Some Aspects of the Anatomy of Movement by L. H . W E L L S P ro fe sso r o f A n a to m y , U n iv e rsity o f C a p e T ow n (S u m m a ry o f lecture g iven in course o f Therapeutic M o v em e n t c onducted in the D ep a rtm e n t o f P hysiotherapy, University o f C ape Town, 6-7 O ctober 1961). O n e is te m p te d to th in k o f th e a n a to m y o f m o v em e n t u n d e r th e b ro a d div isio n s o f s tru c tu re s w hich a re m o v ed a n d th o se w hich m o v e th e m : i.e. b ones a n d jo in ts o ver a g a in st th e m uscles a n d th e n e rv o u s system . H o w ev e r, th e c h a ra c te r o f m o v em e n t d e p en d s as m u ch o n th e a rra n g e m e n t o f th e p a rts w hich a re to b e m oved as o n th e m a c h in e ry availab le fo r m o ving them . T h e lo c o m o to r system o f th e b o d y is very o ften d e scribed as a system o f b o n e s u n ite d by jo in ts w hich a re m oved by m uscles u n d e r th e c o n tro l o f th e v o lu n ta ry n e rv o u s system . T o suggest a m e n d in g th is d e sc rip tio n a n d ra th e r saying th a t th e b ody is a system o f jo in ts m a in ta in e d a t th e a p p ro p ria te distan ces a p a r t by bo n es m ay help us to re m e m b e r th a t jo in ts a re n o t m erely negative in tervals betw een th e en d s o f b o n e s; th e a rtic u la tin g e n d s o f th e bo n es a n d th e stru c tu re s co n n ec tin g th e m c o n s titu te fu n c tio n a l units. M an and the Quadrupeds T h e jo in t p a tte rn o f th e h u m a n b ody is c o n d itio n e d very largely by th e fa c t th a t M a n is an erect b ip ed , u sin g his low er lim bs to s u p p o rt a n d p ro p e l th e b o d y a n d h is u p p e r lim bs to e x p lo re a n d m a n ip u la te th e w o rld a ro u n d him . T h is u n iq u e s tru c tu ra l o rg a n is a tio n , h ow ever, m ak e s use o f e lem ents o f basic s tru c tu re sh a re d also by q u a d ru p e d s. T h e q u a d ru p e d a l b o d y stru c tu re h as been a p tly p ictu red as a “ w a lking b rid g e ” , th e m ain p o rtio n o f th e v e rte b ral c o lu m n fo rm in g an a rc h betw een tw o p a irs o f su p p o rtin g piers, w ith m ovable ex te n sio n s a t th e h e ad a n d ta il e n d s. E a c h lim b is d ivid e d in to three m o v a b le se g m e n ts a lte rn a te ly inclined fo rw a rd s a n d b a c k w a rd s; in th e fore-lim b sc a p u la , h u m eru s, a n d fo re a rm w ith h a n d , a n d in th e h in d -lim b fe m u r, tib ia , a n d foot, th e pelvic girdle, u n lik e th e p e cto ral, being firm ly in c o rp o ra te d w ith th e v e rte b ra l arch (M a rtin , 1933-34). In each lim b th e first jo in t is a b a ll-an d -so ck e t jo in t, allow ing sidew ays as well a s fo rw a rd a n d b a c k w a rd m o v e m e n t; th e jo in ts b e yond th is a re e ssentially hinge jo in ts p e rm ittin g fo rw a rd a n d b a c k w a rd m o v em e n t only. The Adaptation o f M an T h e a d a p ta tio n o f th e h u m a n b o d y to its u p rig h t p o stu re h as involved a long series o f a d ju s tm e n ts in th e sk e leto n a n d jo in ts : th e c o u n te r-c u rv e s o f th e ve rte b ral c o lu m n , th e very w ide ra n g e o f m o b ility o f th e sh o u ld e r g irdle p iv o tin g on th e ste rn o clav ic u la r jo in t, th e p o stu ra l e x tension o f th e elbow , h ip and knee jo in ts , and th e u n iq u e c o n stru c tio n o f th e fo o t as a n a rc h re stin g o n th e heel a n d th e m e ta ta rs a l heads. T h e h u m a n lim bs re ta in th e prim itiv e a rra n g e m e n t, d isc ard e d by th e m ore highly specialised q u a d ru p e d s, fo r ro ta to r y m ove­ m en ts in th e ir d ista l p a rts : p ro n a tio n a n d s u p in a tio n in th e fo rea rm , in v ersio n a n d eversion in th e fo o t. A gain, from the p urely m ec h an ic al s ta n d p o in t, th e h u m a n fo o t c a n be re g ard e d as a u n it eq u iv a len t to th e fo re a rm a n d h a n d to g eth e r, th e heel b e ing c o m p a re d w ith th e o le c ra n o n , a n d th e jo in ts betw een ta lu s a n d calca n e u m w ith th o se betw een r a d iu s a n d u ln a (G ra n d , 1958). T h e axial p a rt o f th e h u m a n b o d y c a n be th o u g h t o f as co m p o sed o f th re e m a jo r blocks, h e ad , th o ra x a n d pelvis, u n ite d by tw o co n n ec tin g links, th e cervical a n d lu m b a r re g io n s o f th e v e rte b ra l c o lu m n . T hese lin k in g segm ents are e ac h co m p o sed o f several a rtic u la tin g u n its , so t h a t sm all ind iv id u a l m o v em en ts a d d u p to a c o n sid e ra b le to ta l. T h is a rra n g e m e n t, re la te d to th e fu n c tio n o f th e v e rte b ral c o lu m n Page 6 P H Y S I O as a p ro te c tiv e case fo r th e sp in a l c o rd , is achieved through a d istin c tiv e ty p e o f jo in t stru c tu re , th e in te rv erte b ral disc w ith its to u g h b u t plia b le p e rip h e ry a n d highly plas tic c e n tra l core. S om e jo in ts m ay be c o n sid ere d in trinsically stable from th e c h a ra c te r o f th e a rtic u la tin g surfaces a n d jo in t structures o th e rs as in trin sic a lly u n s ta b le a n d held to g e th e r only by m u sc u la r a c tiv ity ; th e sac ro -ilia c j o in t m ay be tak e n as an e x tre m e exam p le o f th e fo rm e r a n d th e sh o u ld e r jo in t o f the latte r. T h e s tru c tu ra l in stab ility o f th e h u m a n shoulder jo int h a s been a c c e n tu a te d by its in creased ra n g e o f mobility fo llow ing its lib e ra tio n fro m th e fu n c tio n o f supporting w eight. T h e sta b ilisin g a c tio n o f m uscles in re la tio n to joints is th u s o f e q u al im p o rta n c e w ith th e ir fu n c tio n o f producing a ctive m o v em e n t. The Functional Division o f M uscles and their Nerve Supply T h e fu n c tio n a l division o f th e m uscles as well as their n erve su p p ly rests u p o n th e basis o f an o rig in a l longitudinal se g m e n ta tio n o f th e body. E ach segm ent c o m p rise s primarily a p o s te rio r m uscle m ass b e hind th e sp in a l c o rd , a n d an a n te rio r m ass exte n d in g from th e f ro n t o f .the vertebral c o lu m n a ro u n d th e flank to th e v e n tra l b o d y w a ll; these are su p p lied respectively by th e a n te rio r a n d p o ste rio r primary div isio n s o f th e segm ental nerves. I n c e rta in segm ents the! a n te rio r m uscle m ass is fu rth e r called o n to p ro d u c e the lim b m uscles, w hich are a t first divided in to a d o rsa l ex­ te n s o r a n d a v e n tra l flexor m ass, su p p lied by th e anterior a n d p o s te rio r divisions o f th e n erve plexuses. T h e segm ental p a tte rn has been g reatly o bscured, n o t o nly by fragm en­ ta tio n o f th e segm ental units a n d fu sio n o f a d ja c e n t segments, b u t a lso b y th e tw isting o f th e lim bs in o p p o site directions, so t h a t th e o rig in a l u p p e r surface faces b a ck w a rd s in the u p p e r lim b a n d m ainly fo rw a rd s in th e low er lim b, a n d still f u rth e r by th e en o rm o u s ex p an sio n of th e m uscles linking th e u p p e r lim b to th e tru n k , w hich have com pletely en­ v e loped th e tr u e b a ck m uscles as well as th o se o f th e upper p a r t o f th e th o rax . “ Spurt” and “ Shunt” Muscles T h e m a n y different a rra n g e m e n ts o f th e fibres in indi­ v id u al m uscles can be reduced to tw o basic p a tte rn s . One h as th e fibres directed lo n g itudinally, so th a t th e full extent o f th e ir c o n tra c tio n can be registered as m ov em e n t; the o th e r h a s them directed obliquely, so th a t p a r t o f their c o n tra c tile length is lost, b u t th e ir n u m b e r is increased p ro v id in g a d d itio n a l pow er. A n o th e r n o te w o rth y distinction (M a c C o n a ill, 1949) is betw een th o se m uscles w hich pull acro ss th e angle o f a jo in t (“ s p u r t” m uscles) a n d those w hich alw ays rem ain parallel to th e m oving b o n e (“ s h u n t” m uscles); th e p ro p o sitio n th a t th e fo rm er a re essential in itia to rs o f m ovem ent, while th e la tte r act as synergists o n c e m o v em e n t has been in itiate d , seems to be su p p o rte d ^ b y ele ctro m y o g rap h ic evidence (B asm ajian, 1959). \ The M otor System V o lu n tary , willed m ovem ent d e pends o n th e in tegrity o f th e p y ra m id a l trac t from th e “ m o to r” a rea o f th e c erebral c o rte x to its contacts with th e m o to r nerve cells o f the b ra in s te m a n d spinal cord. T h e p y ram idal system , how ever, c a n n o t fu n c tio n in isolation. I t is de p en d e n t b o th on the inflow to th e cerebral cortex o f sensory im pulses, p a rtic u ­ larly th o se arising in the lo co m o to r system itself, as well as th o se o f o rien tatio n a nd b a lance arising in th e la b y rin th o f th e in te rn a l ear, and on the c o lla b o ra tio n o f the series o f d e sc en d in g fibre-connections bracketed to g e th e r as the e x tra -p y ra m id a l m o to r system, o rig in a tin g p a rtly in the c e re b ra l cortex, partly in the basal ganglia, a n d p a rtly in the re tic u la r fo rm atio n o f the brainstem . T h e e x tra-pyram idal m o to r system is as m uch de p en d e n t as th e p y ra m id al system on th e inflow o f sensory in fo rm a ­ tio n , n o t o nly th at reaching th e c erebral c ortex, but even m o re th a t directed to the cerebellum . In p a rtic u la r, th e re is a c lear re la tio n between th e cerebellar co n n ec tio n s o f the se n so ry a n d extra-pyram idal m o to r system s a n d th e a n ti­ g ra v ity p o stu ra l responses o f th e lo c o m o to r system . F u r th e r ­ m o re in th e hum an brain th e cerebral cortex, th e basal g anglia, th e reticular fo rm atio n , a n d th e cerebellum are T H E R A P Y December, 1961 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) December, 1961 P H Y S I O T H E R A P Y Page 7 O RDER OUT OF CHAOS MISS M. R O P E R , M .C .S .P . L ectu rer in P h ysiotherapy, D ep t, o f P hy sio th erap y , U niversity o f C ape T ow n n pcture delivered a t th e P o s t-G ra d u a te C o u rse o n T h e ra p e u tic M o v e m en t, U niversity o f C a p e T o w n , D e p a rtm e n t ' o f P h y sio th e rap y , O c to b e r 1961.) “A n d the E arth was w ithout fo r m a n d void— a nd the S p irit o f G od m oved.” In o th e r w o rd s o rd e r em erged fro m chaos. [ am not going to tell y ou a n y th in g new, a n y th in g yo u do not already know . I am g o ing to a sk y o u , w ith m e, to th in k over som e o f the basic p rin cip les we all le a rn t as stu d e n ts. I hum bly suggest th a t in th e ru sh a n d b u stle o f o u r clinical work we m ay have fo rg o tte n a n d d isc ard e d som e useful and im p o rta n t c o n c e p ts— o r a t least we h a v e n o t developed and used th em w ith all th e th o u g h t a n d skill in o u r pow er. The definitions o f “ m ove” in C h a m b e r’s D ic tio n a ry are many— here are som e o f th em . “ T o im pel, to excite to a ctio n , to persuade, to in stigate, to a ro u se , to live o n e ’s life” . All germ ane to w hat we th in k a b o u t a n d how we a ct in tea ch in g o u r patients to m ove. P e rh a p s th e m o st p e rtin e n t o f all, the last o ne “ to live o n e ’s life” . As P h y sio th e rap ists isn ’t o u r m ost im p o rta n t a im in all ou r trea tm e n ts to re sto re “ o r d e r ” in m ovem ent th a t has become “ c h a o tic ” — c h a o tic d u e to p ain, lim ited range, loss o f m uscle p ow er a n d n e u ro -m u s c u la r c o -o rd in a tio n ? We have h e ard fro m P ro fe ss o r W ells a n d P ro fe sso r Stam m ers so m e th in g o f th e a n a to m ic a l p h y siological b a ck ­ ground o f th e o rd e re d m o v em e n t, a n d fro m P ro fe ss o r A llen a challenging lectu re o n its im p o rta n c e . B u t is n o t this restoration o f o rd e re d m o v em e n t o u r ow n g re atest c o n tri­ bution to re h ab ilita tio n , p ro v id ed it tak e s in to a cc o u n t the “ w hole p e rs o n ” . In the c rea tio n o f th e U niverse, a n d in it th is W o rld , is not m an th e highest c rea te d being a n d is n o t his gift o f free will the m ost p re cio u s gift w ith w hich he h as been end o w ed ? So in o u r h u m b le effo rts to re sto re o rd e r to a d iso rg a n ised chaotic m o to r system , sh o u ld n o t o u r fo rem o st a im (by arousing, exciting to a ctio n , a n d p e rsu a d in g ) be to enlist the p a tie n t’s free will, a n d help him to d irec t it to w a rd s his (Continued fr o m opposite page) linked to g eth e r by a c om plex system o f in te rc o n n e c tio n s, by m eans o f w hich, it is assu m e d , th e c ere b ral c o rte x e stablishes a p redom inance o v e r the o th e r c o m p o n e n ts o f th e brain. C onsequently the resu lts o f a n a to m ic a l a n d physiological studies o n sim pler ty p e o f a n im a l b ra in c a n n o t necessarily be applied to th e m uch m o re com plexly o rg a n ised h u m a n brain. R e f e r e n c e s General: B arnett, C. H ., D avies, D .V ., a n d M a c C o n aill, M . A . (1961. Synovial Joints. Their Stru c tu re a n d M echanics. L o n d o n : L ongm ans, G re e n a n d C o. xi + 304 pp. Chusid, J. G . a n d M c D o n a ld , J. T . (1960). C orrelative N euroanatom y a n d F unctional N eurology. 10th ed. L os A ltos, C a l.: L an g e M edical P u b lic a tio n s, 360 pp. CIrOS C la rk , W . E . (1952). The Tissues o f the B ody. 3rd ed. O x fo rd : C la re n d o n Press, xi + 407 pp. P a rtic u la r: B asm ajian, J. V. (1959). “ S p u rt” a n d “ s h u n t” m uscles: a n e le c ro m y o g ra p h ic c o n firm a tio n . J . A nat. L ond., Vol. 93, pp. 551-3. J- C . B. (1958). A M e th o d o f A n a to m y. 6th ed. B a ltim o re : W illiam s a n d W ilkins, xxv + 879 pp. M acC onaill, M . A . (1949). T h e m o v em en ts o f b ones a nd jo in ts. 2. F u n c tio n o f th e m u sc u la tu re . J . Bone J t. Surg. Vol. 3IB , pp. 100-104. M a rtin , C. P. (1933-34). A c o m p a ris o n o f th e jo in ts o f th e a rm a n d leg a n d th e significance o f th e s tru c tu ra l diff­ erences betw een th em . J . A n a t. L o n d ., Vol. 68, pp. 511-520. re tu rn to n o rm al o rd e re d bodily fu n c tio n — to live his ow n life? T h is brings m e to m y first p o in t: B ring in the pa tie n t— n o t ju st lite rally b u t in every sense o f th e w ord. P sychologically a n d physiologically he will benefit m o st if he c o -o p era te s as fully as possible in his re h a b ilita tio n p ro g ram m e. P sychologically how d a n g e ro u s d ep en d e n ce o n a n o th e r ’s efforts c a n be. H o w re stric tin g to th e w hole c o n ce p t o f re ­ h a b ilita tio n is ju s t th e alle v ia tio n o f p ain o r even, to ta k e an e x tre m e e xam ple, m a in te n a n c e o f m uscle a n d jo in t by e lectrical m ean s a n d passive m o v em en ts o n ly : passive m o v em e n ts p e rfo rm e d by th e p h y sio th e ra p ist w ith o u t m ak in g th e p a tie n t “ t h in k ” th e m o v em e n t as it is d o n e fo r him . T h is th in k in g th e m ovem ent a t o nce b rin g s him in to th e p ictu re, a n d as we all k n o w is p h y siological c o m m o n - sense in th a t it helps to m a in ta in th e m em o ry p a tte rn . T h e idea o f th a t m ov em e n t is k e p t alive by m ak in g th e p a tie n t realise th e afferen ts fro m m uscle te n d o n a n d jo in t as th e p a tte rn is p e rfo rm e d . P sy chologically it is co m m o n sense as he is a u to m a tic a lly p a rtic ip a tin g in th is in itial a ctivity a n d is th e re fo re realising th a t he has to do so m e th in g him self to effect his ow n cure. M e d ia f o r M o v em e n t— W a te r o r d ry land. W ater will be d e alt w ith by M r. N icol. M a n u a l or M echanical— D ry la n d tre a tm e n ts by m o v e ­ m en t will in clude th e use o f m a n u a l a n d m echanical a ssis­ tan c e o r resistance. B oth have a d v a n ta g e s a n d d isa d v an tag e s as y ou very well k now . W e a re all a w a re o f th e d a n g e r o f u sing m ech an ic al aids to m ov em e n t, m ea n in g specifically m ech an ic al a ssista n ce w ith sp rin g s o r w eights. W e k n o w th e d a n g e r o f o v e r-stre tch in g tissues if th e a id c a n n o t be fully c o n tro lle d , o r th e d a n g e r o f rep etitiv e irrita tin g m o v e ­ m en ts usin g su sp en sio n o r b ila tera l pulleys— yet in selected cases th ey can be m o st valu a b le as th ey m ay p ro v id e a m ean s o f e n a b lin g th e p a tie n t to w o rk on his own, i.e. w ith o u t th e o b v io u s assista n ce o f th e p h y sio th e ra p ist, w hen w ith o u t th e sling o r pulley o r sp rin g he c o u ld do little or n o th in g a t all. M a n u a l assistance o r resistance is so m e tim es b e tte r th a n m ech an ic al m eans. It is sensitive a n d a d a p ta b le to the c h a n g in g sta te s o f tension, spasm o r in c o -o rd in a tio n in the n e u ro -m u s c u la r m ec h an ism , a n d c a n th e re fo re m o re read ily be a d a p te d to m eet these c hanges. O n th e o th e r h a n d to o m uch m a n u a l h a n d lin g c an be psychologically u n d e sirab le, leading to dep en d e n ce o f th e p a tie n t o n th e p h y sio th e ra p ist. M e chanical m eans can be a rra n g e d a n d w o rk e d by th e p a tie n t himself,- even a t hom e. T h ey a re tim e-saving fo r th e p h y sio th e ra p ist, w hereas m an u a l tec h n iq u es a re tim e- c o n su m in g . P e rh a p s th e gre atest d a n g e r o f a ll in using m ech an ic al a p p a ra tu s is th a t it c a n becom e to o a u to m a tic a n d lack th e essence o f tru ly “ live m o v e m e n t” . But a g ain , if scientifically a rra n g e d w ith d u e re g a rd to m echanical a n d physio lo g ic a l p rinciples, th e g re a t a d v a n ta g e o f using w eights, fo r exam ple, is th a t p ro g ress c a n be g ra d e d a c c u r­ a tely a n d th e p a tie n t c a n o ften tre a t h im self a t hom e. Group o f Individual— W hich will suit th is p a tie n t b e st? Q u ite likely he will benefit by so m e o f e ac h . W e a re a p t to th in k we c a n n o t give g ro u p tre a tm e n ts if we have no •gym nasium . I so m e tim es th in k a g y m n asiu m is a b a d th in g in a d e p a rtm e n t. It ten d s to be set a p a r t as a se p a ra te en tity ra th e r th a n being th e c e n tra l c o re o f th e w hole set-up. A c tu ally a ro u n d d e p a rtm e n t w ith cubicles a t th e p eriphery a n d c e n tra l space w ith so m e exercise e q u ip m e n t co u ld be a very g o o d p lan ! H o w ev e r, if we a re really g ro u p m inded, g ro u p tre a tm e n ts can be given, even if th e d e p a rtm e n t or clinic will o n ly h old tw o p a tie n ts a n d th e p h y sio th era p ist. O rg a n isa tio n o f like ty p e o f cases a t th e sa m e tim e fo r o th e r R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )