AUSTRAliAN PHYSIOTHERAPY o RI GI N A L ART Ie LE

MargaretBullock

Research to optimisehuman performance

The need for greaterunderstanding of the factorswhich limit human movement and functionalcapacity and for determining effective methodsfor ensuring optimum performance has led to awide range of related research studies. Thispaper draws on some of the research projectspursued or supervised by the author, to showthe knowledge gained in aspects of movementcapacity, muscle function and the influence ofsensory motor defic.its on movement andfunction. The inter-relationship of the manyfactors influencing functional capacityemphasise the need tothink broadly in research.Studies of effectiveness ofphysiotherapv andcollection of data for ergonomic workplacedesign highlight the importance of bothprevention and therapeutic care anddemonstrate the contributions wh ichphysiotherapists can make through research tooptimise human performance.[Bullock MI: Research to optimise humanperformance. Australian Journal ofPhysiotherapy 40th Jubilee Issue 1994:5-17]

Key words: Ergonomics;Muscles; Rehabilitation;Physical Therapy;Sensory Motor Ability

MIBullockPhD, BScApp,FTS, ATCL,LTCL, istheFoundation Professor of Physiotherapy at TheUniversity of Oueensland and was Head of theDepartment of Physiotherapy 1974-88. Sheserved as Deputy Presidentand President of theAcademic Board for five years.Correspondence: Professor Margaret Bullock,Department of Physiotherapy, The UniversityofQueensland, Brisbane,Queensland 4072.

The importance of pursuingresearch in physiotherapy has

. been recognised for many yearsand is espoused increasingly today.Although physiotherapy expertiserevolves around the analysis ofnormaland abnormal movement, the scope ofphysiotherapy practice is broad,covering both restorative andpreventative roles, and manyopportunities for research exist(Bullock 1976). The choice of researcharea fora physiotherapist may dependana number of factors, including theprofession's priorities for research,availability of resources or personalpreference.. However, wher~ theresearcher carries a responsibility forbeing a catalyst to research, and forestablishing a range of researchendeavours within a UniversityDepartment of Physiotherapy, theymust be prepared to diversify theirinterests and explore a number ofdifferent fields, often concurrently.Such was the case for this author who,after pursuing individual interests andcommissioned projects, was charged byThe University of Queensland withproviding leadership in a range ofresearch areas relevant tophysiotherapy, encouraging higherdegree enrolment, and nurturingbeginning researchers. Because of this,the author has been involved in avariety of research topics, and hassupervised more than 80 higher degreeresearch theses.

Among the broad range offundamental, .applied and clinicalresearch topics. pursued by the authorhas been a concern to enhance humanperformance. As Figure 1 illustrates,

complex inter-relationships existbetween the aspects of humanperformance which influencefunctional capacity. Features whichdemonstrate the function of a musclein individual and co-ordinated activityaffect a person's capacity to movefreely and safely through space,applying forces appropriate to theactivity. The factors associated withmuscle function,movement capacity,force capability and space requirementsare inter-related and, separately andcollectively, influence static anddynamic posture, while central tomany of these expressions of functionis sensory motor ability. Optimisationof human performance can be achievedby a combination of rehabilitation andtherapeutic care, and ergonomic designand prevention. It is on each of theseaspects that the author's research hasdwelt and Figure 1 is offered toillustrate the sphere of research activitypursued by the author and supervisedstudents in areas concerned withoptimisation of human performance.This paper describes only some ofthose projects.

Ergonomic design tooptimise functionalcapacity in the workplaceMovement is the essence of life and thestudy ofthe elements which combineto produce movement is important tothe health of all individuals. However,it is important to realise the extent ofthe body's capacity for movement andthe limitations on demands which mustbe made in recognition of the

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figure 1.Model of research addressing optimisation of human performance.(Topic inter-relationships exist within and between circles).

from Page 5constraints of the basic structure andfunction of the human body (Bullock1985). If the design of a workplace isnot adapted to the natural patterns ofmotion, tolerance limits may bequickly exceeded. To ensure safety, thenature of individual differences in bodysize, strength and endurance must beappreciated when defining designspecifications. Physiotherapistscontribute to this consideration ofman-machine relationships because oftheir ability to analyse bodymovements in detail, to evaluatepostural abuse during dynamicsituations, and to understand theclinical implications of misuse of thebody (Bullock 1974a, 1990a).

Movement capacity: threedimensional motion analysisDetailed analysis of dynamic posturedemands measurement of bodymovements in three dimensions.Recognising this, the author undertookto develop such a process at a timewhen accurate three dimensionalmotion analysis was not consideredpossible. Video cameras and personalcomputers were not yet available andthe design of a measurement processfor analysis of complex motions wasparticularly challenging. Afterextensive trialling, stereoscopicphotogrammetry (a technique used foraerial topographical mapping ofstationary objects) was adapted for

three dimensional motion analysis(Bullock 1974b, 1974c). Specified bonylandmarks were marked with the newlyavailable reflective tape and, using twophototheodolite cameras andsynchronously firing electronic flashunits, successive images of each tapedspot were recorded on film during thesubject's activity. The three spacecoordinates (X, Y, Z) of each imagewere determined on a stereo plotter,allowing calculation of magnitude anddirection of motion of body segments.Evaluation of accuracy showed thatmeasurements of small rapidmovements had a standard error ofonly 0.6mm (Bullock and Harley1972). It is gratifying to note that laterdevelopments in three dimensionalmotion analysis using video cameras

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have incorporated a number of featuresof this pioneering procedure developedby the author.

Optimising <pedal use: iointmovement and controlFollowingsurveys in .industry andagriculture (Bullock 1973a), whichrevealed that more than 50 percent ofoperators reported aching or fatigue inthe lower back, research was institutedto improve the man-machine...taskrelationship during pedal operation.The study focused on 'determining thepedal orientation associated withminimal·spinal movements. Anexperimental seatand pedal assemblywas built with pedal and seatadjustability in all directions. Thepedal could also be rotated to alter itsangle with the horizontal or sagittalplanes. For the experiment, the pedalwas depressed over 135 travel pathsusing various combinations of theseadjustments (Bullock 1974c, 1974d).The subject's body movements duringpedal operation were measured by thestereo photogrammetric processdescribed above. Three pointers, eachbearing three pieces ofreflectivetransfer tape, were fixed between C7and Tl, T12 and Ll, andL5 andSIand reflective tape was glued ontospecified bony points of the pelvis andlower limb.

Movements in each plane for eachjoint, were calculated from dataacquired. Analysis revealed that theoptimal pedal orientation in terms ofminimal spinal movements was withthe pedal orientated at 45 degrees tothe horizontal, continuous with thefoot-on-the-pedallineand locatedanteriorly within a minimal leg reachand with minimal hip abduction or hipflexion4 Information was. also suppliedabout pedal alignments whose usewould be detrimental to the operator(Bullock 1974c, 1974d and 1991).

Further observations of drivers ofheavy machinery showed that vibrationfrom travelling on uneven groundprevented the driver maintaining thefoot pedal in the required semi­depressed position. A subsequentresearch study revealed a deteriorationin ability of subjects to control the foot

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pedal in a number of semi-depressedpositions while exposed to vibration ofvarying frequency and amplitude andthus highlighted the need fora designmodification by engineers (Bullock1990b).

Space and accommodationfor optimum functionIf equipment or work space is to beshared by individuals ofvarying sizes,it is essential that anthropometricmeasurem'entsbe collated forarepresentative sample of the usingpopulation. As clinicians,physiotherapists can also advisepatients about methods of preventingfurther work-related postural problems(Bullock and Bullock-Saxton 1994).Research projects to overcomeanthropometric limitations areessential (Bullock and Lanchester1969, Bullock 1974e).The likely limitations imposed by a

firm torso restraint on pilots oflightaircraft prompted the Department ofCivil Aviation (DCA) to commissionthe author to carry out a study relevantto cockpit design. A preliminary surveyof pilots revealed the nature ofproblems experienced and highlightedthe need for design modifications(Bullock 1973b). Structuralanthropometric data relevant to seatingwere then collected fromrepresentative samples of men andvyomencivilian pilots nflight aircraft,and a wide range of percentiles of eachmeasurement were presented (Bullock1973c, Bullock and Steinberg 1975).Results emphasised the importance ofrecognising individual differences incockpit design.

Without inertia reels, theconstraining effect of a lap and sashharness to functional armreach withinan aircraft cockpit or an automobileincreases the difficulty of reachingcontrols. Recognising this, the reachcapabilities ofAustralian men andwomen light aircraft pilots whilerestrained by firmly secured lap andsash harness were determined (Bullock1974f). To define the space envelopes,arm reach was measured for both armsat 13 horizontal levels from above tobelow the seat at each ofseven angles

to the sagittal plane. Comparisons ofthe boundaries which could be reachedby 95 per cent of male and 95 per centoffemale pilots with the location ofinstrument panels and cockpit floorsillustrated that, when wearing shoulderrestraint, many pilots were unable toreach certain controls. Further studyincorporating the newly availableinertia reel showed that significantincreases to reach boundaries occurred(Bullock 1974g).Subsequently,DCArequired the installation ofinertia reelsin light aircraft cockpits. Furtherresearch at the request of theCommonwealth Department ofTransport allowed application ofrelevant data to be made to functionalarm reach within Australianautomobiles (Bullock 1974h).

The collection of anthropometricdata.relevant to seating design isespecially important for adolescents, inwhom there is considerable variation insize for age, and for the disabled,whose individual needs are frequentlyoverlooked. Because the period ofsecondary school education coincidesclosely with the rapid growth spurtscharacterising puberty, postural habitsformed during this period caninfluence the skeletal and muscularsystems, setting a pattern which couldpersist through life (Bullock (1987).Observations in schools revealed thatproblems of postural pain and fatigueexisted, and anthropometricmeasurements taken of 1JOstudentsallowed recommendations to be maderegarding room use, provision ofcolour coded chairs, supply of differentsized and adjustable furniture and theneed for postural education (Bullock199Gb).

Observations that, for some disabledpersons, the wheelchair did notprovide the anticipated level ofsupport, control and mobility led tocomparison.of patient needs withwheelchair specifications (Nitz andBullock 1983). On investigation, nopatients examined with multiplesclerosis, spinal injury or musculardystrophy displayedanerect,wellsupported posture in their wheelchairand many had an increased thoracic

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from Page 1kyphosis and lumbar curvature and ascoliotic curve. Interference with armmovement from the backrest, limitedaccess to wheels and difficulties inreaching and activating brakes werecommon. Pertinent anthropometricmeasurements and the relevantdimensions and adjustability of thewheelchair features were collected.Analyses highlighted the need for moresuitable armrest heights, someadjustability of lumbar contouring ofthe backrest, at least two sizes in seatdepth and an effective and easilyapplied lever mechanism for brakeapplication. The importance ofphysiotherapists selecting a wheelchairwith specifications matching patients'individual anthropometric dimensionswas emphasised.

Force capabilitiesA person's capacity to carry out afunctional activity effectively at work,sport or at home depends to someextent on muscle strength and alimited capacity to apply anappropriate force could have seriousimplications. Of concern to the DCAduring the 1970s was the relativelyhigh incidence of fatalities in womenparachutists and the number of theseassociated with failure to depJoy theparachute. The DCA believed thatdesign data were needed which wouldensure that forces applied for testing ofparachute ripcord release did notexceed human capacities. Accordingly,a study to specify the maximum pullforce capabilities .ofwomenparachutists relevant to ripcord releasewas commissioned ofthe author.

A lightweight frame was fitted to thesuhject to allow force measurementsfor ripcord handle extraction fromsimulated pockets on each shoulderstrap and for ripcord release on themain and reserve parachutes.Maximum effort in pulling on theparachute handle was measured usingan electric resistance strain gauge.Results revealed that maximum forceswere not large, the·95th percentile pullforce capabilities ranging from 35 Nfor a 2.5 second pull to 71 N fora 0.25second pulL Only 72 per cent of the

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female subjects could exert the 100.Npull force relevant for testingparachute pack opening devices at thetime. In practice, forces required torelease the ripcord pins could beinfluenced by many factors, any ofwhich could increase the forcerequired to release the pins, therebycreating a "hard pull". Results fromthis study were used by the DCAinconsideration ofstandards applied inparachute testing (Bullock 1977 and1978).

These projects highlight the fact·that,in considering the relationship of aperson to their workplace, an insightinto the functioning of the humanbody and the physical limitations tomovement, through research, allowsphysiotherapists to contribute todesign aimed at improving safety,comfort and efficiency.

Movement capacityand therapeutic careAn understanding of normal limits ofhuman performanceis also importantfor therapeutic care. For example,examination of the total spinal motionor inter...segmentalmotion is routinefor manipulative physiotherapists. Toprovide some normative data on whichto make a comparison of motion in lowback pain sufferers, 200 adult subjectsaged between 15 and 65 years werestudied(Jull and Bullock 1987a). ThelumbarsegmentsL5-SI to TI2-Llwere examined by manual methods foraU physiological directions andpostero-anterior glides, using a fivepoint motion rating scale Gull 1985).This study provided data for normalinter-segmental motion for each agegroup, for clinical reference. Resultsdemonstrated an increasing incidenceof hypomobility with age, a greaterdegree of hypomobility being revealedin rotation to the right and lateralflexion to the left than in otherdirections. The study revealed thatsegments L3-L4 .and L4-L5 appearedto be most affected by structuralchanges which cause stiffuessandlimitation with age (Jull and Bullock1987b).

Information about the normal active

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ranges of motion is also essential as abasis ·for diagnosis of abnormality.Lane's (1981) study of active·spinalmovements and passive intervertebralmovement in 200 men and womenaged between 15 and 65 years showedthat, .with increasing age, active rangeof motion decreased. The 40 to 50 yearage span showed the most significantloss of active and passive motion. Theranges of motion of the femalepopulation were significantly greaterthan those of the male population in allmovements, except for lumbar spineflexion, where males exhibited greatermobilityin all age groups. TheL4-L5and L3-L4 intervertebral levelsexhibited the greatest degree ofhypermobility in all age groups in bothgenders and for the majority of passivemovements examined.

Another anatomical area ofconsiderable.importance to thephysiotherapist is the knee joint. It isthe site of frequent injury to both softtissues and skeletal structures, with apredisposition to complications and aresulting. pronounced functionaldeficit. To provide informationregarding the relative frequencies ofthe various forms ofknee injuriesreceiving physiotherapy care, anincidence survey was conducted withthe co-operation of all major hospitalsand local private practitioners (Mooreand Bullock 1977). The analysisrevealed the high incidence ofinjuriesfrom .playing in all football codes andhighlighted the frequency of medialligament and medial meniscus lesions,patella fractures, bruises and tibialfractures. The influence of age, sport,season and occupation were alsorevealed.

It is not only in sport that the knee isinjured. Concerned with the highincidence of knee injuries found in asurvey of 250 ballet dancers inAustralia and Europe (Wohlfahrt andBullock 1982), a study·was initiated tomeasure rotation occurring in hip,knee and ankle during the turn-outposition assumed by dancers. Ofparticular importance, the study resultsrevealed a high frequency ofasymmetry in hip flexibility, which wascorrelated with an increase in lateral

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rotation at the tibiofemoral joint andan associated increase in transversemobility of the patella. The dangersinherent in forcing turn..,out in balletdancers must be acknowledged andboth the ballet teacher and thephysiotherapist must encourage thepractice of careful technique andavoidance of faulty practice habits.

The influence of musclefunction deficits on humanperformanceThe balance of muscle forces about ajoint forms the basis for dynamicactivities, maintenance of stable jointposition and good postural alignment.A change in function of even onemuscle alters the balance betweenmuscles, and can lead toincoordination of movement or pain.Changes in muscle function can beexpressed in terms of alterations inmuscle length, strength, endurance oractivation, as illustrated in Figure 1.Knowledge of their influence onfunction and their inter..,relationships isessential for improving humanperformance.

Muscle length and postureBecause a range of motion greater orless than optimal is likely to lead tomusculoskeletal problems,measurement of muscle length isassessed by physiotherapists indetermining causative factors for suchproblems as joint pain, posturaldeviations or muscle imbalance.

Evaluation of the limit of musclelength involves some subjectivity onthe part of assessors and, for thisreason, the level of repeatability ofdetermination of end feel or theperception of motion of a bodylandmark should be known. This wasevaluated by Bullock-Saxton andBullock (1994) for muscles around thehip and pelvis, using standard positionsand procedures Oanda 1994). Analysisindicated that muscle lengthmeasurement was repeatable, ie ·thatthe degree ofvariation was within 10per cent. Those measures requiringdetermination of end feel of movementshowed a high degree of repeatability.However, for those measurements

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requiringpalpatory skills to detectonset of pelvic movement, the ..spreadofmeasures was greater, suggestingthat the therapist's palpatory skillslightly decreases the chance ofrepeatability. Tests carried out bydifferent physiotherapists and aseparate set of subjects determined asimilar level of repeatability(Toppenberg and Bullock 1990).These studies have provided assurancethat measurements of muscle lengthrecorded by experiencedphysiotherapists should be repeatableand acceptable as a basis forprogressive monitoring.

A diagnosis of muscle tightnessrequires knowledge of the range ofnormality. Collation ofnormative datais essential for reference by clinicians.The vulnerability of adolescents tomuscle imbalances and to spinal painand dysfunction, due in part to theunequal growth rate ofsoft tissues andbones, prompted astudy to collectnormative data for muscle lengthindices in muscles of the hip and pelvisin adolescents (Toppenberg andBullock 1990). Applying testsdescribed byJanda (1994), 103 femaleadolescents were studied, using aninclinometer and a Myringoniometerto record the position where furthermovement was limited by stretch onmuscle fibres and not by other limitingfactors. Muscle length indices werethen calculated (Cobb 1960).Tabulation of the true populationmeasures and the 0.95 individualtolerance limits for each muscle lengthindex offers data for clinical evaluationof normality.

A multiple correlation analysisinvestigated the relationships betweenmuscle length indices measured. Thisrevealed that shorter erector spinaeand longer abdominal musclesoccurred in combination with shorteriliopsoas and rectus femoris and longergluteal muscles, a pattern proposed byJanda (1980) as occurring in the pelviccrossed syndrome.

To determine interrelationships ofmuscle lengths and posture, thedegrees of thoracic kyphosis, lumbarlordosis and pelvic tilt were calculatedin adolescent females by recording the

angle of pelvic inclination and theinclinations of the spine L5-S1, T12­LlandTI-T2, using an inclinometer(Toppenbergand Bullock 1986).Correlation of the degrees of kyphosis,lordosis and pelvic tilt with musclelength· indices revealed that abdominallength was negatively correlated withthoracic kyphosis and positivelycorrelated with lumbar lordosis. Theformer finding suggests the need toassess abdominals in cases of kyphosis.Both hamstring muscle length anderector spinae length were negativelycorrelated with lumbar lordosis.Claims by other authors (Kendall andKendall 1949, Janda 1980) that hyper­lordosis is associated with back painhighlight the importance of routinelyevaluating both the degree of lumbar.spinal curvature and the relevantmuscle lengths when assessing patientswith back pain.

One group with a high incidence ofback pain is women during pregnancy.Although muscle length testing aroundthe pelvis is not practical duringpregnaney, gradual lengthening oftheabdominal musculature is a naturalconsequence of pregnancy and,combined with possible weakness ofabdominal muscles and a .change in thecentre of gravity, compensatorypostural changes are likely to occur.To determine any relationshipbetween postural changes and theincidence oflow back pain duringpregnancy, 34 women were assessed atbetween 14 and 22 weeks gestation andat eight weekly intervals subsequently(Bullock, Jull and Bullock 1986). Thedegrees of thoracic kyphosis, lumbarlordosis and pelvic tilt weredetermined from measures ofspinaland pelvic inclinations, using aninclinometer. Significant increases incurvature were found in the thoracicand lumbar regions during successiveassessment intervals. However,nosignificant relationship between theincidence ofhack pain and posture inthe thoracic, lumbar and pelvic areasduring pregnancy was revealed~

The study supported thephysiotherapy practice ofstrengthening those muscles concerned..

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From Page 9with flattening the lumbar spine andtilting the pelvis posteriorly. Thefinding that kyphosis increased assignificantly as lordosis emphasised theimportance of looking at a woman'stotal posture during assessment ratherthan focusing on the lumbar spine.Bullock-Saxton's (1991a) subsequentstudy demonstrated that the changedposture assumed at the end ofpregnancy was maintained for up tothree months after pregnancy. Thisimplies·that, with repeatedpregnancies, spinal curvatures couldchange markedly. Theinterrelationships between musclelengths and posture demonstrated byToppenberg and Bullock (1986)suggest the need to monitor musclelengths after pregnancy. This is an areaworthy of further study.

The i.nfluence of injuryon muscle functionThe possible influence <?f injury onmuscle function has considerableimplications for patients andphysiotherapists. A deficit in any aspectofsensory or muscle function coulditself be a cause for injury or re-injury.Deficits in muscle endurance,strengthor muscle activation associated withinjury need to be identified to ensureappropriate prophylaxis andrehabilitation... EnduranceTo determine whether local muscleinjury leads to endurance loss,Somerville (1982) compared the levelsof endurance in previously injured butnow pain free hamstring muscles of 20subjects and the non injuredhamstrings of their opposite limb.Side-to-sidedifferences werecompared with those measured inmatched, uninjured subjects.Endurance of hamstrings wasmeasured using the percentage declinein torque over 50 repetitions·ofkneeflexion at a speed of 180 degrees persecond on theCybex dynamometer. Asignificant difference between affectedand non affected sides was found forpreviously injured subjects, but nat forcontrol subjects, suggesting that localmuscle injury is associated ·with a

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decrease in local endurance. Theresults support the inclusion ofendurance exercises in musclerehabilitation after injury.• StrengthAny loss ofstrength associated withinjury has a potential influence onfuture performance and a lmowledgeofthe pattern of strength deficit isimportant in prevention andrehabilitation. To contribute to thisknowledge,$.e effect of a severeunilateralligamentous.ankle injury onthe strength of hip flexors andextensors·and knee flexors andextensors was studied by comparingstrength between two groups ofpreviously injured subjects (categorisedaccording to side of injury) andmatched uninjured control subjects(Bullock-Saxton and Bullock 1993).Isometric muscle strength wasdetermined at outer, middle and innerranges,using positions for antigravitymuscle testing advocated by Kendalland McCreary (1983).

The study showed that a severeunilateral ankle sprain can beassociated with a significant decrease instrength of muscles acting on the hipand knee joints. Compared with thecontrol group, both experimentalgroups exhibited less muscle strengthon both the injured and the uninjuredsides, those with a left ankle sprainshowing a greater degree of wealmess.The study also revealed that the pointin range and the side of injury weresignificant factors influencingweakness..Results highlighted .the needfor rehabilitation following anklesprain, to monitor and to rehabilitatehip and knee muscle strength in allparts ofrange.• MuscleactivationJanda (1983) claims that determinationof the order ofrecruitment oractivation of muscles performing asimple movement helps inunderstanding methods used bypatients to move and that this helps toreveal the area of disability. To gainlmowledge of the influence of injury onfunction of muscles remote from theinjury site, the pattern of recruitmentof muscles at hip and pelvis during hip

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extension· was studied using subjectswho had a previous severe unilateralankle sprain. Electromyography(EMG) monitored muscle activation ineach lumharerector spinae,and thegluteus maximus and hamstringmuscles of both limbs, while subjectsperformed a controlled hip extensionmovement from prone lying (Bullock,...Saxton, Janda and Bullock 1994).

Using a process for quantitativeEMGanalysis developed bySaxton (1993), temporal measures ofthe time span between onset ofactivation of each muscle and thecommencement of hip movement, andthe time span between onset of the firstand last muscles to enter the hipextension activity were calculated.Comparison of results showed that forthe previously injured group, the onsettime ofgluteus maximus wassignificantly delayed relative to hipmovement and the time for gluteusmaximus to reach maximum activationwas also delayed, especially on the leftside. A similar delay, though lessmarked, was found for the hamstringmuscles.

These results highlight the possibilitythat changes in patterns of muscleactivation after injury reflect a lack ofcontribution of individual muscles toinitiation ofmovement and to groupactivity in a movement pattern. Theyalso point to the need for researchwhich would provide guidance inappropriate methods of restoring thisaspect of muscle function. Thisresearch is currently underway.

It is possible that a decrease inproprioception associated with injuryinfluences the changes in muscleactivation through a decrease infacilitation of muscles. Such a deficit inproprioception associated with injuryhas been found by Bullock-Saxton(1992). Further, the existence oflocalsensory deficit following ankle injury,and its inter-relationship with remotemuscle activation changes associatedwith injury, has been demonstrated(Bullock-Saxton 1991band 1993). Thequestion ofwhether subtle sensorydeficits and delayed muscle activationexist prior to injury or are a result ofinjury is currently being investigated.

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Rehabilitation and therapeuticcare: optimisation of musclefunction - sensory motorinfluencesResearch which evaluates theeffectiveness ofdifferent approaches toimproving muscle function will help inthe goal ofoptimising humanperformance, as reference to Figure 1suggests. Several examples illustratethe research which is exploring thistopic.

The quadriceps muscleis frequentlyinjured and guidance for its effectiverehabilitation is essential. To betterunderstand quadriceps function, EMGactivity.of the vastus·lateralis, vastusmedialis and rectus femoris and lateralhamstrings during high speed kneeextension and flexion was monitored(Richardson and Bullock 1986). Inprone lying, the subjects extended theknee from ·45 degrees flexion to 0degrees against a light spring resistanceand then returned to knee flexion.Three different speeds were appliedand the study found that as speed ofmovement increased, highly significantincreases occurred in activity of rectusfemoris and hamstrings compared tothe vasti4

These results suggest that highvelocity, low load activity, particularlyin the prone position, is inappropriatefor improving quadriceps power,because muscle imbalances could occurdue to specific facilitation of rectusfemoris and hamstrings, with apparentinhibition of the vasti. Importantly, thestudy revealed that individual musclesof the knee respond differently whensubjected to high speed alternatingexercise movements in the proneposition. In proposing a new approachto exercise, Richardson (1986) outlinedclearly the need for a balancedprogramme which exercised both themobilisers and the stabilisers toprevent the development of muscleimbalances and offered advice for theprevention of clinical conditionsassociated with sports medicine,suchas patello femoral pain syndrome, shinsplints and back pain.

The interrelationship of variousaspects ofmuscle function are

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important clinically and need to beclarified. In this respect, clinicalobservation suggested that theinfluence of iliopsoas length on gluteusmaximus function had implications forposture and certain musculoskeletalconditions. To.investigate theselength-activation inter-relationships,subjects with at least one tight iliopsoaswere matched to a control groupwithout tight iliopsoas and EMGwasused to examine the magnitude ofgluteus maximus activity and thesequence of onset of gluteus maximusmuscle activation relative to thesynergists during hip extension. EMGalso monitored whether normalisationof iliopsoas length by stretchingtechniques caused an alteration in themotor patterns of erector spinae, upperand lower fibres ofgluteusrnaximusand hamstrings (Souvlis 1985).

Results revealed that subjects with atight iliopsoas exhibited less gluteusmaximus activity before musclestretching than .after, particularly theupper fihresof gluteus maximus. Theactivity of the gluteusmaximus of theexperimental group closely resembledthat of the control population afterstretching, demonstrating theeffectiveness of stretching shortenedmuscles when aiming to restore musclebalance around a joint.In view of the established inter­

relationship between sensory andf!1uscle function (Bullock-Saxton1991b and 1993), it seemedappropriate to investigate whether anincreased sensory input, in the form ofproprioceptive facilitation, wouldeffect an earlier activation of glutealmuscles. Using previously injuredsubjects and a matched control group,EMG signals of gluteus maximusactivation were recorded initiallyduring hip extension from prone lying.Stimuli were then applied throughsmall amplitude f1exion~extensionmovements at the inner range of hipextension, while applying deeppressure to the gluteus maximusinsertion. This stimulation wasalternated with sweep tapping ofgluteus maximus, and then thesubject's maximal contraction ofgluteus maximuswhile holding the leg

in inner range hip extension. Sweeptapping is a brisk form of manualfacilitatory stretch to underlyingmuscle and, after three suchfacilitations,EMG recordings weretaken during each ofthree active hipextension movements. Results showedthat following facilitation, gluteusmaximus onset was significantly earlierfor subjects with previous left sidedinjury compared with the controlgroup (Bullock-Saxton 1992). Furtherstudies are needed to determine thelong term effect of local facilitation inaltering the reflex inhibition of thegluteus maximus.

Considered to be potentially moreeffective in restoring muscle functionin the long term was the generalstimulation of the whole afferentsystem with the aim of improvingsensory and motor integration. Thispossibility was investigated by using asensory motor programme designed byJanda and Vavrova (1990) to enhanceInotor performance. For adults with nohistory of backache, musculoskeletalinjury or postural.defects, faciHtationwas offered for one week throughregular use of"balance shoes" duringwalking. EMG recordings of walkingbarefoot and with balance shoes beforeand after facilitation provided data forevaluation (Bullock-Saxton, Janda andBullock 1993). Results demonstratedthat this form of general facilitationincreased activity of the gluteusmaximus at.a statistically significantlevel. The increase in muscle activityby 209 per cent effected by use ofbalance shoes at the first trialdemonstrated the immediacy ofthebody's response to sensory stimulation.Further, the continued use of thebalance shoes so facilitated the gluteusmaximus that, after one week offacilitation, the muscle was moreeffectively activated with barefootwalking, rendering the difference inactivation between barefoot walkingand balance shoe walking nonsignificant. Extension of this researchto subjects with clinical deficits is nowin progress.

The continued study ofmusclefunction and of factors influencing

From Page 11muscle balance is considered to be oneof the most important areas forphysiotherapy research, as theconsequences of muscle imbalanceinclude many of the signs andsymptoms addressed byphysiotherapists in their managementofpatients with musculo-skeletaldisorders. It is hoped that throughfurther research in these areas, advicecan be given which will enhancephysiotherapy treatment and optimisehuman performance.

Thero>peutic >modolitiesAttention to muscle imbalance is notthe only area for emphasis by thephysiotherapist in restoring muscleactivity and motor performance.Various therapeutic approaches areimportant for relief of pain or theencouragement of muscle contraction.Reviewing the development inknowledge of the effect of ultrasoundon healing, the need for controlledclinical trials in physiotherapeuticpractice was highlighted (FyfeandBullock 1985). The problemconfronting workers with therapeuticultrasound of ensuring the reliablecalibration ofoutput, either for clinicaluse or for research purposes, wasrevealed through Fyfe's (1985)extensive studies on the effect ofultrasound on induced inflammation.Factors capable of affecting treatmentof patients with ultrasound wereidentified and the importance ofapplying the pressure of informedopinion for better testing facilitiesemphasised (Fyfe and Bullock 1986).

The influence of developmentalsensory motor deficitson human performanceInterference with movement is notonly acquired through externalinfluences. It can also exist as a resultof disturbances in the normaldevelopmental process. Normaldevelopment of movement involves thematuration ofsensory and motorprocesses and sensory motor deficitscan be a limiting factor to function.

During the early 1970s, considerable

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attention was focused on problemspresented by children diagnosed ashaving Minimal Cerebral Dysfunction(MCD), a term used at the time torefer to children functioning within thenormal intellectual range, butexhibiting mild clinical neurologicalsymptoms (Bullock and Watter 1978).The term minimal cerebraldysfunction has been replaced now byMotor Coordination Difficulties(MCD).

Recognition of the need for researchrelating to physiotherapy managementof these children led to the author'sestablishment of a research clinicdevoted to exploring some of thechanges inhuman performanceassociated with developmentallimitations in sensory motor capacities,and determining the effectiveness ofphysiotherapy approaches inovercoming those developmentaldeficits. It has been gratifying to seethe advances inlmowledge which haveemanated from this facility.

Sensory motor deficitsin childrenTo gain a better understanding of riskfactors in family and medical historywhich might contribute to sensorymotor deficits in children with MCD,a questionnaire study of 1,020 MeDchildren was carried out. Comparisonwith general population data showed aset of interesting differences (Bullockarid Watter 1987). These included thedevelopmental outcome of twins, theearly background of adopted children,the influence ofcertain prenatal andperinatal factors on development, andthe effects of middle ear infections. Inaddition, the reported frequency ofchildren with MCD in remedialeducation classes suggested the need tolook closely at those referred toGuidance Officers for educational orbehavioural problems, to identify anyneurological deficits which might beassociated with other difficulties.

Initial observations revealed theabsence or decrease in post-rotatorynystagmus in some children withMCD. As nystagmus is commonlyassessed in children with neurologicalproblems, its validity in testing MCD

AUSTRAliAN PHYSIOTHERAPY

children was evaluated. Using arotating chair to provide accelerationand deceleration stimuli, post-rotatorynystagmus was compared betweenMCD hyperactive children withassociated spatial awareness problemsand a matched group of normallyactive children, usingelectronystagmography (ENG)(Harrison and Bullock 1978). Resultsshowed that MCD hyperactivechildren had a reduced duration ofpost-rotatory nystagmus when not ableto visually fixate. Nevertheless, resultsfrom the control group demonstratedthat a test of nystagmus duration alonewas insufficient to discriminatebetween a hyperactive and a normallyactive child. The results also stressedthe importance ofconsideringindividual responses in conjunctionwith other neurological symptoms.eOculo-motordef1citsand

reading skillThe likelihood that children withMCDcould have reading difficultiesassociated with ocular motor ability ledto two supervised studies in this area"Children with MCDoftenshow aninability to move the eyes·smoothlyand regularly in following a movingobject. To· study this, comparisons ofthe smoothness of eye-follow weremade between Mcn children and amatched control group of normalchildren. ENG recorded eyemovements while the child followed alight moving at a controlled speed.Analyses revealed that the MCDchildren had a significantly higher levelof abnormalityin·eye-follow thannormal children (Ovens 1977).

To study the possible contribution ofoculo-motor problems to readingdifficulties in MCD children, Hewitt(1979) compared children of normalintelligence and receiving remedialreading teaching with a matchedcontrol group (not receiving remedialeducation). Neurological testingidentified two sub-groups of childrenwith reading problems:· those withassociated MCD (42 per cent) andthose without MCD (58 per cent).Relevant features of eye movementssuch as right-to-left-scan-back, eye­follow quality and stereoscopic vision

AUSTRAliAN PHYSIOTHERAPY

were examined during the process ofreading, using ENG. Results revealedthat MCD children had poorer qualityeye movements (in number anddirection) than the normal controlgroup and that the MCD groupshowed the greatest variance in scores.MCDchiIdren with reading problemswere shown to have a lower quality ofeye-follow than children with readingdifficulties but no neurologicalimpairment. The latter group wasfound to have significantly worse eye­follow than the normal control group.Consistent with Bullock and Watter's(1978) findings, not all children withMCD showed oculo-motor problems.Nevertheless, the likely interferencewith educational progress makes this afield for closer study.• Hand function and writing skillThe ability to write clearly and withease is fundamental to good progress atschool and a clearer knowledge offeatures associated with developmentofpoor writing skills could help intheir prevention or early resolution.To establish whether hand functiondiffered between MCDand normalchildren, sensory awareness and thequality of fine motor skill performancein .children with MCD and a matchedcontrol group were examined (Kelly1983). This study showed that MCDchildren displayed poorer perceptionof tactile and proprioceptivestimulation in the hands, a slower rateof fine motor skill performance and agreater incidence of excessive effort,associated movement and posturalinstability than their normalcounterparts.

A later study explored relationshipsbetween sensory motor deficits inMCD children and their writingproblems (\Vatter and Bullock 1989a).A comparison of deficits in 372MCDchildren referred because of writingproblems with a control group ofMCD children without writingproblems identified the specific natureof their sensory motor problems. Forexample, 70 per cent ofthe childrenhad deficits relating to proprioceptionin the armand 77 per cent toproprioception in the hand, whiledeficits in tactile function in the hand

oRIGI N A l A.R TIC 1E

(35 per cent) were greater than in thebody{18 per cent). The occurrence ofhand-related deficits in the writingproblem MCD group was greater thanin the control MCDgroup. Anincreased incidence offactors such aspostural instability, excessive effort andassociated movements found in theMCDchildren could have deleteriouseffects upon their quality affine motorperformance and further study of thisimportant area of skill performance inMCD children is warranted.

Senso~ motor developmentin intellectually handicappedchildrenTo explore the sensory motorcapacities of intellectually handicappedchildren, a study was undertaken todetermine whether the sensory motorcapacities of mentally retarded childrenwere more closely related tochronological or mental age andwhether there were any commondeficiencies in the sensory motorcapacities of children with retardedintellectual development. Childrenwith a chronological age of 10 yearsand a mental age of five years werecompared with two groups of childrenwith normal intelligence, one groupaged 1oyears and the other group agedfive years (Chenoweth and Bullock1978). Results of a comprehensiveneuro-developmental assessmentsuggested that the sensory motorcapacities of an intellectuallyhandicapped child were correlatedmore to mental than to physicaldevelopment. Theirbasic problemsincluded tonal abnormalities and poorawareness of body positioning, asmanifested in poor balance (dynamicand static) and in poor coordination(gross and fine). A high incidence ofpoor·vestibular functioningcompounded their balance problems.Results suggested that physiotherapymanagement needed to focus onproviding sensory input to encouragecorrect precise motor responses. Somesuggestions for physiotherapymanagement .arising from this studyhave been offered (Chenoweth et al1978).

Sensory and motordevelopment of preterminfantsRecognising the need for detailedknowledge about preterm infants,Burns (1978) studied the neurological,sensory, motor and .generaldevelopmental progress of135 infantsborn more than five weeks beforeterm. Over a period of 12 months, 122infants had progressive post termevaluations, using a standardised infantability scale and a graded neuro­sensory and motor assessment.Although the abilities of the ageadjustedpreterm infants comparedfavourably with the standardised scaleof expected age normal abilities, therewas some persistence in primitivemotor reflexes and an apparent delay indevelopment of postural·reactions. Sixper cent ofthe group had definiteneurological handicaps (Burns andBullock 1980). Of this initial group, 82per cent were assessed regularlythrough their pre-school years (Burns1984). Results indicated that a normalsequence of development was followedby the majority of children. Althoughthe incidence of cerebral palsy, speechdifficulties and minor motor co­ordination difficulties was higher thanaverage, all but two children wereready to enter school with their peers(Burns etaI1984). At the adjusted ageof five years, the development of 106of the children was compared with thedevelopment of 103 children born atterm and matched for gender, year ofbirth, birthplace, race and residentiallocation (Burns and Bullock 1985).Factors distinguishing the pretermchildren from their full term peersincluded small involuntary handmovements, Jess competent grossmotor ability, poorer verbalperformance and more variability inbehaviour, postural response.andbalance. Thesestudieserrtphasised theneed for regular comprehensivedevelopmental assessment of preterminfants for identification of related agerelated problems.To examine whether a physiotherapy

programme based on sensorystimulation designed specifically toencourage active contraction of

40th JUBILEE ISSUE, 1994 ~ 13

From Page 13developing muscle would be ofvalue· tothe preterm born infant,Cole (1988)srodied 95 verypreterm, very low birthweight infants who showed noevidence of abnormal development.After selection of a suitable sensorymotor stimulation programme and ofreliahle·and valid measures of motorperformance, a longitudinal study ofmotor development while offeringthree different approaches tointervention, was initiated. Resultsdemonstrated that motor performanceinpreterrn born infants withoutdisabilities likely to restrict movementcan be enhanced by 12 months ofadjusted age, with .a physiotherapyprogramme which stimulatesappropriate muscle activity.Improvement appeared robe related tothe duration of offering the stimulationand results suggested that motordevelopment in this group of infantscould be enhanced by a domiciliaryprogramme of physiotherapy followingdischarge from hospital.

Preventive and therapeuticcare: optimisation of sensorymotor function4) Effectiveness of physiotherapy

interventionOf fundamental importance torphysiotherapists is a lmowledge ofwhether the sensory integrativeapproach to management ofMeD iseffective in resolving identifieddevelopmental deficits. A study todetermine this was conducted, inwhich children in experimental andcontrol groups were assessed using aneuro-developmental assessmentoutlined for MCDchildren byWatterand Bullock (1975). A rating scale wasdevised to record degrees ofabnormality (BullockandWatter1977). Forthe experimental group,ahome treatment programme focusedon· the child's most basic level ofproblem and, with improvement, wasmodified to involve higher levels offunctioning. Children were reassessedafter three and six months.

The experimental group showed adecrease of 86 per cent (school age)and 75 per cent (pre-school age) in

14 40th JUBILEE ISSUE, 1994

ORIG IN A1 ARTICLE

total abnormalities exhibited after sixmonths of treatment. These resultssuggested that, after an additionalperiod, return to normality wouldoccur for the majority of children. Onthe other hand, the untreated groupsof children ofsimilar age showed anincrease of 7 per cent and 14 percentrespectively. The. significantdifferences revealed on analysisdemonstrated the effectiveness ofphysiotherapy in resolving sensorymotor deficits (Bullock and Watter1978).• Long term effectivenessA separate study was undertaken toascertain whether any changes infunction effected during six months oftreatment were maintained for afurther six months (vVatter andBullock 1987a). Two matched groupsof children with MCDwere assessedneurologically. One group receivedphysiotherapy managementappropriate to individual needs for sixmonths, but the other did not. Allchildren were reassessed after sixmonths, after which no furthertreatment was offered to theexperimental group, and again after atotal of 12 months.

Initially, the .experimental groupexhibited an abnormality rating of 42per cent and the control group 39 percent. After six months, experimentalgroup abnormalities had decreased to 6per cent (\Vatter and Bullock 1987b),confirming the results of Bullock andWatter's (1978) previous study ofintervention effectiveness. This lowlevel of abnormality remained constantfor six months of non-intervention. Incontrast, after six months, the meanpercentage of abnormalities in thecontrol group rose to 42 per cent, afigure which did not improve after afurther six months. This studyprovided substantial evidence thatsufficient improvement in neurologicalfunctioning could be gained from sixmonths ofphysiotherapy treatment,for children to retain that level ofsensory motor functioning post­treatment.• School based programmes

A further study showed that forchildren with only minor degrees of

AUSTRAliAN PHYSIOTHERAPY

difficulty in motor co-ordination, butfor whom this results in functionalproblems, a physiotherapy directedschool based group programme offeredunder guidance by remedial educationteachers can be an effective means ofresolving problems (\Vatter andBullock ·1989b).• Effectiveness of physiotherapy

for adults with MCDClinical evidence·suggested that someadults could benefit from neurologicalassessment and a sensory integratedapproach to treatment. To investigatethis, a group of 34 adults with longstanding presenting signs ofMCDwere assessed (\Vatter and Bullock1989c). Problems were found inwriting or hand function (61.8 percent), reading (41.2 per cent), spellingand memory (29.4 per cent) and grossmotor coordination (29.4 per cent).Deficits in writing skills, such asillegibility, slowness of writing anddiscomfort or rapid fatigue duringwriting tasks occurred most frequently.Treatment reflected sensory motordeficits and used activities suitable forlifestyle and age, and at monthlyreview, programmes were updated.

After only two months, the problemsof 50 per cent of the subjects had beenresolved and, after five months, 91 percent required no further treatment. Itis interesting to note that the areas ofsensory motor deficits found in adultswere essentialskiUsand, where notresolved in childhood, could contributesignificantly to learning difficulties anda sense of frustration and loss of selfesteem in adults. This study identifieda need for closer investigation of adultswith problems associated with MCDand highlighted the importance ofdeveloping more refined assessmentand treatment strategies appropriate toage.e Effectiveness of physiotherapy

on associated behaviourproblems

Noting that many children with MeDseemed to have associated behaviourproblems, the effect of neuro-sensorymotor therapy on presenting behaviourproblems in MCD children wasevaluated in a supervised·srody(McMahon 1980). Children with

AUSTRAliAN PHYSIOTHERAPY

MeD and associated behaviourproblems were randomly allocated toexperimental or control groups. AQuay Paterson Behaviour Checklistevaluated behaviour problems and aPiers Harris Self Concept test wasadministered before and afterintervention. Treatment for theexperimental group was individualisedaccording to presenting problems,while children in the control groupreceived a modified relaxationprogramme. All children were re...assessed after three months. Resultssupported the notion that there is aprimary relationship between theneuro-sensorydysfunction ofMenchildren and the co-existent conductdisorders reported, and that aprogramme which improves theirneuro-sensorymotor functioning has adirect effect on their presentingbehaviour problems. VVhile furtherresearch is needed in this area, theevidence ofcarry over of improvedneuro-sensory motor function toassociated life problems throughappropriate physiotherapy interventionis encouraging.• Effectiveness of physiotherapy

on associated specific learningdisabilities

In Bullock and Watter's (1978) studyofMCD children, 58 per cent ofschool agedMCDchildrenwere foundto be experiencing learning difficultiesand it was hypothesised that use ofdevelopmental physiotherapy forchildren with both MCD and learningproblems would improve both areas(Watter 1983). A controlled study wasconducted to test this. Of 204 childrenattending remedial education classes,62 exhibiting signs ofMCDwererandomly assigned to one of twomatched groups (land 2). All childrenin Group 1 received six months ofphysiotherapy, while Group 2 receivedno physiotherapy. Neurologicalassessment revealed no significantdifferences in initial scores between thetwo MCD groups. A·second controlgroup of children who did not haveMCD was created by random selectionfrom suitably aged children in remedialeducation classes. Children with MCDwere reassessed after six and 12 months

ORIGIN A1 ARTI CLE

and, in addition, MCDGroup 1 wasassessed after three months oftreatment.

The educational progress ofallchildren was evaluated usingstandardised tests (eg the Milton wordrecognition test) and a variety ofroutine classroom teacher assessments.A scored level of performance forbefore and .after the period ofphysiotherapy intervention inmathematics and English was availableto chart the child's progress, as well assome information for social studies andscience. Eight children in each of thethree groups were assessed by a SchoolGuidance Officer who appliedstandardised tests"VVhile the widevariability in changes occurring overtime suggested the influence ofcomplicating factors other than MeD,results provided some evidence thatphysiotherapy managementprogrammes for children with MeDand associated learning difficulties docontribute to an improvement ineducational progress (Watter andBullock 1983).

The broad implications of deficits indevelopment ofsensory motorfunction for human performancehighlight the need for continuedresearch in this area. The studiescarried out to date provide strongsupport for physiotherapy interventionat an early age to prevent thedeyelopment of sensory motor deficits,and demonstrate that appropriatemanagement can be offered even inadulthood to ameliorate deficits and tooptimise .human function.

ConclusionsImportant to physiotherapy practice isan understanding of the inter­relationships between the manyfeatures influencing human functionalcapacity. The research reported in thispaper has explored some of thesefeatures and has demonstrated theimportance of considering bothprevention and therapeutic care inefforts to optimise performance.Collation of normal data for musclelength measures, joint and bodymotion and anthropometricdimensions for body size, reach

distances and force application hasprovided information useful for clinicaldecisionrnakingandergonomicdesign. Studies of the effect of injuryon aspects of muscle function andmovement capacity have not onlyrevealed the inter-relationshipsbetween sensory and motor function,but have also provided preliminaryevidence of the value ofa sensorymotor approach to physiotherapyintervention. The importance ofexploring the nature and effect ofsensory motor development and thevalue of offering specific physiotherapyintervention programmes has beenhighlighted in studies of preterminfants, and ofchildren and adults withdevelopmental sensory motor deficits.

Optimisation of human performanceis one of the primary aims of thephysiotherapist and much remains tobe learned. The research reported heredemonstrates some of the progresstowards achieving this goal.

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