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We recently did some minor remodeling on our house, and were in need of an electrician. Out and about one day, I saw a work van with a lightning bolt on the side—Stoner Electric. Now, I’m not sure how much business this poor guy has lost because of the name, but I’m guessing it’s more than just me.

And it got me to thinking about names—what they mean or what they connote. When we started teaching con ed courses, we wanted a name that both distinguishes us and defines us. And we came up with Therapeutic Movement Seminars.

 

TherEx

 

This choice in names is obviously a reference to therapeutic exercise, the very life-blood of our profession, but is also meant to draw a distinction between ‘exercise’ and ‘movement’ or ‘movement training’. What are those differences? Well, let’s start with a little thought exercise.

Read through the list of exercises below, and, for each one, think or say to yourself—’what is the purpose(s) of this exercise’ or ‘why am I doing this exercise’? Try not to peek ahead:

• • Supine bridge.
  • Side lie clamshell.
  • Supine marching.
  • Hamstring curls.
  • Standing squats.
  • Bicep curls.
  • Corner stretch.
  • Standing pull heel to glut with hand.

Typically, when asking these questions of our course participants, these are the answers we get to the questions:

• • Supine bridge—strengthen the gluteus maximus.
  • Side lie clamshell—strengthen gluteus medius.
  • Supine marching—strengthen the core.
  • Hamstring curls—strengthen the hamstrings.
  • Standing squats—strengthen the gluts and quads.
  • Bicep curls—strengthen the biceps.
  • Corner stretch—stretch the pectorals.
  • Standing pull heel to glut with hand—stretch the quads/hip flexors.

• • • Is this more or less what you came up with?

 

Uh-huh…and?

 

I apologize for the ‘who’s-buried-in-Grants’-tomb’ flavor of the questions, as this seems like pretty remedial stuff. But if you did answer these questions with some version of ‘to strengthen this muscle’ or ‘to stretch something’, it illustrates a particular thought paradigm—one that, if not recognized and expanded upon, limits the effectiveness of our exercise.

Ok, but how else might we justify or explain the purpose of an exercise? If the target of the exercise isn’t to stretch or strengthen something, to change the physiological property of some tissue, why else might we do it?

To answer this, let’s go back to our list and look at these exercises through a different lens—with a different perspective that prizes ‘movement efficiency’, ‘improved coordination of parts’ or ‘movement optimization’. These are some possible therapeutic movement perspectives/purposes for these same exercises.

• • Supine bridge.

• • • Train the gluteals to posteriorly tilt the pelvis and change the shape of the lumbar spine.
    • Train differentiation of the lumbar extensors from the hip extensors—gluteal excitation, lumbar inhibition.
    • Train sensory awareness of the alignment of knees over feet and of tripod feet.
    • Train awareness of the difference between pushing feet into the floor with hip extensors vs knee extensors.

• • Side lie clamshell

• • • Train the bottom or grounded leg to stabilize the pelvis—to prevent it from rolling forward as you lift the top leg.
    • Highlight the primacy of the hip abductor muscles in controlling pelvic rotational stability—and therefore of lumbar rotational stability.

• • Supine marching.

• • • Recognition of the pelvic/lumbar instability created by the engaged hip flexor of the lifting leg.
    • Train pelvic stabilization from the grounded or standing leg (dynamic integration) rather than the abdominals (static integration/core stabilization).
    • Coordinate pelvic force couple musculature—simultaneous engagement of hip extensors with opposite hip flexors.
    • Wire and fire pelvic rotational synergists.

• • Hamstring curls.

• • • No therapeutic movement corollary. This is a non-functional movement that fails to simulate a meaningful postural or movement relationship.

• • Standing squats.

• • • Training proprioceptive awareness of knees over tripod feet.
    • Training awareness and maintenance of spinal neutral and hip hinge—functional lumbar and cervical stabilization in bending contexts.
    • Recognition and control of knee flexion stresses under load—then redirecting to hip flexion.
    • Utilize the position to constrain lumbar extension and funnel movement/effort to thoracic extension/extensors—lumbothoracic differentiation in both movement and muscular proportions.

• • Bicep curls.

• • • Training scapular stabilization in the presence of a perturbating event for the upper extremity.
    • Wiring and firing co-contracting rotator cuff muscles with scapular stabilizers, thoracic extensors and posterior intercostals.
    • Training recognition and control of a lumbar extension stress.

• • Corner stretch.

• • • Facilitating a global relationship of thoracic extension and scapular retraction.
    • Training a differentiated relationship of scapular retraction and glenohumeral internal rotation.

• • Standing pull heel to glut with hand.

• • • No therapeutic movement corollary. This is a non-functional movement that fails to simulate a meaningful postural or movement relationship.

 

TherMo

 

What are some of the key exercise themes outlined above? In brief, therapeutic movement seeks to:

• • Improve the quality or nature of the relationships among various parts.

• • • Quantitative or objective measures (number of reps, amount of weight, ROM measurements) are de-emphasized…
    • …while qualitative or subjective measurements (comfort, ease, fluidity, preference) are stressed.

• • Simulate or mimic a functional activity.

• • • Wire and fire the same synergists as your targeted function.
    • Reproduce the skeletal relationships found in your optimized targeted function.
    • Simulate the same cognitive processing found in your targeted function.

• • Facilitates proprioceptive acuity by directing patient awareness of the sensations created by a particular movement/position.

• • • Awareness of shape—lumbar or thoracic AP curves.
    • Awareness of alignment—knee over tripod foot.
    • Awareness of effort—finding/engaging target muscle synergists and finding/inhibiting undesirable muscle tension or co-contraction.

 

Either/Or?

 

So therapeutic exercise and therapeutic movement have different paradigms—different purposes. This doesn’t mean one is better than the other, it means that you need to use the right tool for the job. The contexts in which TherMo is a more appropriate choice:

• • Postural optimization.

• • • Foot, knee and hip alignment.
    • Pelvic/spinal balance AP and LR.
    • Reduction of forward head posture.
    • Scapular positioning…etc.

• • Arthrokinematic optimization.

• • • Patellar tracking.
    • Hip impingement control.
    • Lumbar or cervical stabilization.
    • Rotator cuff balance and competence—glenohumeral stability and ‘centeredness’…etc.
    • Scapular stability and integration with thorax.

• • Gross motor optimization.

• • • Bending, lifting, looking, reaching, swimming, stepping, climbing, pushing, rolling over, typing, throwing, raking, pulling, driving, walking…ad infinitum.

This is a pretty big list of rehab relevant goals that ask for a therapeutic movement approach—a ‘kinetic activities’ or ‘therapeutic activities’ billing code. Does this mean that we should do TherEx first to stretch and strengthen, then follow up with TherMo to coordinate and optimize? That would be one way to go, and is most often appropriate when working with traumatic injuries or surgeries, or when working with particularly obtuse and body-unaware individuals.

But when working with repetitive stress injuries or degenerative conditions, there is rarely a need to start with (relatively simpler) TherEx. Instead, we recommend starting right off with (relatively more complex/integrative) TherMo concepts/goals and trust that optimizing the targeted movement will address individual muscle strength or flexibility.

• • Instead of strengthening muscles to improve function, improve function (practicing targeted pattern in both exercise and ADL’s) in order to strengthen individual muscles.

• • • Multi-tasking elegance!

 

Another year, another trip to the optometrist. This familiar ritual consists of various tests and devices designed to periodically reassess my vision enhancement needs. Foremost among these are a series of ‘which is better, A or B’ questions.

Choice is Key to Establishing Preference

In this assessment, I look through a progression of adjustable lenses at a line of highlighted letters. With each change of lens, I am asked to judge which of the two choices presented seemed clearest, or ‘best’. Through some mysterious process of back to back comparisons and trial and error experimentation, my optometrist makes a recommendation about either riding out another year with my current prescription or upgrading to stronger lenses.

His job is to provide the choices and make sense of the responses. My job is to perceive differences between choices and to come to a decision about what amount/type of vision correction is best for me. This is a cooperative venture where he suggests, based on preponderance of evidence—and I decide, based on subjective criteria of preference.

Analogous to Rehab Scenarios

This same division of labor template of professional choice presentation and patient preference decision is (or should be) present with a variety of musculoskeletal complaints. Not all of them, to be sure—and not so much post-surgical or traumatic injury recovery where range of motion and strength of the injured part is primary:

• • Total knee/hip.
  • Proximal humeral fracture.
  • Inversion ankle sprain.

• • • With these kinds of rehab scenarios, the injury creates the movement dysfunction.
    • With these kinds of scenarios, we are not seeking to change historic motor behavior but to restore it.

On the other hand, repetitive stress injuries/degenerative condition are created by dysfunctional or sub-optimal movement/postural patterns.

• • Lumbar and cervical degeneration.
  • Hip and shoulder impingements.
  • Patellar irritation and tennis elbow.

• • • In these scenarios, the movement dysfunction creates the injury/tissue irritation.
    • And, in these scenarios, we are seeking to change motor behavior in order to reduce repetitive/habitual movement.

Lead the Horse to Water…

But, of course, we can’t change someone else’s motor behavior. We can only bring their attention to the negative consequences to that behavior and suggest better options. In this respect, we and optometrists share a common task. We present the choices and encourage our charges to proprioceptively examine their options. They compare what they have been doing (what we have determined to be their ‘pattern at fault’) to our carefully crafted solution (what we have estimated to be their ‘corrective pattern’), then make an informed decision about their ‘pattern of preference’ or our provisional target. Clinical examples of contrasting choices might include:

• • Coming up from bending with a hip extensor emphasis, contrasting to a lumbar extensor emphasis.
  • Looking along with horizon with thoracic integration/support, compared with localized cervical movement.
  • Climbing stairs with the knee falling into valgus or with the knee aligned over the foot.
  • Anchoring the arm to the neck vs anchoring to the back.

Goldilocks & the Three Choices

This is a ‘Goldilocksian’ strategy—intentionally setting up the conditions that encourage our students to compare and contrast (2-3) competing movement or postural choices. Once a preference has been identified and embraced, it then needs to be naturalized or embodied. We do this by prescribing an individually tailored movement practice, along with advice about how/when to apply lessons learned in exercise into daily activity.

• • Recognize the error their ways.
  • Learn the new/improved pattern.
  • Identify it as superior.
  • Practice it to hone it.
  • Use it to habitualize and naturalize it.

• • • All of which require a willingness on the part of your student to pay attention and make changes.
    • Simple!

Not Simple

I must confess to a certain degree of envy when I compare his job to mine/ours. He sees someone maybe once a year—we see folks once or twice a week. The only behavioral changes he asks for are to put on a different pair of glasses—we ask our folks in these scenarios to make fundamental changes to long-standing habitual movement or postural patterns. He works with our #1 sensation (vision)—while we labor in relative obscurity working with our #6 sensation (proprioception).

But being easy isn’t as important to me as being fulfilling, challenging, rewarding and interesting—I like the career choice I have made.

 

 

I was driving home from work a couple weeks ago, taking the backroads and avoiding the freeway. Taking 5 minutes longer than the road more traveled, my back route is rural, or at times foresty. It winds through scattered homes nestled among the evergreen forest or lining the shorelines of placid lakes, then coasts past bucolic pasture land replete with a variety of barnyard animals.

This road is narrow and has no sidewalks—street lights and traffic lights are non-existent. After leaving work, crossing the railroad tracks and leaving suburbia in my rearview, there is a stretch of road where there is a bare 2 foot grassy bumper between the white fog line and a deep, cattail choked ditch.

Look Around

Cruising with traffic and puttering along at about 45 mph, I saw a person on foot up ahead. Cars are passing this figure by at alarmingly slim margins, but the ton of hurdling metal seemed to elicit no reaction from this seemingly fearless pedestrian. As I got closer, I could make out that it is a young woman, head down and eyes glued on the mesmerizing images of her phone.

Apparently, she had supreme confidence in each and every driver that passed, as she didn’t even as much as glance up. Aha! Not brave then, oblivious. Furthermore, instead of seeking the relative safety of the grassy margin, she walked on the edge of the pavement, right on the white line (maybe she didn’t want to get her shoes muddy?).

Instead of being alert to possible danger, instead of looking up and being aware of what was coming toward her, she was lost in some virtual reality. Instead of contemplating the consequences of keeping her shoes clean, instead of walking near the ditch, she sticks her head in the sand and walks the knifes’ edge of pavement. An interesting life choice, to be sure. 

Look Inside

And so, dangers can come from the outside and one should be on the lookout for them. Treacherous  traffic situations, your daughters’ new boyfriend with a knife-through-the-skull tattoo on his neck, the lightning storm approaching your golf course.

But, dangers can also arise from within us. And this applies specifically to repetitive stress injuries of various types:

• • Plantar fasciitis, ankle impingement and Achilles tendonosis.
  • Patellar subluxations and tracking dysfunction.
  • Trochanteric pain syndrome and degenerative lumbar conditions.
  • Cervical degenerative conditions, shoulder girdle myofascial syndromes and glenohumeral impingement syndromes.

These are examples of wear and tear injuries. They arise in response to the way we use our bodies—the way we overuse, misuse, disuse and abuse various tissues. These kinds of dangers can’t be blamed on outside circumstance, so solutions to these dangers can’t be sought exclusively externally.

While injections, surgeries, massage, joint mobs, *insert favorite modality/technique* can be helpful in treating the stressed tissues, they do nothing to affect a positive change in the underlying dysfunctional movement and postural patterns that led to the tissue stress in the first place:

• • Pronating my foot is hurting my foot/ankle, and ibuprofen won’t change it.
  • Valgusing my knee is putting my patella at risk, and cortisone won’t change it.
  • Lateralizing my pelvis in gait and standing hurt my hip and low back, and double knee to chest won’t change it.
  • Thoracic extensor laziness stresses my neck and protracts my scapula, and massage won’t change it.

Behaviors of Self-Harm

These are examples of habitual behaviors, internalized behaviors set by a habit driven nervous system, that lead to internal dangers. The true solutions to these types of conditions needs to be sought internally. Sadly, modern humans are not very proficient at self-examination. The desire for instant gratification, the sensory overload of the electronics revolution, the flickering attention spans and the constant hype and search for excitement are defining features of modern life.

Our time is consumed by, and our attention is riveted by, an ever-changing kaleidoscope of thoughts and emotions, hopes and fears, relationships and social status, politics and religion, sports and celebrity gossip. People mostly attend to events and sensations that are external to ourselves, leaving little room for proprioceptive self-awareness.

Until, that is, something happens to change the equation. And this something usually comes in the form of pain. As a movement teacher, this is our moment. This is our opportunity to preach the benefits of musculoskeletal introspection and to urge the adoption of musculoskeletal optimization. And we should strike while the iron is hot, as these repetitive stress injuries tend to recur or persist—episodic or chronic pain ensues and perpetuates.

Point it Out & Propose a Solution

 The first thing to do when identifying the likely ‘movement mistake’ leading to degeneration or repetitive stress injury is to point this out to your student. And what we point to is not primarily visual (this is what you look like), but proprioceptive (this is what it feels like):

• • How is your weight distributed between inside/outside of your heel, and between first and fifth MT heads?
  • Where is your knee in relation to your foot? Is it inside or outside?
  • Where is your hip in relation to your foot when standing or walking? Is it aligned over your foot or is it collapsing outward?
  • What is the shape of your thorax? Where are your scapula in relation to vertical?

The second thing to do, after identifying and pointing out the offending movement or postural pattern to your charge, is to propose a solution and set up the conditions where your ward can compare and contrast the old/dysfunctional to the new/improved:

• • This is what it feels like when your foot in centered, is a tripod foot.
  • This is what it feels like when your knee is directly over your foot.
  • Notice the sensation of contraction in the muscles you need to use to prevent collapse onto your hip while standing or walking.
  • This is what it feels like to engage your thoracic extensors and posterior intercostals, but to simultaneously relax or differentiate your shoulder girdle retractors.

Internal sensation is the key to identifying the underlying conditions that create repetitive stress injuries. Internal sensation is the key to training the movement/postural optimization that ameliorates these repetitive stresses. Our folks need to know what ‘the bad thing’ feels like, then contrast it with what our proposed ‘good thing’ feels like, then decide (with internal criteria of comfort, ease, balance and, most of all preference) which one they like best.

 

My wife’s car fell sick recently, coughing and sputtering while ‘powering’ up hills. My son-in-law, an amateur mechanic, diagnosed the problem as a bad coil pack. Replacing the suspect parts, however, yielded scant reward. Pinging and sputtering and loss of power persisted.

Bowing to the inevitable, we finally took her car to a professional mechanic. After driving it for 5 minutes, he smirked knowingly and assured us that the culprit was some belt (somewhere) and its’ controlling belt tensioner. Sure enough, replacing these parts brought her car back to robust health (though our bank account was somewhat less lively afterward).

Medical Mechanics

Sometimes I think orthopods are secretly wannabe mechanics, but without the permanently black fingernails. Total hips and knees have been around since I was a rookie PT. Then total shoulders, elbows and ankles. Now total wrists, thumbs and big toes, along with artificial vertebral discs. At the risk of revealing my advanced age, ‘we have the technology’.

Now, while we don’t ply scalpels and bone saws as physical therapists, we are still influenced by a thought process we could call a ‘parts mentality’.

‘Back’ to Basics

We treat lumbar pain and degeneration with eighteen different core strengthening exercises…

• • …while neglecting hip and thoracic hypomobility and/or hypotonicity contributions.
  • …and while failing to set up conditions where our patient can learn to recognize and control:

• • • Flexion stresses in sitting and bending.
    • Extension stresses with standing and carrying heavy objects in front.
    • Rotational stresses while pushing laterally against resistance or while walking.

Core strength alone is not enough. Lumbar pain is about more than the lumbar spine, but its’ relationships up and down chain.

‘Head & Shoulders’ Above the Rest

We treat cervical pain and degeneration with mobility exercises, manual traction and soft tissue work to cervical, sub-occipital and upper shoulder girdle muscles…

• • …while ignoring thoracic mobility, balance and integration.

• • • Have you considered, or even seen examples of, informational exercise that helps our patient to coordinate dynamic thoracic movement with intentional movement of the eyes and head…
    • ….thus simultaneously mobilizing/balancing/strengthening the thoracic area, stabilizing the neck against hypermobility and hypertonicity stresses, and training dynamic integration concepts in the context of orientation up/down, orientation along the horizon L/R, and orientation to a high horizon (improved posture).

• • …and while overlooking how the arms are being ‘anchored to the neck’.

• • • Have you considered or seen exercises that helps your patient to dynamically control scapular movement in a way that reduces over-reliance on the upper trapezius and levator…
    • …while training scapular control from the lower traps and serratus—‘anchoring the arms to the back’.

Treating the neck is not enough, even if you do address thoracic and scapular issues. This area is all interwoven and interdependent, so one exercise for the thorax, another for the scapulae and another for the neck does not follow the Transfer Principle of motor learning—they need to all be incorporated into one (actually several) all-inclusive exercise(s).

Edgy and ‘Hip’

We treat trochanteric pain syndrome with gluteus maximus/medius strengthening and soft tissue work to the hip muscles and ITB…

• • …but don’t commonly/collectively consider training our patient to proprioceptively recognize and control adduction or lateral instability stresses.

• • • Side sleeping without support between the knees.
    • Sitting ‘lady-like’ with knees and feet close together.
    • Standing with most weight on one leg and collapsing or flopping on that hip—bearing weight ligamentously.
    • Landing or shock absorbing while walking by ‘bottoming out’ on that hip—a version of what we call Trendelenburg.

Addressing hip tissues is not enough. Our patients need proprioceptive awareness training (when and where am I placing stress on sensitive tissues) and actionable information on how to control these stresses (not just strengthening the gluteal group, but training them to restrain undesirable pelvic positioning and movement in standing and walking).

Mechanic AND Computer Programmer

What we can sometimes overlook in modern automobiles is that they are now computerized. So even though it seems that we simply replaced some parts in my wife’s car, those parts still needed to be coordinated and timed. Indeed, she actually needed to drive it several miles before the computer caught up with and integrated those new parts into a seamless and efficient whole.

Similarly, according to the Specificity and Transfer principles of motor learning, we should be taking into account two prime elements when working with a client:

• • We need to design exercise that coordinates or integrates various elements of any particular movement, instead of relying on exercises that are designed to just stretch or strengthen individual elements/parts.
  • We need to assist our patient in their necessary job of ‘re-programming’ their nervous system to re-wire muscle firing patterns and re-train sensory-motor elements to habitualized new and improved skeletal relationships.

We can do it and it’s not that hard. It works better and we get better outcomes. Our patients love it and they become better self-regulators. Give it a try!

 

 

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’.

Rainy Day

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.

 

Basketball Analogy

 

It’s NBA basketball playoff time, and (when it’s not a foul-fest) I enjoy watching the most graceful athletes in the world do their thing. One of the most spectacular plays in basketball is the alley-oop dunk, where one player passes the ball up near the rim while the other player jumps, catches the ball and flushes the ball through the hoop, all in one movement.

Most commonly, this play happens off a ‘pick and roll’ play, where one player sets a pick (positioning oneself on the court to block an opposing player that is guarding the person with the ball), then immediately runs (rolls) toward the basket. The person with the ball then passes to the roller for the dunk.

This is a play that requires exquisite timing – when to roll, when and where to pass, when to jump and how to coordinate a nearly simultaneous catch and jam. It is a play that needs to be practiced over and over and over again – with a goal of making it spontaneous or second nature. Obviously, both  of the offensive players need to be on the court at the same time to practice this.

 

Agonist Cooperation

 

Similarly, in an integrated motor system, muscle synergists need to be coordinated and timed to work together – on the same ‘court’ and applied to a specific functional context. And this basic ‘rule’ of motor control exercise (rehab related exercise done for postural, gross motor or arthrokinematic optimization) is summarized by neurophysiologist Donald Hobb

 

• • • Neurons that fire together wire together.

• • • • We want to create/encourage automaticity between relevant muscle synergists.
      • This is accomplished through both axonal sprouting and reduction of the excitation threshold across the relevant synapses.

• • • Neurons that fail to sync together fail to link together.

• • • • In order for muscle synergists to ‘wire together’, they need to be timed or synchronized.
      • We can’t do one exercise for one muscle and another exercise for another muscle, any more than we can have one player practice a pass near one basket while the other player practices dunking on another basket.

 

Antagonist Cooperation

 

Perhaps not as obvious, but the two offensive players in a pick and roll/alley-oop also need two defensive players to simulate game conditions. ‘Practice the way you play’ is a basic athletic axiom, but could just as easily be applied to rehab. In basketball, the two defensive players are not cooperative, but antagonistic – they are trying to prevent the play from happening.

Within the body, and when doing rehab-related exercise for motor control purposes, the action of the muscle antagonists is just as important as the action of the agonists. We call them antagonists, but they are not actually trying to prevent the action of the agonists (ideally):

 

• • • Antagonist musculature needs to be inhibited and allowed to lengthen as the agonists are excited and shortened (in an anti-gravity situation).
    • Therefore, we can say that all four ‘players’ are working cooperatively toward a common goal and for the common good.

 

Rehab Implications

 

When doing exercise for motor control purposes, our traditional roots or common thought processes has implied that:

 

• • • ‘The purpose of this exercise is to strengthen this or that muscle’.
    • ‘If I strengthen all the muscles involved in a particular movement, they will automatically improve the quality of the targeted function’.
    • ‘Optimal muscle engagement for any particular function is primarily a result of the objective strength of the individual muscles’.

 

This approach is not scientific – it is wishful thinking. Instead, we might expand our exercise paradigm to think to ourselves:

 

• • • ‘I am prescribing this exercise to train optimization of this or that particular function’.
    • ‘I know I need to simultaneously coordinate and time the various synergists involved in that function’.
    • ‘I want to train the engagement of these muscle synergists within a specific functional context – train how you play’.
    • ‘I am cognizant of the role of the antagonists while training and coordinating the agonists’.

 

• • • • I need to ensure accurate antagonist inhibition – making sure they are not working unnecessarily against resistance or ‘driving with their brakes on’.
      • I acknowledge the duality of all meaningful movement – the positive/go and negative/stop aspect of each movement.

 

Thus, motor control exercise is not simple or easy – it does not lend itself well to pictures or simplified drawings on a flash card or exercise sheet. And while evaluation and manual therapy are high level skills for the rehab professional, so is movement training/exercise prescription, correction, teaching techniques and appropriate progressions. Exercise is not a low level skill to be passed off to aides or untrained exercise techs.