I was driving the arterial into my neighborhood the other day, tooling along at a pretty good clip. Suddenly, I hit a bone jarring pothole. I knew it was there, as I had seen and avoided it before, but this time I hit it dead center. It didn’t feel good, and I didn’t want to feel it again—so what to do?
Should I replace my ‘weak’ shock absorbers with ‘stronger’ ones? Or should I be more attentive and proactive with my driving? The answer is pretty obvious in this scenario, since the sensory information needed to recognize and control this particular stress is visual.
We Can Do Better
Collectively, we PT’s have been raised to think in terms of strengthening muscles to control tissue stress:
- Strengthening the fibularis to prevent ankle sprains.
- Strengthening the vastus medialis (old school) or gluteus medius (new school) to correct patellar tracking issues.
- Strengthening the transverse abdominus and multifidi to eliminate low back pain.
- Strengthening the infraspinatus and teres minor to cure glenohumeral impingements.
And, certainly, this belief has a degree of workability—it is successful a fair amount of the time. However, we can do better. We need not put all our eggs in the ‘strengthening’ basket, then hope for the best. We can add in training the sensory skill of proprioceptive awareness.
Proprioceptive Recognition & Control
Figure no matter how ‘strong’ my shocks are, my old jalopy is going to complain bitterly if I hit that nasty pothole every single time I drive home. Similarly, why should my tissues need to rely exclusively on muscles to control the stresses when we can train our folks to pay attention to, and to avoid or modify, these potential stresses:
- Train both fibularis engagement and recognition of potential lateral ankle stress by setting up a perturbation event—simulation of lateral deceleration.
- Coach both gluteus medius engagement and recognition of knee valgus stresses by simulating and optimizing the perturbating function—up and down stairs.
- Teach both intersegmental stabilizer engagement and anticipation of lumbar shearing stress by setting up common perturbation events—weight-in-front and rotation-against-resistance stresses.
- Tutor rotator cuff engagement, serratus anterior competence and thoraco-scapular optimization with low weight/long lever arm reaching simulations.
Steps in a Motor Learning Paradigm
Inherent in this motor training approach are five main elements:
- Helping our patient to proprioceptively notice stress to sensitive, vulnerable or worn and torn tissues—recognizing the ‘pattern at fault’.
- Identifying and provisionally suggesting a fix—proposing a ‘corrective pattern’ or an alternative solution.
- Taking your patient through a step-by-step learning experience starting with the cognitive phase and advancing to the associative phase of motor learning—progressively training up the new pattern.
- Prescribing exercise that simultaneously simulates the bony relationships, coordinates the muscular synergists and mimics the cognitive processing of the targeted function—awareness and appropriate muscle ‘strengthening, all in one well-conceived therapeutic activity.
- Describing and providing examples during ADL’s of when your student might use your proposed solution—practicing and functionalizing the pattern to create a ‘new normal’.
So it’s not an either/or situation. You don’t have to choose between proprioceptive awareness and competent muscles. You don’t have to choose between holding an umbrella up all the time just in case it rains and keeping an eye on the weather report—you can both anticipate a rainy day and deploy your umbrella at the appropriate time. You can have strong shocks when needed, but save wear and tear on them avoiding the potholes altogether.