extension • The pattern of dissociation is smooth during
• No fatigue
from the Active Prone Leg Lift Test
ACTIVE PRONE LEG LIFT TEST – PRONE
watch the movement
Hip Forward glide ! !
499
beside the extended knee. The therapist palpates

T82 SUPINE: ACTIVE (VS PASSIVE) the anterior femoral head just inferiorly to the
‘FIGURE 4’ TURNOUT TEST inguinal ligament (Figure 9.73). The therapist
(tests for hip forward glide UCM) then passively stabilises the femoral head by
pushing longitudinally through the femur
(femoral head into the acetabulum) and, while
maintaining hip compression, passively laterally
control femoral head forward glide and perform
rotates and abducts the hip out to the side to
unilateral hip lateral rotation and abduction with
about 60° turnout (the ‘figure 4’ position). This
the hip and knee flexed (‘figure 4’ position).
is to identify the neutral axis of hip lateral
During active hip lateral rotation and abduction
rotation/abduction.
from a flexed hip position there is a biomechani-
cal moment of femoral head anterior translation
femoral head during hip flexion loading. The
that should be controlled by co-activation of the
person is then instructed to actively lower the bent
hip local stabiliser muscles and the deep anterior
leg out into lateral rotation and abduction to 60°
hip flexor muscles.
of turnout (Figure 9.74). During the active lateral
rotation/abduction turnout (‘figure 4’ position)
Test procedure the person should be able to maintain control of
The person commences lying supine with one leg femoral head forward glide. If the forward glide is
extended and the other leg flexed at the hip and controlled, the position of the anterior femoral
knee so that the foot is supported on the floor head should be the same as with the passive test.
Figure 9.73 Start position active ‘figure 4’ turnout test

therapist palpation for hip forward glide Figure 9.74 Benchmark active ‘figure 4’ turnout test
500
The hip Chapter |9|
This test should be performed without any

for correction. The therapist should use palpation
and visual observation to determine whether the
control of femoral forward glide is adequate
when feedback is removed for testing. Assess both
sides.
Hip forward glide UCM

in the hip (clicks or ‘clunks’ in the groin, groin
pain and impingement or lateral trochanteric/
buttock pain). During hip lateral rotation and
Figure 9.75 Correction partial range and self-palpation
abduction turnout (‘figure 4’ position), the hip
has UCM into forward glide. During the active
‘figure 4’ turnout test, the person lacks the ability leg flexed at the hip and knee so that the foot is
to prevent anterior displacement of the femoral supported on the floor beside the extended knee.
head (monitored by palpation at the anterior The person self-palpates the anterior femoral
femoral head). head (Figure 9.75). The person then actively
Under hip lateral rotation and abduction lowers the bent leg out into lateral rotation and
turnout loading, the hip has UCM into femoral abduction only as far as control of femoral
forward glide. During the attempt to dissociate the forward glide is controlled (monitored with
hip forward glide from hip turnout, the person palpation feedback at the anterior femoral head).
either cannot control the UCM or has to concen- At the point in range that the femoral head
trate and try hard to control the hip forward begins to displace anteriorly, the movement
glide. The movement must be assessed on both should stop.
sides. If hip forward glide UCM presents bilater- Conscious co-activation of the local stabilisers
ally, one side may be better or worse than the of the hip may help some people regain control
other. of the femoral forward glide UCM more quickly.
Clinical assessment note for direction-specific local stability muscles can be attempted. This
motor control testing involves visualising or attempting to ‘pull the hip
into the socket’ or trying to ‘shorten the leg’ at the
If some other movement (e.g. a small amount of pelvic same time as performing the active ‘figure 4’
rotation) is observed during a motor control (dissociation) turnout. If this co-activation strategy improves the
test of forward glide control, do not score this as control of the femoral forward glide (monitored
uncontrolled forward glide. The pelvic rotation motor
by palpation of the anterior femoral head), or
uncontrolled. A test for hip forward glide UCM is
decreases pain or clicking, it should be used in
only positive if uncontrolled hip forward glide is conjunction with the correction exercises until
demonstrated. control becomes easy.
The person should self-monitor the hip align-
ment and control extension UCM with a variety
Rating and diagnosis of hip provocation of any symptoms within the range
rotation UCM that the rotation UCM can be controlled.
(T82.1 and T82.2) As control improves, the active turnout is pro-
gressed further into lateral rotation and abduc-
tion range.
Correction
If control is poor, initial retraining is best started
Hip forward glide UCM summary
with reduced range of turnout. The person lies
supine with one leg extended and with the other (Table 9.7)
501
T82.1 Assessment and rating of low threshold recruitment efficiency of the Active ‘Figure 4’ Turnout Test
ACTIVE ‘FIGURE 4’ TURNOUT TEST – SUPINE
Control point:
Movement challenge: unilateral active hip lateral rotation and abduction (’figure 4’ position) (supine)
Benchmark range: 60° hip lateral rotation and abduction turnout

or or
and move hip lateral rotation and abduction confidently prevent UCM into the test
turnout (’Figure 4 position’) direction
range of: 60° unilateral hip lateral rotation concentric and eccentric movement
and abduction turnout • Does not (consistently) use end-range
from the Active ‘Figure 4’ Turnout Test
ACTIVE ‘FIGURE 4’ TURNOUT TEST
– SUPINE position
Hip Forward glide ! ! Adhesive tape Skin tension for tactile feedback
502
The hip Chapter |9|
Table 9.7 Summary and rating of hip forward glide tests

HIP FORWARD GLIDE !
Supine: active (vs passive) straight leg raise
Prone: active (vs passive) prone leg lift
Supine: active (vs passive) ‘figure 4’ turnout
REFERENCES
Arokoski, M.H., Arokoski, J.P., Haara, Lee, Diane, 2001. An Integrated Model lumbar spine. BMC Musculoskeletal
M., Kankaanpää, M., Vesterinen, M., of Joint Function and Its Clinical Disorders 8, 90.
Niemitukia, L.H., et al., 2002. Hip Application. 4th Interdisciplinary Luomajoki, H., Kool, J., de Bruin, E.D.,
muscle strength and muscle cross World Congress on Low Back and Airaksinen, O., 2008. Movement
sectional area in men with and Pelvic Pain. Montreal, Canada, control tests of the low back;
without hip osteoarthritis. Journal 137–151. evaluation of the difference
of Rheumatology 29 (10), Lee, D., 2011. The pelvic girdle: an between patients with low back
2185–2195. integration of clinical expertise and pain and healthy controls. BMC
Bullock-Saxton, J.E., Janda, V., Bullock, research. Churchill Livingstone, Musculoskeletal Disorders 9,
M., 1994. The influence of ankle Edinburgh. 170.
injury on muscle activation during Lehman, G.J., Lennon, D., Tresidder, B., Richardson, C.A., Sims, K., 1991. An
hip extension. International Journal Rayfield, B., Poschar, M., 2004. inner range holding contraction. An
of Sports Medicine 15, 330–334. Muscle recruitment patterns during objective measure of stabilising
Grimaldi, A., Richardson, C., Durbridge, the prone leg extension. BMC function of an antigravity muscle.
G., Donnelly, W., Darnell, R., Hides, Musculoskeletal Disorders 5, 3. In: Proceedings of the 11th
J., 2009. The association between Levinger, P., Gilleard, W., Colemanm, International Congress of the World
degenerative hip joint pathology and C., 2007. Femoral medial deviation Confederation for Physical Therapy,
size of the gluteus maximus and angle during a one-leg squat test in London, p. 829.
tensor fascia lata muscles. Manual individuals with patellofemoral pain Robinson, G., Hine, A.L., Richards, P.J.,
Therapy 14 (6), 611–617. syndrome. Physical Therapy in Sport Heron, C.W., 2005. MRI
Hardcastle, P., Nade, S., 1985. The 8, 163–168. abnormalities of the external rotator
significance of the Trendelenburg Lewis, C.L., Sahrmann, S.A., muscles of the hip. Clinical
test. Journal of Bone and Joint Moran, D.W., 2007. Anterior hip Radiology 60 (3), 401–406.
Surgery British volume 67 (5), joint force increases with hip Sahrmann, S.A., 2002. Diagnosis and
741–746. extension, decreased gluteal force, treatment of movement impairment
Hoeksma, H.L., Dekker, J., Ronday, or decreased iliopsoas force. syndromes. Mosby, St Louis.
H.K., Heering, A., van der Lubbe, N., Journal of Biomechanics 40 (16), Shindle, M.K., Ranawat, A.S., Kelly, B.T.,
Vel, C., et al., 2004. Comparison of 3725–3731. 2006. Diagnosis and management of
manual therapy and exercise therapy Long, W.T., Dorr, L.D., Healy, B., Perry, traumatic and atraumatic hip
in osteoarthritis of the hip: a J., 1993. Functional recovery of instability in the athletic patient.
randomized clinical trial. Arthritis noncemented total hip arthroplasty. Clinics in Sports Medicine 25 (2),
and Rheumatism 51 (5), 722–729. Clinical Orthopaedics and Related 309–326, ix–x. Review.
Janda, V., 1983. On the concept of Research 288, 73–77. Sims, K., 1999. The development of hip
postural muscles and posture in Luomajoki, H., Kool, J., de Bruin, E.D., osteoarthritis: implications for
man. Australian Journal of Airaksinen, O., 2007. Reliability of conservative management. Man Ther
Physiotherapy 29 (3), 83–84. movement control tests in the 4, 127–135.
503
Index
Index
Page numbers followed by ‘f ’ indicate figures, ‘t’ indicate tables, and ‘b’ indicate boxes.
active straight leg raise test, apical drop and inspiration test,
A 493–495, 494b 351–352, 352b
abdominal hollowing and correction of hip rotation UCM correction of thoracic respiratory
expiration test, 357–360, 358b during, 494–495, 494f–495f, UCM during, 352, 353t
correction of thoracic respiratory 496t procedure for, 351–352, 351f
UCM during, 358, 359t hip forward glide UCM during, rating and diagnosis of thoracic
procedure for, 357, 357f–358f 494 respiratory UCM during, 352,
rating and diagnosis of thoracic procedure for, 493–494, 353t
respiratory UCM during, 358, 493f–494f thoracic respiratory UCM during,
359t rating and diagnosis of hip 352
thoracic respiratory UCM during, rotation UCM during, arm abduction tests, 393
357 494–495, 496t procedure for, 393, 393f
abduction control tests see lateral adduction control tests, hip, 487 rating and diagnosis of, 393,
rotation/abduction control single leg stance lateral pelvic 394t
tests shift test, 488–490, 488f– retraining, 393, 395b, 395f
actin-myosin cross-bridges, 26–28, 490f, 489b, 491t arm elevation, impingement and
26f summary for, 490t instability during, 365,
active ‘figure 4’ turnout test, afferent input, sensation of effort 366t–367t
500–501, 501b and, 38–39, 39b arm extension test, 242–243,
correction of hip rotation UCM alternate single leg heel touch, 243b
during, 501, 501f, 502t 103–104, 103f, 147, 147f for shoulder girdle UCM,
hip forward glide UCM during, alternative therapies, for UCM, 7–9, 398–400
501 8b–9b procedure for, 396f, 398, 398f
procedure for, 500–501, 500f ankle dorsiflexion, gastrocnemius rating and diagnosis, 398–400,
rating and diagnosis of hip or talocrural joint restriction of, 399t
rotation UCM during, 501, 421 retraining, 398–400,
502t anterior capsule, in hip extension 400f–401f, 401b
active prone leg raise test, 497–498, control, 440–441 for upper cervical flexion control
498b anterior costal lift and expiration assessment goals for evaluating
correction of hip rotation UCM test, 354–355, 355b site and direction of UCM
during, 498, 498f, 499t correction of thoracic respiratory during, 241t
hip forward glide UCM during, UCM during, 355, 356t correction of upper cervical
498 procedure for, 354–355, 354f flexion UCM during, 243,
procedure for, 497–498, 497f rating and diagnosis of thoracic 243f, 244t
rating and diagnosis of hip respiratory UCM during, 355, procedure for, 242, 242f
rotation UCM during, 498, 356t rating and diagnosis of upper
499t thoracic respiratory UCM during, cervical flexion UCM
active restrictions, 48–49 355 during, 243, 244t
505
Index
upper cervical flexion UCM correction of upper cervical rating and diagnosis of thoracic
during, 242–243 extension UCM during, extension UCM during,
arm flexion tests, 388–390 248–251, 249f, 250t 324–326, 325t
procedure for, 388, 388f procedure for, 247, 247f–248f thoracic extension UCM during,
rating and diagnosis of, 388–390, rating and diagnosis of upper 324
389t cervical extension UCM bilateral forward reach test,
retraining, 390, 390b, 390f during, 248–251, 250t 308–309, 309b
articular dysfunction, 51–52, 51t upper cervical extension UCM correction of thoracic flexion
articular restriction during, 247–248 UCM during, 309, 310t, 311f
in neck extension, 245 backward push test, 97–98, 98b procedure for, 308–309, 308f
in neck rotation, 264–266, correction of lumbar flexion rating and diagnosis of thoracic
264f–266f UCM during, 98, 98f, 99t flexion UCM during, 309,
in neck side-bending, 268–269 lumbar flexion UCM during, 310t
assessment 98 thoracic flexion UCM during,
of contextual factors in UCM, 14, procedure for, 97, 97f 309
16 rating and diagnosis of lumbar bilateral overhead reach test,
disablement assessment model flexion UCM during, 98, 99t 313–314, 314b
in, 17–19, 17f–18f backward rocking correction of thoracic extension
for environmental and personal movement faults associated with, UCM during, 314, 314f, 315t
factors, 14, 16 422 procedure for, 313–314, 313f
of movement faults, model for, observation and analysis of, 422, rating and diagnosis of thoracic
7–9, 8b–9b, 8f 422f extension UCM during, 314,
principles of, 12, 53–54 behavioural traits, for motivation 315t
relation of findings to disability, and compliance, 74–76, 74f, thoracic extension UCM during,
11, 11b 75b, 76t 314
of UCM, clinical assessment, bent knee fall out test, 169–173, bridge single leg lift test, 483–484,
54–59, 56b, 59b, 59t 171b 483b
asymmetry correction of lumbopelvic correction of hip lateral rotation/
in neck extension, 246 rotation UCM during, 171, abduction UCM during, 484,
in neck flexion, 225 172t 485t
external oblique abdominal hip lateral rotation/abduction
B recruitment, 171 UCM during, 483
internal oblique abdominal procedure for, 483, 483f
back flattening test, 296–297, 297b recruitment, 171–173 rating and diagnosis of hip lateral
correction of thoracic flexion lumbopelvic rotation UCM rotation/abduction UCM
UCM during, 297, 297f, 298t, during, 169–171 during, 484, 485t
299f procedure for, 169, 169f–170f
procedure for, 296, 296f rating and diagnosis of C
rating and diagnosis of thoracic lumbopelvic rotation UCM
flexion UCM during, 297, 298t during, 171–173, 172t capsular restriction
thoracic flexion UCM during, 297 bent knee hip extension test, in glenohumeral lateral rotation,
back flattening on wall, 122, 122f 479–481, 480b 376
correction of, 122 correction of hip lateral rotation/ in glenohumeral medial rotation,
dysfunctional action, 122 abduction UCM during, 370
ideal action, 122, 122f 480–481, 480f, 482t central fatigue, 39, 39b
backward arching, observation and hip lateral rotation/abduction cervical spine
analysis of, 120–121, 120f UCM during, 480 disability questionnaires for, 11b
ideal pattern of lumbar procedure for, 479–480, 479f muscle function within, 219–220,
extension, 120, 120f rating and diagnosis of hip lateral 220f
indications to test for lumbar rotation/abduction UCM neutral training region of,
extension UCM, 121 during, 480–481, 482t 223–224, 223f, 224b
movement faults associated with biceps, in shoulder movement, 364 relative stiffness and flexibility in,
lumbar extension, 120–121 bilateral backward reach test, 46
backward head lift test, 247–251, 323–326, 324b cervical spine UCM, 218–291
248b correction of thoracic extension cervical rotation, 263–267,
assessment goals for evaluating UCM during, 324–326, 324f, 263f–267f
site and direction of UCM 325t relative flexibility in, 269
during, 250t procedure for, 323–324, 323f UCM in, 222t
506
Index
cervical side-bend, 267–269 observation and analysis of mid-cervical forward UCM

observation and analysis of, neck flexion, 225 during, 260
267–269 occiput lift test, 226–227, 226f, procedure for, 259–260, 259f
relative flexibility in, 266, 227b, 228t, 229f rating and diagnosis of cervical
267f overhead arm lift test, 233– extension UCM during,
cervical spine muscle function 235, 233f–235f, 234b, 236t 260–261, 262t
and, 219–220, 220f thoracic flexion test, 230–231, clinical assessment, of UCM,
identification of, 221 230f, 231b, 232t 54–59, 56b, 59b, 59t
mid-cervical extension rotation and side-bend control indications for testing of UCM,
abnormal translation during, tests, 263–267, 270–289 56–57
256 head tilt test, 276–278, 276f, MCRS, 54–55, 57–59, 59b, 59t
normal translation during, 277b, 277t, 278f, movement control test procedure,
256 279t–280t, 280f 57–59, 59b, 59t
palpation during, 256b head turn test, 270–273, testing for site and direction of
mid-cervical translation 270f–273f, 271b, 271t, UCM, 55–57, 56b
abnormal translation during, 274t–275t clinical reasoning, 10–15, 10b–11b,
256 lower neck lean test, 285–289, 10t–12t, 13f–14f, 15t
normal translation during, 256 285f–286f, 286b, 286t, in diagnostic framework, 15–16,
palpation during, 256b 288t 17f
UCM in, 222t observation and analysis of step 1: diagnosis of movement
rehabilitation for, 220–221 neck rotation, 263–267, dysfunction, 16
site and direction of 263f–267f step 2: clinical diagnosis of
diagnosis of, 221, 221t–222t observation and analysis of neck pain-sensitive or pain-
identification of, 221–224, side-bending, 109, 163f generating structures, 16
223f, 224b summary for, 289t step 3: clinical diagnosis of
upper cervical extension upper neck tilt test, 281–283, presenting pain
relative flexibility in, 246, 266, 281f–283f, 282b, 282t, mechanisms, 16
267f, 269 284t step 4: assessment of
UCM in, 222t cervicothoracic flexion, relative contextual factors, 16
upper cervical flexion flexibility in, 225 in 10 point analysis for UCM,
relative flexibility in, 225 cervicothoracic restriction, of neck 10–15, 10b–11b, 10t–12t,
restriction of, 225 extension, 245, 245f–246f 13f–14f, 15t
UCM in, 222t chest drop test, 109–112, 110b in therapeutic exercise
cervical spine UCM tests, 225 correction of lumbar flexion prescription, 66, 66b
extension control tests, 245–253, UCM during, 110–112, 111t, closed chain rotation control tests
255–261 112f lumbopelvic, 192–213
backward head lift test, lumbar flexion UCM during, 110 crook-lying single leg bridge
247–251, 247f–249f, 248b, procedure for, 109, 109f extension test, 192–194,
250t rating and diagnosis of lumbar 192f–193f, 193b, 195t
chin lift hinge test, 259–261, flexion UCM during, 110–112, standing double knee swing
259f, 260b, 261f, 262t 111t test, 200–202, 200f, 201b,
head back hinge test, chest lift (tilt) test, 132–136, 133b 202f–204f, 205t
255–257, 255f–257f, 256b, correction of lumbar extension standing pelvic side-shift test,
258t UCM during, 133–136, 134t, 210–213, 210f, 211b, 212t
horizontal retraction test, 135f standing thoracic rotation test,
252–253, 252f–253f, 253b, lumbar extension UCM during, 196–198, 196f, 197b, 198f,
254t 133 199t
observation and analysis of procedure for, 132–133, 132f standing trunk side-bend test,
neck extension, 245–246, rating and diagnosis of lumbar 206–208, 206f, 207b, 209t
245f–246f extension UCM during, summary for, 214t
flexion control tests, 225–235, 133–136, 134t coactivation of lateral abdominals
237–243 chin lift hinge test, 259–261, 260b and gluteals, 106, 122–123
arm extension test, 241t, assessment goals for evaluating correction of, 123
242–243, 242f–243f, 243b, site and direction of UCM dysfunctional action, 123
244t during, 262t ideal action, 106, 122
forward head lean test, correction of cervical extension co-contraction rigidity
237–239, 237f–238f, 239b, UCM during, 260b, 261f, in glenohumeral lateral rotation,
240f, 241t 262t 377
507
Index
in glenohumeral medial rotation, static diagonal with isometric double bent leg lift test, 100–104,
370 opposite knee to hand 102b
cognitive awareness, in retraining, push, 146, 146f correction of lumbar flexion
68–69, 71 lumbar extension UCM during, UCM during, 102, 102f–103f,
compensation 145 105t
cervical procedure for, 144–145, alternate single leg heel touch
in head tilt test, 277, 277t 144f–145f (Sahrmann level 1),
in head turn test, 271, 271t rating and diagnosis of lumbar 103–104, 103f
in lower neck lean test, extension UCM during, multifidus facilitation, 102,
285–286, 286t 145–147, 148t 102f
scapula, 266–267, 269 crook-lying single leg bridge static diagonal heel lift with
in upper neck tilt test, 281– extension test, 192–194, 193b isometric knee to hand
282, 282t correction of lumbopelvic push and second heel lift,
for restrictions, UCM rotation UCM during, 103, 103f
resulting from, 49–52, 193–194, 193f, 195t static diagonal with isometric
50t–51t lumbopelvic rotation UCM opposite knee to hand
compliance, personality and during, 192 push, 102, 102f
behavioural traits for, 74–76, procedure for, 192, 192f lumbar flexion UCM during,
74f, 75b, 76t rating and diagnosis of 101
contextual factors in UCM, lumbopelvic rotation UCM procedure for, 100–101,
assessment of, 14, 16 during, 193–194, 195t 100f–101f
crook-lying double bent leg lift test, cross-bridges see actin-myosin rating and diagnosis of lumbar
100–104, 102b cross-bridges flexion UCM during, 102–
correction of lumbar flexion 104, 105t
UCM during, 102, 102f–103f, D double bent leg lower test, 144–
105t 147, 145b
alternate single leg heel touch diagnosis, clinical reasoning correction of lumbar extension
(Sahrmann level 1), applied to, 15–16, 17f UCM during, 145–146,
103–104, 103f step 1: diagnosis of movement 146f–147f, 148t
multifidus facilitation, 102, dysfunction, 16 alternate single leg heel touch,
102f step 2: clinical diagnosis of 147, 147f
static diagonal heel lift with pain-sensitive or pain- oblique abdominal facilitation,
isometric knee to hand generating structures, 16 146
push and second heel lift, step 3: clinical diagnosis of static diagonal heel lift with
103, 103f presenting pain mechanisms, isometric knee to hand
static diagonal with isometric 16 push and second heel lift,
opposite knee to hand step 4: assessment of contextual 146–147, 146f
push, 102, 102f factors, 16 static diagonal with isometric
lumbar flexion UCM during, direct overfacilitation, UCM opposite knee to hand
101 resulting from, 49–50 push, 146, 146f
procedure for, 100–101, direction of UCM see site and lumbar extension UCM during,
100f–101f direction of UCM 145
rating and diagnosis of lumbar disability procedure for, 144–145,
flexion UCM during, 102– relation of assessment findings 144f–145f
104, 105t to, 11, 11b rating and diagnosis of lumbar
crook-lying double bent leg lower with UCM, 5–6 extension UCM during,
test, 144–147, 145b disability questionnaires, 11b 145–147, 148t
correction of lumbar disablement assessment model, double knee bend test, 149–152,
extension UCM during, 17–19, 17f–18f 150b
145–146, 146f–147f, 148t dissociation, integrative, 75 correction of lumbar extension
alternate single leg heel touch, dissociation tests, 46–47, 53–57 UCM during, 150–152, 150f,
147, 147f dissociation in parallel, 55–56 151t, 152f
oblique abdominal facilitation, dissociation in series, 55 lumbar extension UCM during,
146 for lumbopelvic UCM, 90 149
static diagonal heel lift with retraining based on, 67–69, procedure for, 149, 149f
isometric knee to hand 68f–69f rating and diagnosis of lumbar
push and second heel lift, for shoulder girdle UCM, 402, 402t extension UCM during,
146–147, 146f test procedure, 57–59, 59b, 59t 150–152, 151t
508
Index
double knee extension test, hip, 441–452 standing bilateral overhead

113–114, 114b indications for, 441 reach test, 313–314,
correction of lumbar flexion standing single knee lift and 313f–314f, 314b, 315t
UCM during, 114, 115t anterior tilt test, 446–448, summary for, 326t
lumbar flexion UCM during, 446f–447f, 447b, 449t extension hinge see segmental
113–114 standing single knee lift and extension hinge
procedure for, 113, 113f knee extension test, 450– extension UCM, lumbopelvic,
rating and diagnosis of lumbar 452, 450f–451f, 451b, 453t 86–87, 86t
flexion UCM during, 114, standing thoracolumbar clinical example of, 87–88
115t extension test, 442–444, indications to test for, 121
double knee swing test, 200–202, 442f–443f, 443b, 445t external oblique abdominal
201b summary for, 452t recruitment
correction of lumbopelvic lumbar, 120–121, 124–159 during prone single hip rotation
rotation UCM during, crook-lying double bent leg test, 181
201–202, 202f–204f, 205t lower test, 144–147, during side-lying top leg turn out
lumbopelvic rotation UCM 144f–147f, 145b, 148t test, 175
during, 201 extension control rehabilitation during supine bent knee fall out
procedure for, 200–201, 200f and, 120 test, 171
rating and diagnosis of extension load testing during supine single heel slide
lumbopelvic rotation UCM prerequisites, 106, 121–123, test, 168
during, 201–202, 205t 122f
dynamic movement faults, with four point forward rocking test, F
shoulder dysfunction, 363 140–142, 140f–142f, 141b,
dysfacilitation, 37, 37t 143t fascial restriction, in neck
dysfunction observation and analysis of extension, 246
in motor recruitment lumbar extension and fast motor units (FMUs), 31–32,
altered strategies in, 37–38, 38f backward arching, 120–121, 32f, 32t
inhibition and dysfacilitation, 120f recruitment of, 32–34, 33f, 33t,
37, 37t prone double knee bend test, 70–71, 70t, 71b
neuromusculoskeletal, challenges 149–152, 149f–150f, 150b, in mobiliser muscles, 34
in retraining of, 71–72 151t, 152f pain and, 36–37, 37f
see also movement dysfunction prone (table) hip extension lift fatigue
dysfunction loop, 39, 39f test, 153–156, 153f–154f, central, 39, 39b
154b, 155t, 156f peripheral, 38, 39b
E sitting chest lift (tilt) test, feedback for UCM retraining, 67
132–136, 132f, 133b, 134t, femoral forward glide control,
elbow straightening, for shoulder 135f 492
girdle UCM, 402t sitting forward lean test, femoral forward glide UCM, 417,
environmental factors, assessment 137–138, 137f, 138b, 139t 492
of, 14, 16 standing hip extension toe flexibility, 45–46, 45f
extension control rehabilitation, slide test, 157–159, in glenohumeral medial rotation,
lumbar, extension control tests 157f–159f, 158b, 160t 371
and, 120 standing thoracic extension in hip adduction control, 486
extension control tests (sway) test, 124–126, in hip extension control, 441
cervical, 245–253, 255–261 124f–126f, 125b, 127t in hip rotation control, 454–455
backward head lift test, standing thoracic extension in hip UCM
247–251, 247f–249f, 248b, (tilt) test, 128–131, with backward rocking, 422
250t 128f–129f, 129b, 130t with forward bending, 421
chin lift hinge test, 259–261, summary for, 161t with SKB, 423
259f, 260b, 261f, 262t thoracic, 312 in lumbar extension, 120–121
head back hinge test, 255–257, sitting head raise test, 316–317, in lumbar flexion, 91–92
255f–257f, 256b, 258t 316f–317f, 317b, 318t in lumbopelvic rotation,
horizontal retraction test, sitting pelvic tail lift test, 162–163
252–253, 252f–253f, 253b, 319–321, 319f–321f, 320b, in neck extension, 246
254t 322t in neck flexion, 225
observation and analysis of standing bilateral backward in neck rotation, 266–267, 267f
neck extension, 245–246, reach test, 323–326, in neck side-bending, 269
245f–246f 323f–324f, 324b, 325t in thoracic flexion, 295
509
Index
flexion control rehabilitation, thoracic, 296–309 rating and diagnosis of upper

lumbar, flexion control tests sitting bilateral forward reach cervical flexion UCM during,
and, 90 test, 308–309, 308f, 309b, 239, 241t
flexion control tests 310t, 311f upper cervical flexion UCM
cervical, 225–235, 237–243 sitting head hang test, 300– during, 238–239
arm extension test, 241t, 301, 300f, 301b, 302t, 303f forward lean test, 106–107, 107b
242–243, 242f–243f, 243b, sitting pelvic tail tuck test, 304– for lumbar extension UCM,
244t 306, 304f–306f, 305b, 307t 137–138, 138b
forward head lean test, standing back flattening test, correction of lumbar extension
237–239, 237f–238f, 239b, 296–297, 296f–297f, 297b, UCM during, 138, 139t
240f, 241t 298t, 299f lumbar extension UCM during,
observation and analysis of summary for, 309t 138
neck flexion, 225 flexion hinge see segmental flexion procedure for, 137, 137f
occiput lift test, 226–227, 226f, hinge rating and diagnosis of lumbar
227b, 228t, 229f flexion UCM, lumbopelvic, 86–87, extension UCM during,
overhead arm lift test, 233– 86t 119, 139t
235, 233f–235f, 234b, 236t clinical example of, 88 for lumbar flexion UCM
thoracic flexion test, 230–231, indications to test for, 92 correction of lumbar flexion
230f, 231b, 232t FMUs see fast motor units UCM during, 107, 108t
hip, 426–438 forearm twist, for shoulder girdle lumbar flexion UCM during,
side-lying single leg abduction UCM, 402t 106
test, 437–438, 437f, 438b, forward bending procedure for, 106, 106f–107f
439t hip sagittal motion control and rating and diagnosis of lumbar
standing single foot lift test, 430– ideal pattern of, 421, 421f flexion UCM during, 107,
431, 430f–431f, 431b, 432t movement faults with, 421 108t
standing spinal roll down test, observation and analysis of, forward rocking test, 140–142,
433–435, 433f–434f, 434b, 421–423 141b
436t observation and analysis of, correction of lumbar extension
standing vertical trunk single 91–92, 91f UCM during, 141–142,
leg 1/4 squat test, 426–428, ideal pattern of lumbar flexion, 141f–142f, 143t
426f–428f, 427b, 429t 91, 91f lumbar extension UCM during,
summary for, 438t indications to test for lumbar 141
lumbar, 90–119 flexion UCM, 92 procedure for, 140–141, 140f
crook-lying double bent leg lift movement faults associated rating and diagnosis of lumbar
test, 100–104, 100f–103f, with lumbar flexion, extension UCM during,
102b, 105t 91–92 141–142, 143t
flexion control rehabilitation forward glide control tests, hip, four point bent knee hip extension
and, 90 492 test, 479–481, 480b
four point kneeling backward prone active prone leg raise test, correction of hip lateral rotation/
push test, 97–98, 97f–98f, 497–498, 497f–498f, 498b, abduction UCM during,
98b, 99t 499t 480–481, 480f, 482t
observation and analysis of summary for, 503t hip lateral rotation/abduction
lumbar flexion and forward supine active ‘figure 4’ turnout UCM during, 480
bending, 91–92, 91f test, 500–501, 500f–501f, procedure for, 479–480, 479f
sitting chest drop test, 109–112, 501b, 502t rating and diagnosis of hip lateral
109f, 110b, 111t, 112f supine active straight leg raise rotation/abduction UCM
sitting double knee extension test, 493–495, 493f–495f, during, 480–481, 482t
test, 113–114, 113f, 114b, 494b, 496t four point forward rocking test,
115t forward head lean test, 237–239, 140–142, 141b
sitting forward lean test, 239b correction of lumbar extension
106–107, 106f–107f, 107b, assessment goals for evaluating UCM during, 141–142,
108t site and direction of UCM 141f–142f, 143t
standing trunk lean test, 93– during, 241t lumbar extension UCM during,
96, 93f–94f, 94b, 95t, 96f correction of upper cervical 141
stand-to-sit ischial weight flexion UCM during, 239, procedure for, 140–141, 140f
bearing test, 116–119, 240f, 241t rating and diagnosis of lumbar
116f–117f, 117b, 118t procedure for, 237–238, extension UCM during,
summary for, 119t 237f–238f 141–142, 143t
510
Index
four point kneeling backward push arm extension test for, glenohumeral lateral rotation,
test, 97–98, 98b 398–400 movement faults associated
correction of lumbar flexion procedure for, 396f, 398, with, 376–377
UCM during, 98, 98f, 99t 398f reduced, 376–377
lumbar flexion UCM during, 98 rating and diagnosis of, relative stiffness, 376–377
procedure for, 97, 97f 398–400, 399t uncontrolled movement, 377
rating and diagnosis of lumbar retraining, 398–400, 400f– glenohumeral medial rotation,
flexion UCM during, 98, 99t 401f, 401b movement faults associated
four point one arm lift test, arm flexion tests for, 388–390 with, 370–371
340–341, 341b procedure for, 388, 388f relative flexibility, 371
correction of thoracic rotation rating and diagnosis of, relative stiffness, 370
UCM during, 341, 341f–342f, 388–390, 389t global mobility muscles, 29t, 31
343t retraining, 390, 390b, 390f global muscle systems, 24–26, 25t
procedure for, 340–341, 340f compensatory strategies for, 371 global range-specific UCM
rating and diagnosis of thoracic identification of, 364 in hip, 417–420
rotation UCM during, 341, identifying site and direction of, in shoulder girdle, 369–370
343t 365–370 global stability muscles, 29t, 31
thoracic rotation UCM during, global range-specific UCM, gluteals
341 369–370 in hip pain, 415–416
full chest turn, for shoulder girdle neutral training region, lateral abdominals coactivation
UCM, 402t 365–367, 367f–368f, with, 106, 122–123
full head turn, for shoulder girdle 368b gluteus maximus, in hip pain, 416
UCM, 402t segmental translatatory UCM, gluteus medius (GMD), in hip
functional classification, of muscle 369 pain, 416
roles, 28, 28f, 29t impingement and instability GMD see gluteus medius
functional efficiency, of muscles, with
26–28, 26f–27f correction of, 404 H
functional tasks, integrating movement faults related to,
retraining into, 72–77, 73f–74f, 404–405, 404b hamstrings, restriction of hip
75b, 76t–77t retraining, 404–405, 405f– flexion by, 91
length of training, 77 406f, 406b, 409f–410f head back hinge test, 255–257,
manual therapy, 76–77 inferior translation, 387, 392 256b
movement control retraining, 77, KLRT for, 378–383 assessment goals for evaluating
77t part 1, 378, 378f–379f site and direction of UCM
personality and behavioural traits part 2, 379 during, 258t
for motivation and rating and diagnosis of, correction of cervical extension
compliance, 74–76, 74f, 75b, 379–383, 380t UCM during, 256–257, 257f,
76t retraining, 379–383, 383b, 258t
using training tools/equipment, 383f–384f mid-cervical forward UCM
76 risks with, 379, 381t, during, 255–256
382f–383f procedure for, 255, 255f–256f,
G scapular contributions v., 379, 256b
381f rating and diagnosis of cervical
gastrocnemius joint restriction, of KMRT for, 372–374 extension UCM during,
ankle dorsiflexion, 421 rating and diagnosis of, 256–257, 258t
gemellus inferior, in hip pain, 416 372–374, 373t–374t, head hang test, 300–301, 301b
glenohumeral joint 374f–375f correction of thoracic flexion
diagnosis of site and direction of retraining for, 372–374, 374b, UCM during, 301, 302t, 303f
UCM at, 365, 365t 375f procedure for, 300, 300f
function of, 363–364 medial rotation, 387, 397 rating and diagnosis of thoracic
muscle stiffness at, 364 rotation, 392 flexion UCM during, 301, 302t
glenohumeral joint UCM shoulder abduction control in, thoracic flexion UCM during,
anterior translation, 377, 397 392 300–301
arm abduction tests for, 393 shoulder extension control in, head raise test, 316–317, 317b
procedure for, 393, 393f 397 correction of thoracic extension
rating and diagnosis of, 393, shoulder flexion control in, 387 UCM during, 317, 317f,
394t symptom presentation and site 318t
retraining, 393, 395b, 395f of, 365, 366t–367t procedure for, 316–317, 316f
511
Index
rating and diagnosis of thoracic hip adduction control, 486–487 hip flexors, restriction of hip
extension UCM during, 317, observation and analysis of, extension by, 120
318t 486 hip lateral rotation/abduction,
thoracic extension UCM during, ideal pattern for, 486, 486f restriction of, 486
317 relative flexibility, 486 hip medial rotation, 454–455
head tilt test, 276–278, 277b relative stiffness, 486 decreased, 455
assessment goals for evaluating hip extension excessive, 455
site and direction of UCM excessive, 441 restriction of, 454, 486
during, 279t hip flexor restriction of, 120 hip rotation control, 454–455
correction of UCM during, hip extension control, 440–441 assessment of relative range of,
277–278, 278f, 280f, 280t movement faults associated with, 455
procedure for, 276–277, 276f 440–441 faults of, 455
rating and diagnosis of UCM modified Thomas test for, 440, correcting neutral rotational
during, 277–278, 279t 440f alignment of SKB, 456f, 457
UCM during, 277, 277t relative flexibility, 441 dysfunction assessment of,
head turn test relative stiffness, 440–441, 455–458
for cervical rotation UCM, 441f lower quadrant rotational
270–273, 271b hip extension lift test alignment evaluation,
assessment goals for evaluating for lumbar extension UCM, 455–456, 456f
site and direction of UCM 153–156, 154b dysfunctions of, 456, 456f–
during, 274t correction of lumbar extension 458f, 463f
cervical rotation UCM, 271, UCM during, 154–156, ideal rotational alignment, 456
271t 154f, 155t, 156f movement faults associated with,
correction of cervical rotation lumbar extension UCM during, 454–455
UCM, 271–273, 271f–273f, 153–154 relative flexibility, 454–455
275t procedure for, 153, 153f relative stiffness, 454
procedure for, 270–271, rating and diagnosis of lumbar observation and analysis of,
270f extension UCM during, 454–455
rating and diagnosis of cervical 154–156, 155t ideal pattern for, 454, 454f
rotation UCM, 271–273, for lumbopelvic rotation UCM, hip rotation restriction, 162
274t 186–187, 186b hip sagittal motion control, 421
for thoracic rotation UCM, correction of lumbopelvic alignment evaluation, 423–425
328–348, 329b rotation UCM during, 187, ideal sagittal alignment, 423f,
correction of thoracic rotation 188t 424–425
UCM during, 329, 329f, lumbopelvic rotation UCM dysfunction of, 423f–424f,
330t during, 186 424–425
procedure for, 328–329, procedure for, 186, 186f observation and analysis of,
328f rating and diagnosis of 421–423
rating and diagnosis of thoracic lumbopelvic rotation UCM backward rocking and, 422,
rotation UCM during, 329, during, 187, 188t 422f
330t hip extension toe slide test, forward bending and, 421, 421f
thoracic rotation UCM during, 157–159, 158b SKB, 422, 423f
329 correction of lumbar extension supine passive hip flexion, 422
heel lift with isometric knee to UCM during, 158–159, 159f, hip UCM, 416
hand push and second heel lift, 160t adduction UCM
146–147, 146f lumbar extension UCM during, indication for tests for, 487
high threshold recruitment 158 site and direction of, 418t,
versus low, 32–34, 33f, 33t procedure for, 157–158, 420
training of, 40, 40t 157f–158f diagnosis of site and direction of,
hinge see segmental extension rating and diagnosis of lumbar 416–417, 417b
hinge; segmental flexion hinge extension UCM during, extension UCM, site and
hip, 414–503 158–159, 160t direction of, 418t, 419–420
disability questionnaires for, hip flexion flexion UCM see also hip sagittal
11b hamstrings restriction of, 91 motion control
muscle function changes around, supine passive, ideal pattern of, indications to test for, 425
415–416 422 site and direction of, 417–420,
osteoarthritis of, 415–416 thoracolumbar restriction of, 418t
hip adduction, 486 421–422 tests and rehabilitation for, 425
512
Index
forward glide UCM, indications forward glide control tests, 492 hyperflexion see multisegmental
to test for, 492 prone active prone leg raise hyperflexion
identifying of site and direction test, 497–498, 497f–498f,
of, 417–420 498b, 499t I
global range-specific, 417–420 summary for, 503t
segmental translatatory, 417 supine active ‘figure 4’ turnout IAG see inferior anterior glenoid
lateral rotation/abduction UCM, test, 500–501, 500f–501f, ideal sagittal alignment, 423f,
455 501b, 502t 424–425
decreased, 455 supine active straight leg raise iliacus, in hip extension control,
excessive, 455 test, 493–495, 493f–495f, 440–441
indications to test for, 470 494b, 496t iliotibial band, in hip extension
restriction of, 454 lateral rotation/abduction control control, 440, 441f
site and direction of, 419–420 tests, 470 impingement
medial rotation UCM bridge single leg lift test, during arm elevation, 365,
indications to test for, 458 483–484, 483b, 483f, 485t 366t–367t
site and direction of, 419–420 four point bent knee hip shoulder girdle UCM
movement faults with extension test, 479–481, correction of, 404
backward rocking, 422 479f–480f, 480b, 482t movement faults related to,
forward bending, 421 standing one leg small knee 404–405, 404b
small knee bend, 423 bend and trunk rotation retraining, 404–405, 405f–
rotation UCM, site and direction towards test, 475–477, 406f, 406b
of, 418t 475f–476f, 476b, 478t impingement risk
site and symptom presentation standing single leg high knee with KLRT, 379, 381t, 382f
in, 417, 418t lift test, 471–473, 471f, with KMRT, 374f, 374t
tests for, 421 472b, 473f, 474t inferior anterior glenoid (IAG),
hip sagittal motion control, 421 summary for, 484t 367, 369f
hip UCM tests medial rotation control tests, inhibition, 37, 37t
adduction control tests, 487 457–458 injury risk, with UCM, 6–7
single leg stance lateral pelvic side-lying top leg turnout lift innominate, directions of UCM in,
shift test, 488–490, test, 467–468, 467f–468f, 89t
488f–490f, 489b, 491t 468b, 469t instability
summary for, 490t standing one leg small knee during arm elevation, 365,
extension control tests, 441–452 bend and trunk rotation 366t–367t
indications for, 441 away test, 463–465, shoulder girdle UCM
standing single knee lift and 463f–464f, 464b, 466t correction of, 404
anterior tilt test, 446–448, standing single leg small knee movement faults related to,
446f–447f, 447b, 449t bend test, 459–462, 459f– 404–405, 404b
standing single knee lift and 460f, 460b, 462f, 466t retraining, 404–405, 405f–
knee extension test, 450– summary for, 468t 406f, 406b
452, 450f–451f, 451b, 453t horizontal retraction test, 252–253, instability risk
standing thoracolumbar 253b with KLRT, 379, 381t, 383f
extension test, 442–444, assessment goals for evaluating with KMRT, 374t, 375f
442f–443f, 443b, 445t site and direction of UCM insufficiency, of muscles, 26–27
summary for, 452t during, 254t integrated model of mechanical
flexion control tests, 426–438 correction of upper cervical movement dysfunction, 52–53,
side-lying single leg abduction extension UCM during, 253, 53f, 63–64, 64f
test, 437–438, 437f, 438b, 253f, 254t integrative dissociation, 75
439t procedure for, 252, 252f interarticular UCM, 51t, 52
standing single foot lift test, rating and diagnosis of upper internal oblique abdominal
430–431, 430f–431f, 431b, cervical extension UCM recruitment
432t during, 253, 254t during prone single hip rotation
standing spinal roll down test, upper cervical extension UCM test, 181–182
433–435, 433f–434f, 434b, during, 252–253 during side-lying top leg turn out
436t humerus translation, in test, 175–177
standing vertical trunk single glenohumeral lateral rotation, during supine bent knee fall out
leg 1/4 squat test, 426–428, 376–377 test, 171–173
426f–428f, 427b, 429t hyperextension see multisegmental during supine single heel slide
summary for, 438t hyperextension test, 168, 168f
513
Index
International Classification of rectus abdominis imbalance with, low cervical flexion control tests,
Functioning, Disability, and 24 226–235
Health, 17–18, 17f lateral arm lift test, 344–345, 345b occiput lift test, 226–227, 226f,
intra-articular UCM, 51–52, 51t correction of thoracic rotation 227b, 228t, 229f
intrinsic muscle stiffness, 34–35 UCM during, 345, 346t overhead arm lift test, 233–235,
ischial weight bearing test, 116–119, procedure for, 344–345, 344f 233f–235f, 234b, 236t
117b rating and diagnosis of thoracic thoracic flexion test, 230–231,
correction of lumbar flexion rotation UCM during, 345, 230f, 231b, 232t
UCM during, 117–119, 117f, 346t low load proprioceptive stimulus,
118t thoracic rotation UCM during, 75
lumbar flexion UCM during, 345 low threshold recruitment
116–117 lateral pelvic shift test, 488–490, versus high, 32–34, 33f, 33t
procedure for, 116, 116f 489b timing and, 35–36, 35f
rating and diagnosis of lumbar correction of hip adduction UCM training of, 39–40, 40t
flexion UCM during, 117–119, during, 489–490, 489f–490f, low threshold recruitment
118t 491t efficiency, 58–59, 59b
isometric knee to hand push and hip adduction UCM during, 489 lower neck lean test, 285–289,
heel lift, 146–147, 146f procedure for, 488, 488f 286b
isometric knee to hand push with rating and diagnosis of hip assessment goals for evaluating
second heel lift, 103, 103f adduction UCM during, site and direction of UCM
isometric opposite knee to hand 489–490, 491t during, 288t
push, 102, 102f, 146, 146f lateral rotation/abduction control correction of upper cervical
tests, hip, 470 side-bend UCM during,
K bridge single leg lift test, 483– 286–287, 286f, 288t
484, 483b, 483f, 485t procedure for, 285, 285f
kinetic lateral rotation test (KLRT), four point bent knee hip rating and diagnosis of upper
for shoulder girdle UCM, extension test, 479–481, cervical side-bend UCM
378–383 479f–480f, 480b, 482t during, 286–287, 288t
glenohumeral v. scapular standing one leg small knee bend upper cervical side-bend UCM
contributions in, 379, 381f and trunk rotation towards during, 285–286, 286t
procedure part 1, 378, 378f–379f test, 475–477, 475f–476f, lumbar extension, observation and
procedure part 2, 379 476b, 478t analysis of, 120–121,
rating and diagnosis of, 379–383, standing single leg high knee lift 120f
380t test, 471–473, 471f, 472b, ideal pattern of lumbar
retraining, 379–383, 383b, 473f, 474t extension, 120, 120f
383f–384f summary for, 484t indications to test for lumbar
risks with, 379, 381t, 382f–383f latissimus dorsi, function of, 23–24 extension UCM, 121
kinetic medial rotation test LBP see low back pain movement faults associated
(KMRT), for shoulder girdle length, of muscles, 26–28, 26f–27f with lumbar extension,
UCM, 372–374 lengthened muscles, 26f–27f, 27 120–121
procedure for, 372, 372f lever arm, of muscles, 27–28 lumbar flexion
rating and diagnosis, 372–374, loading, during retraining, 69 observation and analysis of,
373t–374t local muscle systems, 24–26, 25t 91–92, 91f
retraining for, 372–374, 374b, local stability muscles, 29t, 31 ideal pattern of lumbar flexion,
375f low back pain (LBP) 91, 91f
risks associated with, 374f–375f, lumbopelvic UCM in, 83 indications to test for lumbar
374t efficacy of treatment to retrain flexion UCM, 92
KLRT see kinetic lateral rotation test control of, 83–84 movement faults associated
KMRT see kinetic medial rotation movement and postural with lumbar flexion,
test control changes causing, 91–92
knee, relative stiffness and 83–84 relative flexibility in, 91
flexibility in, 45, 45f MCI in, 47–48 lumbar spine
MSI in, 47 alignment in, UCM due to
L rectus abdominis and lateral changes in, 84
abdominal stabiliser diagnosis of site and direction of
lateral abdominals imbalance in, 24 UCM in, 85, 85t–86t
gluteal coactivation with, 106, relative stiffness and flexibility in, disability questionnaires for,
122–123 45–46 11b
514
Index
identification of site and lumbopelvic UCM tests, 90 standing trunk lean test, 93–
direction of UCM in, 86–87 lumbar extension control tests, 96, 93f–94f, 94b, 95t, 96f
multisegmental UCM, 87 120–121, 124–159 stand-to-sit ischial weight
segmental UCM, 86–87 crook-lying double bent leg bearing test, 116–119,
management plan for back pain lower test, 144–147, 116f–117f, 117b, 118t
and UCM in, 14f 144f–147f, 145b, 148t summary for, 119t
MSI in, 47 extension control rehabilitation review of principles of, 90
muscle roles in, 28f and, 120 rotation control tests, 162–163
relative stiffness and flexibility in, extension load testing crook-lying single leg bridge
45–46 prerequisites, 106, 121–123, extension test, 192–194,
UCM and restrictions at, 12t 122f 192f–193f, 193b, 195t
lumbopelvic rotation, observation four point forward rocking test, observation and analysis of
and analysis of, 109, 163f 140–142, 140f–142f, 141b, lumbopelvic rotation and
ideal pattern of lumbopelvic 143t side-bend, 162, 163f
rotation, 162, 163f observation and analysis of prone (table) hip extension lift
indications to test for lumbar extension and test, 186–187, 186b, 186f,
lumbopelvic rotation UCM, backward arching, 120–121, 188t
163 120f prone single hip rotation test,
movement faults associated with prone double knee bend test, 178–182, 178f–179f, 179b,
lumbopelvic rotation, 149–152, 149f–150f, 150b, 180t
162–163 151t, 152f prone single knee flexion test,
lumbopelvic rotation control prone (table) hip extension lift 183–184, 183b, 183f, 185t
rehabilitation, rotation control test, 153–156, 153f–154f, rotation control rehabilitation
tests and, 162 154b, 155t, 156f and, 162
lumbopelvic UCM, 82–216 sitting chest lift (tilt) test, 132– side-lying top leg turn out
changes in movement and 136, 132f, 133b, 134t, 135f test, 174–177, 174f, 175b,
postural control contributing sitting forward lean test, 176t
to, 83–84 137–138, 137f, 138b, 139t sitting single knee extension
clinical examples of, 87–88 standing hip extension toe test, 189–190, 189f, 190b,
lumbar extension UCM, 87–88 slide test, 157–159, 191t
lumbar flexion UCM, 88 157f–159f, 158b, 160t standing double knee swing
efficacy of treatment to retrain standing thoracic extension test, 200–202, 200f, 201b,
control of, 84–85 (sway) test, 124–126, 202f–204f, 205t
extension UCM, 86–87, 86t 124f–126f, 125b, 127t standing pelvic side-shift test,
clinical example of, 87–88 standing thoracic extension 210–213, 210f, 211b, 212t
indications to test for, 121 (tilt) test, 128–131, standing thoracic rotation test,
flexion UCM, 86–87, 86t 128f–129f, 129b, 130t 196–198, 196f, 197b, 198f,
clinical example of, 88 summary for, 161t 199t
indications to test for, 92 lumbar flexion control tests, standing trunk side-bend test,
at lumbar spine 90–119 206–208, 206f, 207b, 209t
diagnosis of site and direction crook-lying double bent leg lift supine bent knee fall out test,
of UCM in, 85, 85t–86t test, 100–104, 100f–103f, 169–173, 169f–170f, 171b,
identifying site and direction of 102b, 105t 172t
UCM in, 86–87 flexion control rehabilitation supine single heel slide test,
multisegmental UCM, 87 and, 90 164–168, 164f–166f, 166b,
segmental UCM, 86–87 four point kneeling backward 167t, 168f
at pelvis push test, 97–98, 97f–98f,
identifying UCM in, 88–90, 89t 98b, 99t M
movement and postural observation and analysis of
control in, 88–90, 89t lumbar flexion and forward management plans, for UCM and
reliability of movement bending, 91–92, 91f restrictions, 12, 13f–14f
observation, 84 sitting chest drop test, 109–112, manual therapy, with retraining,
rotation UCM, 86t 109f, 110b, 111t, 112f 76–77
side-bend UCM, 86t sitting double knee extension MCD see movement control
at SIJ test, 113–114, 113f, 114b, dysfunction
identifying UCM in, 88–90, 89t 115t MCI see motor control impairments
movement and postural sitting forward lean test, 106– MCRS see movement control rating
control in, 88–90, 89t 107, 106f–107f, 107b, 108t system
515
Index
mechanical insufficiency, of motor control impairments (MCI), movement faults, 3–5

muscles, 26–27 47–48 assessment of, 7–9, 8b–9b, 8f
mechanical movement dysfunction, motor recruitment, 31–32, 32f, 32t in glenohumeral joint UCM,
integrated model of, 52–53, dysfunction in, 37, 37t 404–405, 404b
53f, 63–64, 64f altered strategies in, 37–38, 38f in glenohumeral lateral rotation,
medial rotation control tests, hip, inhibition and dysfacilitation, 376–377
457–458 37, 37t reduced, 376–377
side-lying top leg turnout lift test, low v. high threshold relative stiffness, 376–377
467–468, 467f–468f, 468b, recruitment, 32–34, 33f, 33t uncontrolled movement, 377
469t motor unit, 31–32, 32f, 32t, in glenohumeral medial rotation,
standing one leg small knee bend 70–71, 70t, 71b 370–371
and trunk rotation away test, sensation of effort and, 38–39, relative flexibility, 371
463–465, 463f–464f, 464b, 39b relative stiffness, 370
466t timing and low threshold in hip extension control,
standing single leg small knee recruitment, 35–36, 35f 440–441
bend test, 459–462, 459f– training of, 39–40, 70–71, 70t, modified Thomas test for, 440,
460f, 460b, 462f, 466t 71b 440f
summary for, 468t clinical guidelines for, 40, 40t relative flexibility, 441
mid-cervical extension high threshold recruitment relative stiffness, 440–441,
abnormal translation during, 256 dominance, 40, 40t 441f
normal translation during, 256 low threshold recruitment in hip rotation control,
palpation during, 256b dominance, 39–40, 40t 454–455
mid-cervical extension (translation) motor unit, 31–32, 32f, 32t, 70–71, relative flexibility, 454–455
control tests, 255–261 70t, 71b relative stiffness, 454
chin lift hinge test, 259–261, movement analysis model, 7–9, 8f in hip sagittal motion control,
259f, 260b, 261f, 262t movement control 421
head back hinge test, 255–257, in lumbopelvic UCM, 83–84 in hip UCM
255f–257f, 256b, 258t in muscle function and backward rocking, 422
mid-cervical flexion, restriction of, physiology, 23 forward bending, 421
225 procedure for testing of, 57–59, small knee bend, 423
mid-cervical shear, relative 59b, 59t in lumbar extension, 120–121
flexibility in, 246 retraining of, 70–71, 70t, 71b, 77, in lumbar flexion, 91–92
mid-cervical translation 77t in lumbopelvic rotation,
abnormal translation during, cognitive awareness, 68–69, 162–163
256 71 in neck extension, 245–246,
normal translation during, 256 motor unit recruitment, 70–71, 245f–246f
palpation during, 256b 70t, 71b in neck flexion, 225
UCM in, 222t posture effects on, 71 in neck rotation, 263–267,
mindful movements, in retraining, at SIJ and pelvis, 88–90, 89t 264f–267f
68–69 movement control dysfunction in neck side-bending, 268–269
mobiliser muscles, 23–24, 24t (MCD), 46–47 retraining of, 7–9, 8b–9b, 8f
in altered strategies in movement control rating system in scapula UCM, 404–405,
dysfunctional situations, (MCRS), 54–55, 57–59, 59b, 404b
37–38, 38f 59t in shoulder abduction control,
recruitment in, 33, 33f movement dysfunction, 3–5 391
pain and, 36–37, 37f analysis of, 9–10, 9b glenohumeral control, 392
mobility dysfunction, during classification based on, 44–48, scapulothoracic control,
standing back flattening on 45f 391–392
wall, 122 MCD, 46–47 in shoulder dysfunction, 363
mobility muscles, global, 29t, 31 MCI, 47–48 in shoulder extension control,
model for assessment and MSI, 47 396–397
retraining of movement faults, relative stiffness and relative of glenohumeral control, 397
7–9, 8b–9b, 8f flexibility, 45–46, 45f of scapula-thoracic control,
modified Thomas test, for hip diagnosis of, 16 396–397
extension control, 440, 440f integrated model of, 52–53, 53f, in shoulder flexion control, 385
motivation, personality and 63–64, 64f of glenohumeral control, 387
behavioural traits for, 74–76, with UCM, 6 of scapulothoracic control,
74f, 75b, 76t movement dysfunction model, 4 385–387
516
Index
in shoulder girdle UCM, 404– during forward head lean test, low threshold recruitment
405, 404b 239 dominance, 39–40, 40t
in shoulder lateral rotation during four point backward push sensation of effort, afferent input
control, 376–377 test, 98 and recruitment, 38–39, 39b
reduced, 376–377 in lumbar flexion, 92 stiffness, 34–36, 34f–35f
relative stiffness, 376–377 in neck extension, 245 low threshold recruitment and
uncontrolled movement, 377 with occiput lift test, 227 timing, 35–36, 35f
in shoulder medial rotation with overhead arm lift test, 234 muscle spindles, 34–35, 34f
control, 370–371 during sitting chest drop test, musculoskeletal dysfunction,
relative flexibility, 371 110 challenges in retraining of,
relative stiffness, 370 during sitting double knee 71–72
in SKB, 423–425, 423f–424f extension test, 114 musculoskeletal pain, classification
in thoracic flexion, 295 during sitting forward lean test, of subgroups in, 43–53, 44b
relative flexibility, 295 107 based on movement dysfunction,
relative stiffness, 295 during standing trunk lean test, 94 44–48, 45f
in weight transfer, 486 during stand-to-sit ischial weight integrated model of mechanical
relative flexibility, 486 bearing test, 117 movement dysfunction,
relative stiffness, 486 during thoracic flexion test, 231 52–53, 53f, 63–64, 64f
movement observation, reliability multisegmental UCM, in lumbar UCM and pain, 48–52, 48b, 49f,
of, 84 spine, 87 50t–51t
movement system, components of, multitasking muscles, 31 MWM see Mulligan’s Mobilisations
3, 4f muscle function and physiology, with Movement
movement system impairments 23–42 myofascial dysfunction, 51t, 52
(MSI), 47 analysis of, 23–31, 24t–25t, myofascial restriction
Mulligan’s Mobilisations with 26f–28f, 29t in glenohumeral lateral rotation,
Movement (MWM), 77 functional classification of 377
multifidus facilitation, 102, 102f muscle roles, 28, 28f, 29t in glenohumeral medial rotation,
multisegmental hyperextension, functional efficiency, 26–28, 370
87 26f–27f in neck extension, 245–246
during arm extension test, 243 local and global function, in neck rotation, 264–266,
during backward head lift test, 24–26, 25t 264f–266f
248 muscle characterisation, 28–31, in neck side-bending, 268–269
clinical example of, 87–88 29t myosin see actin-myosin
during crook-lying double bent stabiliser and mobiliser cross-bridges
leg lower test, 145 function, 23–24, 24t
during four point forward dysfunction loop, 39, 39f N
rocking test, 141 movement control, 23
during horizontal retraction test, pain and recruitment, 36–37, neck extension, observation and
253 37f analysis of, 245–246,
in lumbar extension, 121 primary role of muscles, 31 245f–246f
in lumbar flexion, 92 multitasking muscles, 31 ideal pattern of neck extension,
in neck extension, 246 single-task muscles, 31 245
in neck flexion, 225 recruitment, 31–32, 32f, 32t movement faults associated with
during prone double knee bend low v. high threshold neck extension, 245–246,
test, 149 recruitment, 32–34, 33f, 245f–246f
during prone (table) hip 33t neck flexion
extension lift test, 154 motor units, 31–32, 32f, 32t, observation and analysis of,
during sitting chest lift (tilt) test, 70–71, 70t, 71b 225
133 recruitment dysfunction ideal pattern of neck flexion,
sitting forward lean test, 138 altered strategies in, 37–38, 225
during standing hip extension toe 38f movement faults associated
slide test, 158 inhibition and dysfacilitation, with neck flexion, 225
during standing thoracic 37, 37t for shoulder girdle UCM, 402t
extension (tilt) test, 129 recruitment training, 39–40, neck pain, 219–220, 220f
multisegmental hyperflexion, 87 70–71, 70t, 71b neck rotation, observation and
clinical example of, 88 clinical guidelines for, 40, 40t analysis of, 263–267, 263f–267f
during crook-lying double bent high threshold recruitment ideal pattern of neck rotation,
leg lift test, 101 dominance, 40, 40t 263, 263f
517
Index
movement faults associated with observational assessment one arm wall push test, 337–338,
neck rotation, 263–267, of backward rocking, 422, 338b
264f–267f 422f correction of thoracic rotation
neck side-bending, observation of hip adduction control, 486, UCM during, 338, 339t
and analysis of, 486f procedure for, 337–338, 337f
267–269 of hip rotation control, 454–455, rating and diagnosis of thoracic
ideal pattern of neck 454f rotation UCM during, 338,
side-bending, 267–268 of hip sagittal motion control, 339t
movement faults associated with 421–423, 421f–423f thoracic rotation UCM during,
neck side-bending, 268–269 of lumbar extension and 338
neural restriction backward arching, 120–121, one leg small knee bend and trunk
in neck rotation, 264–265, 120f rotation away test, 463–465,
264f–266f of lumbar flexion and forward 464b
in neck side-bending, 268–269 bending, 91–92, 91f correction of hip medial rotation
neuromatrix theory of pain, 16 of lumbopelvic rotation and UCM during, 464–465, 464f,
neuromusculoskeletal dysfunction, side-bend, 109, 163f 466t
challenges in retraining of, of neck extension, 245–246, hip medial rotation UCM during,
71–72 245f–246f 463–464
neuromusculoskeletal pain, of neck flexion, 225 procedure for, 463, 463f–464f
classification of subgroups in, of neck rotation, 263–267, rating and diagnosis of hip
43–53, 44b 263f–267f medial rotation UCM during,
based on movement dysfunction, of neck side-bending, 267–269 464–465, 466t
44–48, 45f reliability of, 84 one leg small knee bend and trunk
integrated model of mechanical of shoulder abduction control, rotation towards test, 475–477,
movement dysfunction, 391–392, 391f–392f 476b
52–53, 53f, 63–64, 64f of shoulder extension control, correction of hip lateral rotation/
UCM and pain, 48–52, 48b, 49f, 396–397, 396f abduction UCM during,
50t–51t of shoulder flexion control, 476–477, 476f, 478t
neutral training region, 53–54 385–387, 385f–386f hip lateral rotation/abduction
of cervical spine, 223–224, 223f, of shoulder lateral rotation UCM during, 475–476
224b control, 376–377 procedure for, 475, 475f–476f
of scapula, 223–224, 223f, of shoulder medial rotation rating and diagnosis of hip
224b control, 370–371, 370f lateral rotation/abduction
of TMJ, 223–224, 223f, 224b obturator externus, in hip pain, UCM during, 476–477, 478t
nodding, 226–227, 227b 416 open chain rotation control tests
assessment goals for evaluating occiput lift test, 226–227, 227b lumbopelvic, 164–190
site and direction of UCM assessment goals for evaluating prone (table) hip extension lift
during, 228t site and direction of UCM test, 186–187, 186b, 186f,
correction of low cervical during, 228t 188t
flexion UCM during, 227, correction of low cervical prone single hip rotation test,
228t, 229f flexion UCM during, 227, 178–182, 178f–179f, 179b,
low cervical flexion UCM during, 228t, 229f 180t
227 low cervical flexion UCM during, prone single knee flexion test,
procedure for, 226–227, 226f 227 183–184, 183b, 183f, 185t
rating and diagnosis of low procedure for, 226–227, 226f side-lying top leg turn out test,
cervical flexion UCM during, rating and diagnosis of low 174–177, 174f, 175b, 176t
227, 228t cervical flexion UCM during, sitting single knee extension
non-specific musculoskeletal 227, 228t test, 189–190, 189f, 190b,
pain one arm lift test, 340–341, 341b 191t
challenges in retraining of, 71 correction of thoracic rotation supine bent knee fall out test,
classification of subgroups in, UCM during, 341, 341f–342f, 169–173, 169f–170f, 171b,
43–44, 44b 343t 172t
procedure for, 340–341, 340f supine single heel slide test,
O rating and diagnosis of thoracic 164–168, 164f–166f, 166b,
rotation UCM during, 341, 167t, 168f
OA see osteoarthritis 343t summary for, 213t
oblique abdominal facilitation, thoracic rotation UCM during, osteoarthritis (OA), of hip,
146 341 415–416
518
Index
overfacilitation, UCM resulting UCM and, 5, 48–52, 48b, 49f, pelvic twist test, 331–332, 332b
from, 49–50 50t–51t correction of thoracic rotation
overhead arm lift test, 233–235, aetiology of UCM, 49–52, UCM during, 332, 333t
234b 50t–51t procedure for, 331–332, 331f
assessment goals for evaluating development of motion rating and diagnosis of thoracic
site and direction of UCM restrictions in function, rotation UCM during, 332,
during, 236t 48–49, 48b, 51t 333t
correction of low cervical flexion passive restrictions, 48–49 thoracic rotation UCM during,
UCM during, 234–235, pelvic girdle 332
234f–235f, 236t pain in pelvis
low cervical flexion UCM during, lumbopelvic UCM in, 85 identifying UCM at, 88–90,
233–234 SIJ and pelvis movement and 89t
procedure for, 233, 233f postural control in, 88–90, movement and postural control
rating and diagnosis of low 89t at, 88–90, 89t
cervical flexion UCM during, site and direction of UCM in, performance, with UCM, 7
234–235, 236t 89t peripheral fatigue, 38, 39b
pelvic muscle, in hip pain, 415–416 personal factors, assessment of, 14,
pelvic side-shift test 16
P for lumbopelvic rotation control, personality traits, for motivation
pain 210–213, 211b and compliance, 74–76, 74f,
clinical diagnosis of correction of lumbopelvic 75b, 76t
pain-sensitive or pain- rotation UCM during, phasic muscles, 24
generating structures, 16 211–213, 212t physiological insufficiency, of
presenting mechanisms, 16 lumbopelvic rotation UCM muscles, 26–27
in dysfunction loop, 39, 39f during, 211 Pilates method, 75–76, 76t
functional links between UCM procedure for, 210–211, 210f piriformis, in hip pain, 416
and, 5, 5f rating and diagnosis of positional diagnosis, of SIJ and
in hip, 415–416 lumbopelvic rotation UCM pelvis UCM, 89–90, 89t
LBP during, 211–213, 212t postural control
lumbopelvic UCM in, 83–84 for thoracic rotation control, in lumbopelvic UCM, 83–84
MCI in, 47–48 334–335, 335b at SIJ and pelvis, 88–90, 89t
MSI in, 47 correction of thoracic rotation postural muscles, 24
rectus abdominis and lateral UCM during, 335, 335f, postural positioning, UCM
abdominal stabiliser 336t resulting from, 50
imbalance in, 24 procedure for, 334–335, 334f posture, retraining response to,
relative stiffness and flexibility rating and diagnosis of thoracic 71
in, 45–46 rotation UCM during, 335, prognosis
in lumbar spine, 14f 336t of retraining, 69
in neck, 219–220, 220f thoracic rotation UCM during, of UCM, 15
neuromatrix theory of, 16 335 progression, in retraining, 69
neuromusculoskeletal, pelvic tail lift test, 319–321, 320b when training site and direction
classification of subgroups in, correction of thoracic extension of UCM, 69
43–53, 44b, 45f, 48b, 49f, UCM during, 320–321, prone active prone leg raise test,
50t–51t, 53f 320f–321f, 322t 497–498, 498b
non-specific procedure for, 319–320, 319f correction of hip rotation UCM
challenges in retraining of, rating and diagnosis of thoracic during, 498, 498f, 499t
71 extension UCM during, hip forward glide UCM during,
classification of subgroups in, 320–321, 322t 498
43–44, 44b thoracic flexion UCM during, 320 procedure for, 497–498, 497f
in pelvic girdle, 85, 88–90, 89t pelvic tail tuck test, 304–306, 305b rating and diagnosis of hip
lumbopelvic UCM in, 85 correction of thoracic flexion rotation UCM during, 498,
SIJ and pelvis movement and UCM during, 305–306, 499t
postural control in, 88–90, 305f–306f, 307t prone coactivation of lateral
89t procedure for, 304–305, 304f abdominals and gluteals, 106,
recruitment and, 36–37, 37f rating and diagnosis of thoracic 122–123
relating presentation to, 13 flexion UCM during, 305– correction of, 123
in shoulder, 13f 306, 307t dysfunctional action, 123
in SIJ, 85 thoracic flexion UCM during, 305 ideal action, 106, 122
519
Index
prone double knee bend test, rating and diagnosis of of lumbar extension control,
149–152, 150b lumbopelvic rotation UCM extension control tests and,
correction of lumbar extension during, 184, 120
UCM during, 150–152, 150f, 185t of lumbar flexion control, flexion
151t, 152f proprioceptive deficits, retraining in control tests and, 90
lumbar extension UCM during, patients with, 69 of lumbopelvic rotation control,
149 proprioceptive stimulus, for rotation control tests and,
procedure for, 149, 149f retraining, 75 162
rating and diagnosis of lumbar protocol-based training regimens, retraining and, 63–64, 64f
extension UCM during, 64–65 see also retraining
150–152, 151t pubis, directions of UCM in, 89t rehabilitation problem solving
prone (table) hip extension lift (RPS) form, 17–18, 18f
test R relative flexibility, 45–46, 45f
for lumbar extension UCM, in glenohumeral medial rotation,
153–156, 154b range dysfunction, 51t, 52 371
correction of lumbar extension rating, of UCM tests, lumbopelvic in hip adduction control, 486
UCM during, 154–156, tests, 90 in hip extension control, 441
154f, 155t, 156f recruitment in hip rotation control, 454–455
lumbar extension UCM during, low v. high threshold, 32–34, in hip UCM
153–154 33f, 33t with backward rocking, 422
procedure for, 153, 153f of motor units, 31–32, 32f, 32t, with forward bending, 421
rating and diagnosis of lumbar 70–71, 70t, 71b with SKB, 423
extension UCM during, pain and, 36–37, 37f in lumbar extension, 120–121
154–156, 155t sensation of effort and, 38–39, in lumbar flexion, 91–92
for lumbopelvic rotation UCM, 39b in lumbopelvic rotation,
186–187, 186b timing and low threshold 162–163
correction of lumbopelvic recruitment, 35–36, 35f in neck extension, 246
rotation UCM during, 187, training of, 39–40, 70–71, 70t, in neck flexion, 225
188t 71b in neck rotation, 266–267,
lumbopelvic rotation UCM clinical guidelines for, 40, 40t 267f
during, 186 high threshold recruitment in neck side-bending, 269
procedure for, 186, 186f dominance, 40, 40t in thoracic flexion, 295
rating and diagnosis of low threshold recruitment relative stiffness, 45–46, 45f
lumbopelvic rotation UCM dominance, 39–40, 40t in glenohumeral lateral rotation,
during, 187, 188t recruitment dysfunction 376–377
prone single hip rotation test, altered strategies in, 37–38, 38f in glenohumeral medial rotation,
178–182, 179b inhibition and dysfacilitation, 37, 370
correction of lumbopelvic 37t in hip adduction control, 486
rotation UCM during, during prone coactivation of in hip extension control,
179–181, 180t, 181f lateral abdominals and 440–441, 441f
external oblique abdominal gluteals, 123 in hip rotation control, 454
recruitment, 181 during standing back flattening in hip UCM
internal oblique abdominal on wall, 122 with backward rocking, 422
recruitment, 181–182 rectus abdominis with forward bending, 421
lumbopelvic rotation UCM excessive recruitment of, during with SKB, 423
during, 179 crook-lying double bent leg in lumbar extension, 120
procedure for, 178, 178f–179f lift test, 101 in lumbar flexion, 91
rating and diagnosis of lateral abdominal stabiliser in lumbopelvic rotation, 162
lumbopelvic rotation UCM imbalance with, 24 in neck extension, 245–246,
during, 179–182, 180t rectus femoris, in hip extension 245f–246f
prone single knee flexion test, control, 440, 441f in neck flexion, 225
183–184, 183b recurrence, with UCM, 6 in neck rotation, 263–266,
correction of lumbopelvic red dot functional integration, 75 264f–266f
rotation UCM during, 184, reflex mediated muscle stiffness, 35 in neck side-bending, 263–264,
185t regional UCM, 51t, 52 268–269
lumbopelvic rotation UCM rehabilitation in thoracic flexion, 295
during, 183 for cervical spine UCM, 220–221 reliability, of movement
procedure for, 183, 183f for hip UCM, 425 observation, 84
520
Index
repetitions, for retraining, 67–68, of hip extension UCM of lumbar extension UCM
68f–69f with standing single knee lift with crook-lying double bent
respiratory control tests, thoracic, and anterior tilt test, leg lower test, 145–146,
350 447–448, 447f, 449t 146f–147f, 148t
standing abdominal hollowing with standing single knee lift with four point forward
and expiration test, 357–360, and knee extension test, rocking test, 141–142,
357f–358f, 358b, 359t 451–452, 451f, 453t 141f–142f, 143t
standing anterior costal lift and with standing thoracolumbar with prone coactivation of
expiration test, 354–355, extension test, 443–444, lateral abdominals and
354f, 355b, 356t 443f, 445t gluteals, 123
standing apical drop and of hip flexion UCM with prone double knee bend
inspiration test, 351–352, with side-lying single leg test, 150–152, 150f, 151t,
351f, 352b, 353t abduction test, 438, 439t 152f
summary for, 360t with standing single foot lift with prone (table) hip
resting length, of muscles, 26, 26f test, 432t extension lift test, 154–156,
restrictions with standing spinal roll down 154f, 155t, 156f
in ankle dorsiflexion, 421 test, 434–435, 434f, 436t with sitting chest lift (tilt) test,
capsular with standing vertical trunk 133–136, 134t, 135f
in glenohumeral lateral single leg 1/4 squat test, with sitting forward lean test,
rotation, 376 428, 428f, 429t 138, 139t
in glenohumeral medial of hip forward glide UCM with standing back flattening
rotation, 370 with prone active prone leg on wall, 122
compensation for, UCM resulting raise test, 498, 498f, 499t with standing hip extension toe
from, 49–52, 50t–51t with supine active ‘figure 4’ slide test, 158–159, 159f,
developing management plans turnout test, 501, 501f, 502t 160t
for, 12, 13f–14f with supine active straight leg with standing thoracic
development of, 48–49, 48b, 51t raise test, 494–495, extension (sway) test,
identification of, 11–12, 11t–12t 494f–495f, 496t 125–126, 126f, 127t
in lumbar extension, 120 of hip lateral rotation/abduction with standing thoracic
in lumbar flexion, 91 UCM extension (tilt) test,
in lumbopelvic rotation, 162 with bridge single leg lift test, 129–131, 129f, 130t
in neck extension, 245–246, 484, 485t of lumbar flexion UCM
245f–246f with four point bent knee hip with crook-lying double bent
in neck flexion, 225 extension test, 480–481, leg lift test, 102, 102f–103f,
in neck rotation, 263–266, 480f, 482t 105t
264f–266f with standing one leg small with four point backward push
in neck side-bending, 263–264, knee bend and trunk test, 98, 98f, 99t
268–269 rotation towards test, with sitting chest drop test,
retraining 476–477, 476f, 478t 110–112, 111t, 112f
of cervical extension UCM with standing single leg high with sitting double knee
with chin lift hinge, 260b, knee lift test, 472–473, extension test, 114, 115t
261f, 262t 473f, 474t with sitting forward lean test,
with head back hinge, 256– of hip medial rotation UCM 107, 108t
257, 257f, 258t with side-lying top leg turnout with standing trunk lean test,
of cervical rotation UCM lift test, 468, 468f, 469t 94–96, 95t, 96f
with head tilt, 277–278, 278f, with standing one leg small with stand-to-sit ischial weight
280f, 280t knee bend and trunk bearing test, 117–119, 117f,
with head turn, 271–273, rotation away test, 464– 118t
271f–273f, 275t 465, 464f, 466t of lumbopelvic rotation UCM
with lower neck lean, 286–287, with standing single leg small with crook-lying single leg
286f, 288t knee bend test, 460–462, bridge extension test,
with upper neck tilt, 282–283, 462f, 466t 193–194, 193f, 195t
282f–283f, 284t of low cervical flexion UCM with prone (table) hip
with dissociation, 56b with occiput lift, 227, 228t, extension lift test, 187, 188t
of hip adduction UCM, with 229f with prone single hip rotation
single leg stance lateral pelvic with overhead arm lift test, test, 179–181, 180t, 181f
shift test, 489–490, 489f– 234–235, 234f–235f, 236t with prone single knee flexion
490f, 491t with thoracic flexion, 231, 232t test, 184, 185t
521
Index
with side-lying top leg turn out of thoracic extension UCM rotation control rehabilitation,
test, 175, 176t with sitting head raise test, 317, lumbopelvic, rotation control
with sitting single knee 317f, 318t tests and, 162
extension test, 190, 191t with sitting pelvic tail lift test, rotation control tests
with standing double knee 320–321, 320f–321f, 322t cervical, 263–267, 270–289
swing test, 201–202, with standing bilateral head tilt test, 276–278, 276f,
202f–204f, 205t backward reach test, 277b, 277t, 278f, 279t–
with standing pelvic side-shift 324–326, 324f, 325t 280t, 280f
test, 211–213, 212t with standing bilateral head turn test, 270–273,
with standing thoracic rotation overhead reach test, 314, 270f–273f, 271b, 271t,
test, 197–198, 198f, 199t 314f, 315t 274t–275t
with standing trunk side-bend of thoracic flexion UCM lower neck lean test, 285–289,
test, 208, 209t with sitting bilateral forward 285f–286f, 286b, 286t,
with supine bent knee fall out reach test, 309, 310t, 311f 288t
test, 171, 172t with sitting head hang test, observation and analysis of
with supine single heel slide test, 301, 302t, 303f neck rotation, 263–267,
166–168, 166f, 167t, 168f with sitting pelvic tail tuck test, 263f–267f
of lumbopelvic UCM control, 305–306, 305f–306f, 307t summary for, 289t
efficacy of treatment for, with standing back flattening upper neck tilt test, 281–283,
84–85 test, 297, 297f, 298t, 299f 281f–283f, 282b, 282t, 284t
of movement faults, model for, of thoracic respiratory UCM hip lateral rotation/abduction
7–9, 8b–9b, 8f with standing abdominal control tests, 470
principles of, 12 hollowing and expiration bridge single leg lift test,
of recruitment, 39–40, 70–71, test, 358, 359t 483–484, 483b, 483f, 485t
70t, 71b with standing anterior costal four point bent knee hip
clinical guidelines for, 40, 40t lift and expiration test, 355, extension test, 479–481,
high threshold recruitment 356t 479f–480f, 480b, 482t
dominance, 40, 40t with standing apical drop and standing one leg small knee
low threshold recruitment inspiration test, 352, 353t bend and trunk rotation
dominance, 39–40, 40t of thoracic rotation UCM towards test, 475–477,
of shoulder girdle UCM with four point one arm lift 475f–476f, 476b, 478t
with arm abduction tests, 393, test, 341, 341f–342f, 343t standing single leg high knee
395b, 395f with side-lying lateral arm lift lift test, 471–473, 471f,
with arm extension test, test, 345, 346t 472b, 473f, 474t
398–400, 400f–401f, 401b with side-lying side bridge test, summary for, 484t
with arm flexion control, 390, 348, 348f, 349t hip medial rotation control,
390b, 390f with sitting head turn test, 329, 457–458
impingement and instability, 329f, 330t side-lying top leg turnout lift
404–405, 405f–406f, 406b with sitting pelvic twist test, test, 467–468, 467f–468f,
KLRT for, 379–383, 383b, 332, 333t 468b, 469t
383f–384f with standing one arm wall standing one leg small knee
KMRT for, 372–374, 374b, 375f push test, 338, 339t bend and trunk rotation
strategies for, 63–80, 78b with standing pelvic side-shift away test, 463–465,
challenges in retraining test, 335, 335f, 336t 463f–464f, 464b, 466t
neuromusculoskeletal of upper cervical extension standing single leg small knee
dysfunction, 71–72 UCM bend test, 459–462, 459f–
integration into functional with backward head lift, 460f, 460b, 462f, 466t
tasks and activities, 72–77, 248–251, 249f, 250t summary for, 468t
73f–74f, 75b, 76t–77t with horizontal retraction, 253, lumbopelvic, 162–163
key principles in retraining 253f, 254t crook-lying single leg bridge
movement control patterns, of upper cervical flexion UCM extension test, 192–194,
70–71, 70t, 71b, 77, 77t with arm extension, 243, 243f, 192f–193f, 193b, 195t
rehabilitation management 244t observation and analysis of
and, 63–64, 64f with forward head lean, 239, lumbopelvic rotation and
retraining site and direction of 240f, 241t sidebend, 162, 163f
UCM, 67–70, 68f–69f, 70b rib respiratory control tests see prone (table) hip extension lift
therapeutic exercise, 64–67, thoracic respiratory control tests test, 186–187, 186b, 186f,
65f, 66b risk of injury, with UCM, 6–7 188t
522
Index
prone single hip rotation test, lumbopelvic UCM causing pain retraining, 404–405, 405f–
178–182, 178f–179f, 179b, in, 85 408f, 406b
180t movement and postural control KLRT for, 378–383
prone single knee flexion test, at, 88–90, 89t glenohumeral contributions v.,
183–184, 183b, 183f, 185t range of motion at, 88–89 379, 381f
rotation control rehabilitation sacrum, directions of UCM in, 89t part 1, 378, 378f–379f
and, 162 sagittal plane, lumbopelvic UCM part 2, 379
side-lying top leg turn out test, in, 86–87 rating and diagnosis of,
174–177, 174f, 175b, 176t Sahrmann level 1 alternate single 379–383, 380t
sitting single knee extension leg heel touch, 103–104, 103f, retraining, 379–383, 383b,
test, 189–190, 189f, 190b, 147, 147f 383f–384f
191t sarcomeres, 26f, 27 risks with, 379, 381t,
standing double knee swing scapula 382f–383f
test, 200–202, 200f, 201b, compensation by KMRT for, 372–374
202f–204f, 205t in neck rotation, 266–267 rating and diagnosis,
standing pelvic side-shift test, in neck side-bending, 269 372–374, 373t–374t,
210–213, 210f, 211b, 212t function of, 363–364 374f–375f
standing thoracic rotation test, muscle stiffness at, 364 retraining for, 372–374, 374b,
196–198, 196f, 197b, 198f, neutral training region of, 375f
199t 223–224, 223f, 224b protraction, 386
standing trunk side-bend test, scapula UCM retraction, 377, 396
206–208, 206f, 207b, 209t arm abduction tests for, 393 shoulder abduction control in,
supine bent knee fall out test, procedure for, 393, 393f 391–392
169–173, 169f–170f, 171b, rating and diagnosis of, 393, shoulder extension control in,
172t 394t 396–397
supine single heel slide test, retraining, 393, 395b, 395f shoulder flexion control in,
164–168, 164f–166f, 166b, arm extension test for, 398–400 385–387
167t, 168f procedure for, 396f, 398, 398f symptom presentation and site
summary for, 213t–214t rating and diagnosis, 398–400, of, 365, 366t–367t
thoracic, 327 399t winging, 386, 392, 396–397
four point one arm lift test, retraining, 398–400, 400f– scapular dyskinesis, classification
340–341, 340f–342f, 341b, 401f, 401b of, 363
343t arm flexion tests for, 388–390 segmental dysfunction,
side-lying lateral arm lift test, procedure for, 388, 388f lumbopelvic UCM due to,
344–345, 344f, 345b, 346t rating and diagnosis of, 84
side-lying side bridge test, 347– 388–390, 389t segmental extension hinge, 87
348, 347b, 347f–348f, 349t retraining, 390, 390b, 390f during arm extension test, 243
sitting head turn test, 328–348, compensatory strategies for, 371 during backward head lift test,
328f–329f, 329b, 330t diagnosis of site and direction of, 248
sitting pelvic twist test, 365, 365t during chin lift hinge test, 259
331–332, 331f, 332b, 333t downward rotation, 377, clinical example of, 87–88
standing one arm wall push test, 385–386, 391, 396 during four point forward
337–338, 337f, 338b, 339t elevation, 386, 392 rocking test, 141
standing pelvic side-shift test, forward tilt, 377, 386, 392, 397 during head back hinge test,
334–335, 334f–335f, 335b, identification of, 364 255
336t identifying site and direction of, during horizontal retraction test,
summary for, 348t 365–370 253
rotation UCM, lumbar, 86t global range-specific UCM, in lumbar extension, 121
rotator cuff, in shoulder movement, 369–370 in neck extension, 246
364 IAG, 367, 369f during prone double knee bend
RPS form see rehabilitation neutral training region, test, 149
problem solving form 365–367, 367f–368f, 368b during prone (table) hip
segmental translatatory UCM, extension lift test, 154
S 369 during standing hip extension toe
impingement and instability with slide test, 158
sacroiliac joint (SIJ) correction of, 404 during standing thoracic
identifying UCM at, 88–90, movement faults related to, extension (sway) test,
89t 402, 404b 124–125
523
Index
segmental flexion hinge, 86–87 shoulder extension control, identifying site and direction of,
clinical example of, 88 396–397 365–370
during forward head lean test, indications to test for, 397 global range-specific UCM,
239 movement faults associated with, 369–370
during four point backward push 396–397 IAG, 367, 369f
test, 98 of glenohumeral control, 397 neutral training region,
in lumbar flexion, 91–92 of scapula-thoracic control, 365–367, 367f–368f, 368b
in neck extension, 245 396–397 segmental translatatory UCM,
in neck flexion, 225 observation and analysis of, 369
with occiput lift test, 227 396–397 impingement and instability
with overhead arm lift test, 234 ideal pattern for, 396, 396f with
during sitting chest drop test, 110 test of, 398–405 correction of, 404
during sitting double knee shoulder flexion control, 385–387 movement faults related to,
extension test, 114 indications to test for, 387 404–405, 404b
during sitting forward lean test, movement faults associated with, retraining, 404–405, 405f–
107 385 406f, 406b
during standing trunk lean test, of glenohumeral control, 387 KLRT for
94 of scapulothoracic control, glenohumeral v. scapular
during stand-to-sit ischial weight 385–387 contributions in, 379,
bearing test, 117 observation and analysis of, 381f
during thoracic flexion test, 231 385–387 procedure part 1, 378,
segmental lower cervical, in neck ideal pattern for, 385, 378f–379f
side-bending, 269 385f–386f procedure part 2, 379
segmental translatatory UCM test of, 388–390 rating and diagnosis of,
in hip, 417 shoulder forward reach, for 379–383, 380t
in shoulder girdle, 369 shoulder girdle UCM, 402t retraining, 379–383, 383b,
segmental UCM, in lumbar spine, shoulder girdle, 362–413 383f–384f
86–87 dissociation movements for, 402, risks with, 379, 381t,
segmental uncontrolled articular 402t 382f–383f
rotation, cervical, 266 function of, 363–364 KMRT for, 372–374
segmental uncontrolled articular muscle function in, 364 procedure for, 372, 372f
side-bending, in neck neutral training region, 365–367, for rating and diagnosis,
side-bending, 269 367f–368f, 368b 372–374, 373t–374t,
segmental upper cervical, in neck relative stiffness and flexibility in, 374f–375f
side-bending, 269 46 retraining for, 372–374, 374b,
sensation of effort, afferent input therapy for, 363 375f
and recruitment in, 38–39, shoulder girdle UCM, 12t symptom presentation and site
39b arm abduction tests for, 393 of, 365, 366t–367t
shortened muscles, 26f–27f, 27 procedure for, 393, 393f tests for, 370
shoulder rating and diagnosis of, 393, of shoulder abduction control,
disability questionnaires for, 11b 394t 391–392
management plan for pain and retraining, 393, 395b, 395f of shoulder extension control,
UCM in, 13f arm extension test for, 396–397
shoulder abduction control, 398–400 of shoulder flexion control,
391–392 procedure for, 396f, 398, 398f 385–387
indications to test for, 392 rating and diagnosis, 398–400, of shoulder lateral rotation
movement faults associated with, 399t control, 376–377
391 retraining, 398–400, 400f– of shoulder medial rotation
glenohumeral control, 392 401f, 401b control, 370–371
scapulothoracic control, arm flexion tests for, 388–390 shoulder lateral rotation control,
391–392 procedure for, 388, 388f 376–377
observation and analysis of, rating and diagnosis of, indications to test for, 377
391–392 388–390, 389t movement faults associated with,
ideal pattern for, 391, retraining, 390, 390b, 390f 376–377
391f–392f diagnosis of site and direction of, reduced, 376–377
test of, 393 365, 365t relative stiffness, 376–377
shoulder dysfunction, dynamic dissociation tests for, 402, 402t uncontrolled movement,
movement faults with, 363 identification of, 364 377
524
Index
observation and analysis of, lumbopelvic rotation UCM single foot lift test, 430–431, 431b
376–377 during, 174–175 correction of hip flexion during,
ideal pattern for, 376 procedure for, 174, 174f 431, 431f, 432t
test for, 378–383 rating and diagnosis of hip flexion UCM during,
shoulder medial rotation control, lumbopelvic rotation UCM 430–431
370–371 during, 175–177, 176t procedure for, 430, 430f
indications to test for, 371 side-lying top leg turnout lift test, rating and diagnosis of hip
movement faults associated with, 467–468, 468b flexion UCM during, 431,
370–371 correction of hip medial rotation 432t
relative flexibility, 371 UCM during, 468, 468f, 469t single heel slide test, 164–168, 166b
relative stiffness, 370 hip medial rotation UCM during, correction of lumbopelvic
observation and analysis of, 467–468 rotation UCM during,
370–371 procedure for, 467, 467f 166–168, 166f, 167t, 168f
ideal pattern for, 370, 370f rating and diagnosis of hip external oblique abdominal
test for, 372–374 medial rotation UCM during, recruitment, 168
shoulder overhead reach, for 468, 469t internal oblique abdominal
shoulder girdle UCM, 402t side-bend recruitment, 168, 168f
shoulder press off elbows, for cervical, 267–269 lumbopelvic rotation UCM
shoulder girdle UCM, 402t observation and analysis of, during, 165–166
side-lying lateral arm lift test, 267–269 procedure for, 164–165,
344–345, 345b relative flexibility in, 266, 267f 164f–165f
correction of thoracic rotation observation and analysis of, 109, rating and diagnosis of
UCM during, 345, 346t 163f lumbopelvic rotation UCM
procedure for, 344–345, 344f ideal pattern of lumbopelvic during, 166–168, 167t
rating and diagnosis of thoracic rotation, 162, 163f single hip rotation test, 178–182,
rotation UCM during, 345, indications to test for 179b
346t lumbopelvic rotation UCM, correction of lumbopelvic
thoracic rotation UCM during, 163 rotation UCM during,
345 movement faults associated 179–181, 180t, 181f
side-lying side bridge test, 347– with lumbopelvic rotation, external oblique abdominal
348, 347b 162–163 recruitment, 181
correction of thoracic rotation standing trunk test, 206–208, internal oblique abdominal
UCM during, 348, 348f, 207b recruitment, 181–182
349t correction of lumbopelvic lumbopelvic rotation UCM
procedure for, 347, 347f rotation UCM during, 208, during, 179
rating and diagnosis of thoracic 209t procedure for, 178, 178f–179f
rotation UCM during, 348, lumbopelvic rotation UCM rating and diagnosis of
349t during, 207 lumbopelvic rotation UCM
thoracic rotation UCM during, procedure for, 206, 206f during, 179–182, 180t
347 rating and diagnosis of single knee extension test, 189–
side-lying single leg abduction test, lumbopelvic rotation UCM 190, 190b
437–438, 438b during, 208, 209t correction of lumbopelvic
correction of hip flexion during, thoracolumbar restriction of, 486 rotation UCM during, 190,
438, 439t side-bend control tests, cervical, 191t
hip medial rotation UCM during, 263–267, 270–289 lumbopelvic rotation UCM
437 head tilt test, 276–278, 276f, during, 189–190
procedure for, 437, 437f 277b, 277t, 278f, 279t–280t, procedure for, 189, 189f
rating and diagnosis of hip 280f rating and diagnosis of
flexion during, 438, 439t head turn test, 270–273, 270f– lumbopelvic rotation UCM
side-lying top leg turn out test, 273f, 271b, 271t, 274t–275t during, 190, 191t
174–177, 175b lower neck lean test, 285–289, single knee flexion test, 183–184,
correction of lumbopelvic 285f–286f, 286b, 286t, 288t 183b
rotation UCM during, 175, observation and analysis of neck correction of lumbopelvic
176t side-bending, 109, 163f rotation UCM during, 184,
external oblique abdominal summary for, 289t 185t
recruitment, 175 upper neck tilt test, 281–283, lumbopelvic rotation UCM
internal oblique abdominal 281f–283f, 282b, 282t, 284t during, 183
recruitment, 175–177 SIJ see sacroiliac joint procedure for, 183, 183f
525
Index
rating and diagnosis of hip lateral rotation/abduction procedure for, 308–309, 308f
lumbopelvic rotation UCM UCM during, 483 rating and diagnosis of thoracic
during, 184, 185t procedure for, 483, 483f flexion UCM during, 309,
single knee lift and anterior tilt test, rating and diagnosis of hip lateral 310t
446–448, 447b rotation/abduction UCM thoracic flexion UCM during, 309
correction of hip extension UCM during, 484, 485t sitting chest drop test, 109–112,
during, 447–448, 447f, 449t single leg small knee bend test, 110b
hip extension UCM during, 447 459–462, 460b correction of lumbar flexion
procedure for, 446–447, 446f correction of hip medial rotation UCM during, 110–112, 111t,
rating and diagnosis of hip UCM during, 460–462, 462f, 112f
extension UCM during, 466t lumbar flexion UCM during,
447–448, 449t hip medial rotation UCM during, 110
single knee lift and knee extension 459–460 procedure for, 109, 109f
test, 450–452, 451b procedure for, 459, 459f–460f rating and diagnosis of lumbar
correction of hip extension UCM rating and diagnosis of hip flexion UCM during, 110–112,
during, 451–452, 451f, 453t medial rotation UCM during, 111t
hip extension UCM during, 451 460–462, 466t sitting chest lift (tilt) test, 132–136,
procedure for, 450–451, 450f single leg stance lateral pelvic shift 133b
rating and diagnosis of hip test, 488–490, 489b correction of lumbar extension
extension UCM during, correction of hip adduction UCM UCM during, 133–136, 134t,
451–452, 453t during, 489–490, 489f–490f, 135f
single leg abduction test, 437–438, 491t lumbar extension UCM during,
438b hip adduction UCM during, 489 133
correction of hip flexion during, procedure for, 488, 488f procedure for, 132–133, 132f
438, 439t rating and diagnosis of hip rating and diagnosis of lumbar
hip medial rotation UCM during, adduction UCM during, extension UCM during,
437 489–490, 491t 133–136, 134t
procedure for, 437, 437f single-task muscles, 31 sitting double knee extension test,
rating and diagnosis of hip site and direction of UCM 113–114, 114b
flexion during, 438, 439t in cervical spine correction of lumbar flexion
single leg bridge extension test, diagnosis of, 221, 221t–222t UCM during, 114, 115t
192–194, 193b identification of, 221–224, lumbar flexion UCM during,
correction of lumbopelvic 223f, 224b 113–114
rotation UCM during, classification of, 10–11, 10t procedure for, 113, 113f
193–194, 193f, 195t of correction of hip rotation rating and diagnosis of lumbar
lumbopelvic rotation UCM UCM, 499t flexion UCM during, 114,
during, 192 diagnosis of, 16 115t
procedure for, 192, 192f at hip, 417–420 sitting forward lean test
rating and diagnosis of diagnosis of, 416–417, 417b for lumbar extension UCM,
lumbopelvic rotation UCM global range-specific, 417–420 137–138, 138b
during, 193–194, 195t segmental translatatory, 417 correction of lumbar extension
single leg heel touch, 103–104, in lumbar spine UCM during, 138, 139t
103f, 147, 147f diagnosis of, 85, 85t–86t lumbar extension UCM during,
single leg high knee lift test, identification of, 86–87 138
471–473, 472b retraining of, 67–70, 70b procedure for, 137, 137f
correction of hip lateral rotation/ for control of UCM, 67–69, rating and diagnosis of lumbar
abduction UCM during, 68f–69f extension UCM during,
472–473, 473f, 474t progression of, 69 119, 139t
hip lateral rotation/abduction for symptom management, for lumbar flexion UCM,
UCM during, 472 69–70 106–107, 107b
procedure for, 471–472, 471f at SIJ and pelvis, 88–90, 89t correction of lumbar flexion
rating and diagnosis of hip lateral testing for, 55–57, 56b UCM during, 107, 108t
rotation/abduction UCM in thoracic spine, 293–294, lumbar flexion UCM during,
during, 472–473, 474t 294t 106
single leg lift, 483–484, 483b sitting bilateral forward reach test, procedure for, 106, 106f–107f
correction of hip lateral rotation/ 308–309, 309b rating and diagnosis of lumbar
abduction UCM during, 484, correction of thoracic flexion flexion UCM during, 107,
485t UCM during, 309, 310t, 311f 108t
526
Index
sitting head hang test, 300–301, sitting posture, in lumbopelvic spondylosis, retraining lumbopelvic
301b UCM, 83–84 UCM control in patients with,
correction of thoracic flexion sitting single knee extension test, 85
UCM during, 301, 302t, 303f 189–190, 190b stabiliser muscles, 23–24, 24t
procedure for, 300, 300f correction of lumbopelvic in altered strategies in
rating and diagnosis of thoracic rotation UCM during, 190, dysfunctional situations,
flexion UCM during, 301, 302t 191t 37–38, 38f
thoracic flexion UCM during, lumbopelvic rotation UCM recruitment of, 34, 33f
300–301 during, 189–190 pain and, 36–37, 37f
sitting head raise test, 316–317, 317b procedure for, 189, 189f stabilising exercise, for retraining
correction of thoracic extension rating and diagnosis of control of lumbopelvic UCM,
UCM during, 317, 317f, 318t lumbopelvic rotation UCM 84–85
procedure for, 316–317, 316f during, 190, 191t stability
rating and diagnosis of thoracic SKB see small knee bend in muscle function and
extension UCM during, 317, skin taping, 77 physiology, 23
318t slow motor units (SMUs), 31–32, stability muscles
thoracic extension UCM during, 32f, 32t global, 29t, 31
317 recruitment of, 32–34, 33f, 33t, local, 29t, 31
sitting head turn test, 328–348, 70–71, 70t, 71b standing abdominal hollowing and
329b pain and, 36–37, 37f expiration test, 357–360, 358b
correction of thoracic rotation in stabiliser muscles, 34 correction of thoracic respiratory
UCM during, 329, 329f, 330t slump sitting posture, in UCM during, 358, 359t
procedure for, 328–329, 328f lumbopelvic UCM, 83–84 procedure for, 357, 357f–358f
rating and diagnosis of thoracic small knee bend (SKB) rating and diagnosis of thoracic
rotation UCM during, 329, ideal pattern of, 422, 423f respiratory UCM during, 358,
330t sagittal movement faults with, 359t
thoracic rotation UCM during, 423–425, 423f–424f thoracic respiratory UCM during,
329 in standing vertical trunk single 357
sitting pelvic tail lift test, 319–321, leg 1/4 squat test, 426 standing anterior costal lift and
320b SMT see spinal manipulative expiration test, 354–355, 355b
correction of thoracic extension therapy correction of thoracic respiratory
UCM during, 320–321, SMUs see slow motor units UCM during, 355, 356t
320f–321f, 322t specific musculoskeletal pain, procedure for, 354–355, 354f
procedure for, 319–320, 319f classification of subgroups in, rating and diagnosis of thoracic
rating and diagnosis of thoracic 44 respiratory UCM during, 355,
extension UCM during, spinal alignment, lumbopelvic 356t
320–321, 322t UCM due to changes in, 84 thoracic respiratory UCM during,
thoracic flexion UCM during, 320 spinal manipulative therapy (SMT), 355
sitting pelvic tail tuck test, 304– 76–77 standing apical drop and
306, 305b spinal roll down test, 433–435, inspiration test, 351–352, 352b
correction of thoracic flexion 434b correction of thoracic respiratory
UCM during, 305–306, correction of hip flexion during, UCM during, 352, 353t
305f–306f, 307t 434–435, 434f, 436t procedure for, 351–352, 351f
procedure for, 304–305, 304f hip flexion UCM during, 434 rating and diagnosis of thoracic
rating and diagnosis of thoracic procedure for, 433–434, 433f respiratory UCM during, 352,
flexion UCM during, 305– rating and diagnosis of hip 353t
306, 307t flexion UCM during, 434– thoracic respiratory UCM during,
thoracic flexion UCM during, 305 435, 436t 352
sitting pelvic twist test, 331–332, spinal segments standing back flattening test,
332b lumbopelvic UCM due to 296–297, 297b
correction of thoracic rotation dysfunction in, 84 correction of thoracic flexion
UCM during, 332, 333t MCI in, 47–48 UCM during, 297, 297f, 298t,
procedure for, 331–332, 331f see also segmental extension hinge; 299f
rating and diagnosis of thoracic segmental flexion hinge procedure for, 296, 296f
rotation UCM during, 332, spinal stability, 23 rating and diagnosis of thoracic
333t spondylolisthesis, retraining flexion UCM during, 297,
thoracic rotation UCM during, lumbopelvic UCM control in 298t
332 patients with, 85 thoracic flexion UCM during, 297
527
Index
standing back flattening on wall, thoracic rotation UCM during, rating and diagnosis of hip
122, 122f 338 flexion UCM during, 431,
correction of, 122 standing one leg small knee bend 432t
dysfunctional action, 122 and trunk rotation away test, standing single knee lift and
ideal action, 122, 122f 463–465, 464b anterior tilt test, 446–448, 447b
standing bilateral backward reach correction of hip medial rotation correction of hip extension UCM
test, 323–326, 324b UCM during, 464–465, 464f, during, 447–448, 447f, 449t
correction of thoracic extension 466t hip extension UCM during,
UCM during, 324–326, 324f, hip medial rotation UCM during, 447
325t 463–464 procedure for, 446–447, 446f
procedure for, 323–324, 323f procedure for, 463, 463f–464f rating and diagnosis of hip
rating and diagnosis of thoracic rating and diagnosis of hip extension UCM during,
extension UCM during, medial rotation UCM during, 447–448, 449t
324–326, 325t 464–465, 466t standing single knee lift and knee
thoracic extension UCM during, standing one leg small knee bend extension test, 450–452, 451b
324 and trunk rotation towards test, correction of hip extension UCM
standing bilateral overhead reach 475–477, 476b during, 451–452, 451f, 453t
test, 313–314, 314b correction of hip lateral rotation/ hip extension UCM during, 451
correction of thoracic extension abduction UCM during, procedure for, 450–451, 450f
UCM during, 314, 314f, 476–477, 476f, 478t rating and diagnosis of hip
315t hip lateral rotation/abduction extension UCM during,
procedure for, 313–314, 313f UCM during, 475–476 451–452, 453t
rating and diagnosis of thoracic procedure for, 475, 475f–476f standing single leg high knee lift
extension UCM during, 314, rating and diagnosis of hip lateral test, 471–473, 472b
315t rotation/abduction UCM correction of hip lateral rotation/
thoracic extension UCM during, during, 476–477, 478t abduction UCM during,
314 standing pelvic side-shift test 472–473, 473f, 474t
standing double knee swing test, for lumbopelvic rotation control, hip lateral rotation/abduction
200–202, 201b 210–213, 211b UCM during, 472
correction of lumbopelvic correction of lumbopelvic procedure for, 471–472, 471f
rotation UCM during, rotation UCM during, rating and diagnosis of hip lateral
201–202, 202f–204f, 205t 211–213, 212t rotation/abduction UCM
lumbopelvic rotation UCM lumbopelvic rotation UCM during, 472–473, 474t
during, 201 during, 211 standing single leg small knee bend
procedure for, 200–201, 200f procedure for, 210–211, 210f test, 459–462, 460b
rating and diagnosis of rating and diagnosis of correction of hip medial rotation
lumbopelvic rotation UCM lumbopelvic rotation UCM UCM during, 460–462, 462f,
during, 201–202, 205t during, 211–213, 212t 466t
standing hip extension toe slide for thoracic rotation control, hip medial rotation UCM during,
test, 157–159, 158b 334–335, 335b 459–460
correction of lumbar extension correction of thoracic rotation procedure for, 459, 459f–460f
UCM during, 158–159, 159f, UCM during, 335, 335f, rating and diagnosis of hip
160t 336t medial rotation UCM during,
lumbar extension UCM during, procedure for, 334–335, 334f 460–462, 466t
158 rating and diagnosis of thoracic standing spinal roll down test,
procedure for, 157–158, rotation UCM during, 335, 433–435, 434b
157f–158f 336t correction of hip flexion during,
rating and diagnosis of lumbar thoracic rotation UCM during, 434–435, 434f, 436t
extension UCM during, 335 hip flexion UCM during, 434
158–159, 160t standing posture, in lumbopelvic procedure for, 433–434, 433f
standing one arm wall push test, UCM, 83–84 rating and diagnosis of hip
337–338, 338b standing single foot lift test, flexion UCM during, 434–
correction of thoracic rotation 430–431, 431b 435, 436t
UCM during, 338, 339t correction of hip flexion during, standing thoracic extension
procedure for, 337–338, 337f 431, 431f, 432t (sway) test, 124–126, 125b
rating and diagnosis of thoracic hip flexion UCM during, correction of lumbar extension
rotation UCM during, 338, 430–431 UCM during, 125–126, 126f,
339t procedure for, 430, 430f 127t
528
Index
lumbar extension UCM during, standing vertical trunk single leg supine active ‘figure 4’ turnout test,
124–125 1/4 squat test, 426–428, 500–501, 501b
procedure for, 124, 124f–125f 427b correction of hip rotation UCM
rating and diagnosis of lumbar correction of hip flexion UCM during, 501, 501f, 502t
extension UCM during, during, 428, 428f, 429t hip forward glide UCM during,
125–126, 127t hip flexion UCM during, 501
standing thoracic extension (tilt) 426–427 procedure for, 500–501, 500f
test, 128–131, 129b procedure for, 426, 426f–427f rating and diagnosis of hip
correction of lumbar extension rating and diagnosis of hip rotation UCM during, 501,
UCM during, 129–131, 129f, flexion UCM during, 427– 502t
130t 428, 429t supine active straight leg raise test,
lumbar extension UCM during, stand-to-sit ischial weight bearing 493–495, 494b
129 test, 116–119, 117b correction of hip rotation UCM
procedure for, 128, 128f correction of lumbar flexion during, 494–495, 494f–495f,
rating and diagnosis of lumbar UCM during, 117–119, 117f, 496t
extension UCM during, 118t hip forward glide UCM during,
129–131, 130t lumbar flexion UCM during, 494
standing thoracic rotation test, 116–117 procedure for, 493–494,
196–198, 197b procedure for, 116, 116f 493f–494f
correction of lumbopelvic rating and diagnosis of lumbar rating and diagnosis of hip
rotation UCM during, flexion UCM during, 117–119, rotation UCM during,
197–198, 198f, 199t 118t 494–495, 496t
lumbopelvic rotation UCM static diagonal heel lift with supine bent knee fall out test,
during, 197 isometric knee to hand push 169–173, 171b
procedure for, 196–197, 196f and second heel correction of lumbopelvic
rating and diagnosis of lift, 103, 103f, 146–147, 146f rotation UCM during, 171,
lumbopelvic rotation UCM static diagonal with isometric 172t
during, 197–198, 199t opposite knee to hand push, external oblique abdominal
standing thoracolumbar extension 102, 102f, 146, recruitment, 171
test, 442–444, 443b 146f internal oblique abdominal
correction of hip extension UCM stiffness, 45–46, 45f recruitment, 171–173
during, 443–444, 443f, 445t in glenohumeral lateral rotation, lumbopelvic rotation UCM
hip extension UCM during, 376–377 during, 169–171
442 in glenohumeral medial rotation, procedure for, 169, 169f–170f
procedure for, 442, 442f–443f 370 rating and diagnosis of
rating and diagnosis of hip in hip adduction control, 486 lumbopelvic rotation UCM
extension UCM during, in hip extension control, during, 171–173, 172t
443–444, 445t 440–441, 441f supine single heel slide test,
standing trunk lean test, 93–96, in hip rotation control, 454 164–168, 166b
94b in hip UCM correction of lumbopelvic
correction of lumbar flexion with backward rocking, 422 rotation UCM during,
UCM during, 94–96, 95t, 96f with forward bending, 421 166–168, 166f, 167t, 168f
lumbar flexion UCM during, 94 with SKB, 423 external oblique abdominal
procedure for, 93–94, 93f–94f in lumbar extension, 120 recruitment, 168
rating and diagnosis of lumbar in lumbar flexion, 91 internal oblique abdominal
flexion UCM during, 94–96, in lumbopelvic rotation, 162 recruitment, 168, 168f
95t of muscle, 34–36, 34f–35f lumbopelvic rotation UCM
standing trunk side-bend test, in neck extension, 245–246, during, 165–166
206–208, 207b 245f–246f procedure for, 164–165,
correction of lumbopelvic in neck flexion, 225 164f–165f
rotation UCM during, 208, in neck rotation, 263–266, rating and diagnosis of
209t 264f–266f lumbopelvic rotation UCM
lumbopelvic rotation UCM in neck side-bending, 263–264, during, 166–168, 167t
during, 207 268–269 sustained passive postural
procedure for, 206, 206f in thoracic flexion, 295 positioning, UCM resulting
rating and diagnosis of strength training, 40 from, 50
lumbopelvic rotation UCM subscapularis, function of, sway standing posture, in
during, 208, 209t 23–24 lumbopelvic UCM, 83–84
529
Index
symptoms step 9: integrate other approaches thoracic flexion control, 295

consideration of tissues or or modalities, 14–15, thoracic flexion control tests,
structures contributing to, 14 15t 296–309
retraining for management of, step 10: discuss prognosis, 15 sitting bilateral forward reach
69–70 tension, of muscles, 26–28, test, 308–309, 308f, 309b,
with UCM, 5, 11 26f–27f 310t, 311f
tensor fasciae latae (TFL) sitting head hang test, 300–301,
T in hip extension control, 440, 300f, 301b, 302t, 303f
441f sitting pelvic tail tuck test, 304–
table hip extension lift test in hip pain, 416 306, 304f–306f, 305b, 307t
for lumbar extension UCM, therapeutic exercise, 64–67, 65f, standing back flattening test,
153–156, 154b 66b 296–297, 296f–297f, 297b,
correction of lumbar extension thigh muscles, in hip pain, 298t, 299f
UCM during, 154–156, 415–416 summary for, 309t
154f, 155t, 156f thoracic extension control tests, thoracic flexion test, 230–231, 231b
lumbar extension UCM during, 312 assessment goals for evaluating
153–154 sitting head raise test, 316–317, site and direction of UCM
procedure for, 153, 153f 316f–317f, 317b, 318t during, 232t
rating and diagnosis of lumbar sitting pelvic tail lift test, 319– correction of low cervical flexion
extension UCM during, 321, 319f–321f, 320b, 322t UCM during, 231, 232t
154–156, 155t standing bilateral backward reach low cervical flexion UCM during,
for lumbopelvic rotation UCM, test, 323–326, 323f–324f, 230–231
186–187, 186b 324b, 325t procedure for, 230, 230f
correction of lumbopelvic standing bilateral overhead reach rating and diagnosis of low
rotation UCM during, 187, test, 313–314, 313f–314f, cervical flexion UCM during,
188t 314b, 315t 231, 232t
lumbopelvic rotation UCM summary for, 326t thoracic flexion UCM, indications
during, 186 thoracic extension (sway) test, to test for, 295
procedure for, 186, 186f 124–126, 125b thoracic respiratory control tests,
rating and diagnosis of correction of lumbar extension 350
lumbopelvic rotation UCM UCM during, 125–126, 126f, standing abdominal hollowing
during, 187, 188t 127t and expiration test, 357–360,
talocrural joint restriction, of ankle lumbar extension UCM during, 357f–358f, 358b, 359t
dorsiflexion, 421 124–125 standing anterior costal lift and
temporomandibular joint (TMJ), procedure for, 124, 124f–125f expiration test, 354–355,
neutral training region of, rating and diagnosis of lumbar 354f, 355b, 356t
223–224, 223f, 224b extension UCM during, standing apical drop and
10 point analysis, for UCM, 125–126, 127t inspiration test, 351–352,
10–15, 10b–11b, 10t–12t, thoracic extension (tilt) test, 351f, 352b, 353t
13f–14f, 15t 128–131, 129b summary for, 360t
step 1: classify site and direction correction of lumbar extension thoracic respiratory UCM,
of UCM, 10–11, 10t UCM during, 129–131, 129f, indications to test for, 350
step 2: relate UCM to symptoms, 130t thoracic restriction
11 lumbar extension UCM during, of extension, 120
step 3: relate assessment findings 129 of flexion, 91
to disability, 11, 11b procedure for, 128, 128f thoracic rotation control tests, 327
step 4: identify UCM and rating and diagnosis of lumbar four point one arm lift test,
restrictions, 11–12, 11t–12t extension UCM during, 340–341, 340f–342f, 341b,
step 5: develop management plan 129–131, 130t 343t
for UCM and restrictions, 12, thoracic extension UCM, side-lying lateral arm lift test,
13f–14f indications to test for, 344–345, 344f, 345b, 346t
step 6: relate pain mechanisms to 312 side-lying side bridge test,
presentation, 13 thoracic flexion 347–348, 347b, 347f–348f,
step 7: consider tissues or movement faults associated with, 349t
structures contributing to 295 sitting head turn test, 328–348,
symptoms, 14 relative flexibility, 295 328f–329f, 329b, 330t
step 8: assess for environmental relative stiffness, 295 sitting pelvic twist, 331–332,
and personal factors, 14 restriction of, 225 331f, 332b, 333t
530
Index
standing one arm wall push, top leg turnout lift test, 467–468, rating and diagnosis of
337–338, 337f, 338b, 339t 468b lumbopelvic rotation UCM
standing pelvic side-shift test, correction of hip medial rotation during, 208, 209t
334–335, 334f–335f, 335b, UCM during, 468, 468f, 469t trunk turning, hip rotation control
336t hip medial rotation UCM during, and, 454–455
summary for, 348t 467–468
thoracic rotation restriction, 162 procedure for, 467, 467f U
thoracic rotation test, 196–198, rating and diagnosis of hip
197b medial rotation UCM during, UCM see uncontrolled movement
correction of lumbopelvic 468, 469t uncontrolled movement (UCM),
rotation UCM during, training tools/equipment, for 3–22
197–198, 198f, 199t retraining, 76 aetiology of, 49–52, 50t–51t
lumbopelvic rotation UCM translation alternative therapies for, 7–9,
during, 197 of glenohumeral joint 8b–9b
procedure for, 196–197, 196f anterior, 377, 397 assessment and classification of,
rating and diagnosis of inferior, 387, 392 43–62
lumbopelvic rotation UCM humerus, in glenohumeral lateral clinical assessment, 54–59,
during, 197–198, 199t rotation, 376–377 56b, 59b, 59t
thoracic rotation UCM, indications mid-cervical principles of assessment,
to test for, 327 abnormal translation during, 53–54
thoracic spine, 292–360 256 of subgroups in
changes in movement and normal translation during, neuromusculoskeletal pain,
postural control in, 293 256 43–53, 44b, 45f, 48b, 49f,
thoracic spine UCM palpation during, 256b 50t–51t, 53f
diagnosis of site and direction of, UCM in, 222t assessment and management of,
293–294, 294t translation control tests, 9–10, 9b
symptom presentation and site 255–261 classifying site and direction of,
of, 293–294, 294t chin lift hinge test, 259–261, 10–11, 10t
tests for, 295 259f, 260b, 261f, 262t clinical reasoning in diagnostic
thoracolumbar extension test, head back hinge test, 255–257, framework for, 15–16,
442–444, 443b 255f–257f, 256b, 258t 17f
correction of hip extension UCM translational dysfunction, 51–52, step 1: diagnosis of movement
during, 443–444, 443f, 445t 51t dysfunction, 16
hip extension UCM during, 442 translational shear step 2: clinical diagnosis of
procedure for, 442, 442f–443f during chin lift hinge test, 259 pain-sensitive or pain-
rating and diagnosis of hip during head back hinge test, 255 generating structures,
extension UCM during, transversus abdominis, in SIJ 16
443–444, 445t stiffness, 88 step 3: clinical diagnosis of
thoracolumbar restriction trapezius, in shoulder movement, presenting pain
of hip flexion, 421 364 mechanisms, 16
of hip rotation, 454 trauma, UCM resulting from, 50 step 4: assessment of
of side-bend, 486 trunk lean test, 93–96, 94b contextual factors, 16
TMJ see temporomandibular joint correction of lumbar flexion clinical reasoning process
top leg turn out test, 174–177, UCM during, 94–96, 95t, applied to, 10–15, 10b–11b,
175b 96f 10t–12t, 13f–14f, 15t
correction of lumbopelvic lumbar flexion UCM during, 94 10 point analysis for UCM,
rotation UCM during, 175, procedure for, 93–94, 93f–94f 10–15, 10b–11b, 10t–12t,
176t rating and diagnosis of lumbar 13f–14f, 15t
external oblique abdominal flexion UCM during, 94–96, developing management plans
recruitment, 175 95t for, 12, 13f–14f
internal oblique abdominal trunk side-bend test, 206–208, disablement assessment model
recruitment, 175–177 207b applied to, 17–19, 17f–18f
lumbopelvic rotation UCM correction of lumbopelvic functional links between pain
during, 174–175 rotation UCM during, 208, and, 5, 5f
procedure for, 174, 174f 209t identification and classification
rating and diagnosis of lumbopelvic rotation UCM of, 5–7, 5f, 11–12, 11t–12t
lumbopelvic rotation UCM during, 207 disability, 5–6
during, 175–177, 176t procedure for, 206, 206f dysfunction, 6
531
Index
performance, 7 unilateral movement control correction of low cervical

recurrence, 6 cervical rotation, 263–267 side-bend UCM during,
risk of injury, 6–7 observation and analysis of 282–283, 282f–283f,
symptoms, 5 neck rotation, 263–267, 284t
model for assessment and 263f–267f low cervical side-bend UCM
retraining of movement cervical side-bend, 267–269 during, 281–282, 282t
faults, 7–9, 8b–9b, 8f observation and analysis of procedure for, 281, 281f
pain and, 48–52, 48b, 49f, neck side-bending, 267–269 rating and diagnosis of low
50t–51t relative flexibility in, 266, 267f cervical side-bend UCM
aetiology of UCM, 49–52, upper cervical extension during, 282–283, 284t
50t–51t relative flexibility in, 246, 266, upright posture, in lumbopelvic
development of motion 267f, 269 UCM, 83–84
restrictions in function, UCM in, 222t
48–49, 48b, 51t upper cervical extension control V
relating symptoms to, 11 tests, 247–253
retraining strategies for, 63–80, backward head lift test, 247–251, vertical trunk single leg 1/4 squat
78b 247f–249f, 248b, 250t test, 426–428, 427b
challenges in retraining horizontal retraction test, correction of hip flexion UCM
neuromusculoskeletal 252–253, 252f–253f, 253b, during, 428, 428f, 429t
dysfunction, 71–72 254t hip flexion UCM during,
integration into functional upper cervical flexion 426–427
tasks and activities, 72–77, relative flexibility in, 225 procedure for, 426,
73f–74f, 75b, 76t–77t restriction of, 225 426f–427f
key principles in retraining UCM in, 222t rating and diagnosis of hip
movement control patterns, upper cervical flexion control tests, flexion UCM during, 427–
70–71, 70t, 71b, 77, 77t 237–243 428, 429t
rehabilitation management arm extension test, 241t, 242–
and, 63–64, 64f 243, 242f–243f, 243b, 244t W
retraining site and direction forward head lean test, 237–239,
of UCM, 67–70, 68f–69f, 237f–238f, 239b, 240f, 241t weight transfer
70b upper cervicothoracic restriction, of hip adduction control and,
therapeutic exercise, 64–67, neck extension, 245, 245f–246f 486
65f, 66b upper neck tilt test, 281–283, 282b movement faults associated with,
understanding movement and assessment goals for 486
function, 3–5, 4f evaluating site and direction relative flexibility, 486
see also specific types of UCM during, 284t relative stiffness, 486
532

Screenshot 2022-04-17 at 12.08.10 AM

Uploaded by

Copyright:

Available Formats

Screenshot 2022-04-17 at 12.08.10 AM

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Screenshot 2022-04-17 at 12.08.10 AM

Uploaded by

Copyright:

Available Formats

Kinetic Control

Mark Comerford, BPhty, MCSP, MAPA

Sarah Mottram, MSc, MCSP, MMACP

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto

Elsevier Australia. ACN 001 002 357

© 2012 Elsevier Australia

National Library of Australia Cataloguing-in-Publication Data

Publisher: Melinda McEvoy

Preface ............................................................ vii Section 2

Section 1 7 The thoracic spine ................................. 292

1 Uncontrolled movement ........................... 3

2 Muscle function and physiology ............ 23 9 The hip .................................................... 414

Index ............................................................. 505

4 Retraining strategies for

Recurrent musculoskeletal pain has a significant impact on health care costs,

Shirley Sahrmann, PT, PhD, FAPTA

Technical Reviewer Philippa Tindle BSc. BA. MCSP

Normal or ideal movement is difficult to define. Movement faults

© 2012 Elsevier Australia

Figure 1.1 Inter-related components of the movement system

relates to the direction of tissue stress or strain

Assessment of muscle function

Force closure model Analysis and development of

Model of clinical ‘Alternative’ therapies

Figure 1.4 The development of the movement analysis model

clinical evidence (Emery et al 2010; Rydeard et al

Box 1.3 Procedure for analysis of movement dysfunction

(Comerford & Mottram 2011)

(Comerford & Mottram 2011). An understanding

Chapter 3 of this text will explain the process

3 Relate assessment findings to disability

Uncontrolled translation Uncontrolled range

Target local muscle system Target global muscle system

Site and direction of

Retrain site and direction of

Articular restriction Myofascial restriction

Manual therapy Regain extensibility of global mobility

Figure 1.5 The management planning outline

Uncontrolled translation Uncontrolled range

Target local muscle system Target global muscle system

(e.g. site: scapulothoracic, direction:

Articular restriction Myofascial restriction

Manual therapy Regain extensibility of global mobility muscle

Uncontrolled translation Uncontrolled range

Target local muscle system Target global muscle system

Articular restriction Myofascial restriction

Manual therapy Regain extensibility of global mobility muscle

7 Consideration of tissues or structures objectively assessed (and reassessed) with valid

OTHER THERAPEUTIC EXAMPLES

1 Diagnosis of movement with chronic pain suggests it is more appropriate

In the ICF model the horizontal dimension of

frame’. In contrast, the disablement process rep-

• course (normal or aberrant)

managed in a holistic way with consideration of neuromusculoskeletal disorders. To assist in this

Muscle function and physiology

INTRODUCTION: ANALYSIS OF MUSCLE FUNCTION

© 2012 Elsevier Australia

Table 2.1 Characteristics of muscles with stabiliser and mobiliser roles

STABILITY MUSCLE ROLE CHARACTERISTICS MOBILITY MUSCLE ROLE CHARACTERISTICS

EXAMPLES OF STABILISER MUSCLES EXAMPLES OF MOBILISER MUSCLES