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Interpreting the Reviews

Preparing for a backpacking trip into Canyonlands National Park last year, I started looking into getting a new pair of sandals. My beloved Chacos had finally completely fallen apart, and I wanted a style of sandal with a closed toe box for river crossings. Doing research and reading the reviews for a number of different sandal brands, I narrowed it down to a couple different options.

Trying on my various choices, I really liked the Keen Newport H2. They have good arch support and good sole traction, the straps are smooth and comfortable, my delicate toes are protected from stubbing and, most importantly, they are aesthetically pleasing! However, when reading the customer reviews, I started having second thoughts.

Most of the reviews were four and five stars—these people loved and raved about them. Very few reviews were middling, but the red flags popped up when I saw several one stars, accompanied by some truly scathing comments. The common complaint was that the stitching for the heel strap would tear out, sometimes within just a couple months. I agonized over the decision for a minute or two, but they were so comfy (and so handsome) that I threw caution to the wind and brought them home.

Figuring Out What Went Wrong

After a couple days of wearing them, I figured out why the heel stitching was problematic for some people. Taking a movement short-cut, I found myself kicking out of them by stabilizing the heel with the opposite foot and just pulling my foot out. I noticed how the heel strap kind of ‘stuck’ to my heel and was pulled straight up and away from the foot bed when doing it this way.

Aha! Stress noted—now for a new strategy. I needed to devise a different solution for taking the sandal off that didn’t pull the stitches in a ‘non-physiological’ direction. Bend over. Loosen the straps. Pull the heel strap down and over the heel so the stitches weren’t stressed. No brainer—as long as you can make the correlation between movement stress and ‘tissue breakdown’.

Application to Practice

And this is a perfect analogy for how we can think about repetitive stress injuries and degenerative conditions.

• Help your client to recognize the stress—not just intellectually but proprioceptively.
• Explain how the movement and postural stresses lead to tissue breakdown and resultant pain.
• Propose movement and postural based solutions that control stresses on the relevant tissues.
• Prescribe exercises or design a movement practice that reinforces desirable movement patterns and optimal muscle synergy combinations.
• Provide examples of when these proposed solutions should be utilized in daily activities—and encourage your charge to look for related examples or situations.

Movement Model of Musculoskeletal Pain

This is a ‘movement model’ of musculoskeletal pain in a nutshell—and is very different from the traditional ‘medical model’ that our beloved profession tends to follow. With our emphasis on differential diagnoses, we have historically stressed identification of the ‘tissues at fault’. But while helpful, knowing the location or origin of pain in the context of repetitive stress or degenerative conditions is much less valuable than recognizing (and being able to control) the ‘patterns at fault’.

Controlling stresses requires recognition of stresses—which is a matter of paying attention. This is the difference between having a one star or a five star experience of your body.

Where to Look?

 

We should include subjective criteria in a PT musculoskeletal evaluation, and movement quality can be assessed as ‘good’ or ‘bad’. What do you think of these statements? Are they self-evident? Or do they seem vaguely heretical?

 

We can sometimes misinterpret calls for evidence based practice as meaning that every item on your assessment list needs to be quantifiable and objective.

 

• Measuring ROM at a joint.
• Evaluating individual muscle strength (an illusion, but not the topic for this month).
• Counting how many times someone can move from sit to stand in a minute.

 

Good stuff, good info for traumatic injury recovery especially—but incomplete, particularly when it comes to repetitive stress injuries and degenerative conditions. Since many of these kinds of conditions feature hypermobile joints and hypertonic muscles, resorting to goniometry, manual muscle testing or any activity involving a stop watch is going to be of limited benefit,.

 

Like & Feel are not Unscientific

 

But there is a subjective aspect to rehab-related evaluation of common musculoskeletal conditions—an aspect that asks ‘what would I like to see here’. And it’s probable that you are already assessing ‘subjectively’ as illustrated by these examples:

 

• • Rather than measuring lumbar ROM with low back pain, we get better actionable information by assessing distribution of movement.

• • • I would ‘like to see’ free and easy hip and thoracic mobility, with no ROM limitations that could contribute to lumbar hypermobility stresses.

• • Rather than testing quadraceps strength with patellar issues, we get a bigger picture when we assess proportionality of effort.

• • • I would ‘like to see’ the big hip extensor muscles doing their fair share with stairs or sit to stand.

• • Rather than counting sit to stand reps with plantar fasciitis, we identify the mistake by watching for sub-optimal skeletal alignment.

• • • I would ‘like to see’ the feet bear weight as centered tripods instead of collapsing into pronation.

 

Video Examples

 

For the rest of this blog, we will defer to the magic of video, where we will use two examples to illustrate this concept of looking at musculoskeletal evaluation and optimal movement assessment through the lens of ‘what I would like to see’.

 

• • Observing the ‘mistake’—a qualitative judgment—helps us to identify the ‘pattern at fault’ or the ‘directional stress’ for that particular condition.
  • Establishing a ‘target’—also a qualitative judgment—helps us to list our clinical goals for that particular condition.
  • Practicing the ‘target’—turning goal into exercise.
  • We will use two common examples to illustrate these ideas further:

• • • Trochanteric pain syndrome.
    • Patellar tracking or anterior knee pain.

 

Video BL-15: Assessing with Subjectivity

Previous Topic

In our March and April 2020 blogs, we suggested principles of Optimal Movement that we could be teaching our patients:

 

• • Fascio-Skeletal Weight Bearing
  • Appropriate Distribution of Movement
  • Proportional Use of Synergists
  • Minimization of Unnecessary Effort

 

Application to Low Back Pain

Let’s now get more specific by talking about the 800 pound gorilla of physical therapy—low back pain. According to that font of all medical wisdom, the internet, low back pain is the third most common reason for a doctor visit in the US. Coming out of PT school in 1983, lumbar stabilization wasn’t even on the radar screen.

 

• • We stretched the back into flexion (William’s), extension (McKenzie’s), side-bending and rotation.
  • We then strengthened the back, belly and hip muscles.

 

We believed that the back hurt because it was stiff and/or weak—it would feel better if it were flexible and strong. A brief perusal of back pain books on Amazon will show that old ideas die hard, and the stretch and strengthen paradigm is still alive and kicking.

 

Switching Paradigms

Fast forward to the Age of Pilates and we have the more accurate idea that the back can hurt because of hypermobility. However, we tend to still have ‘if only’ concepts of what it takes to stabilize the back. ‘If only’ my multifidi and transverse abdominus were stronger I won’t have back pain. Core stabilization is king! Hmmm.

 

• • Even if I still sit habitually slumped at end-range flexion?
  • Even if I still stand sway backed at end-range extension?
  • Even if I twist with inadequate hip or thoracic rotation?
  • Even if I bend with inadequate hip hinge?
  • Even if I serve in tennis with a stiff thoracic kyphosis?

 

There are larger forces at play in these scenarios which need to be addressed, along with a self-awareness component—what am I doing wrong/how could I move better? Optimal movement principles germane to this topic are Appropriate Distribution of Movement and Proportional Use of Synergists (Division of Labor blog April 2020).

 

• • If my gluts/hams are tight and I’m not using myhip flexors to drive anterior pelvic tilt in sitting and bending, I flex too much in my lumbar spine and create hypermobilities.
  • If my hip flexors are tight and I’m not using my hip extensors to drive posterior tilt in standing or walking, I lordose and jam my lower back.
  • If my hip rotators are short I twist too much at my lower back when golfing or working on an assembly line.
  • If my thoracic spine has fossilized and my thoracic extensors are on permanent holiday, I am required to move and work too much in my lower back.

 

Check it Out

There is current research that backs this up. For just a few examples, go to PubMed and type in:

 

• • Relationship between the hip and low back pain in athletes who participate in rotation-related sports.
  • Hip stiffness patterns in lumbar flexion or extension-based movement syndromes.
  • Elimination of intermittent chronic low back pain in a recreational golfer following improvement of hip range of motion impairments.
  • The hips influence on low back pain: a distal link to a proximal problem.
  • Factors affecting shoulder-pelvic integration during axial trunk rotation is subjects with recurrent low back pain.

 

We’re not tossing out the baby with the bath water here—core muscle activation has an important role to play, just not the only role. The game here would be to create situations where we simultaneously mobilize hips and thorax while keeping the back stable. And this is much easier said than done.

 

We Have Room for Improvement

The typical types of exercise we have historically prescribed to improve hip or thoracic mobility are non-specific and global instead of pattern-specific and differentiated. Because of the tendency to move in ‘paths of least resistance’, we need to be clever in how we position our patient to constrain lumbar movement and to funnel movement and effort to under-performing areas.

 

Furthermore, according to the Transfer Principle, our exercises should be linked to the specific functional contexts in which our patients run into trouble (bending, lifting, pushing, etc.) and should have a sensory training aspect and some kind of decision making algorithm:

 

• • What is the shape of my lower back?
  • What do I want the shape of my low back to be—what is my target?
  • Where is my movement or effort occurring when I perform a functional activity—how is movement and effort distributed?
  • Where should I be moving and working in order to reduce stress on sensitive tissues?

 

Motor adequacy (muscle length/strength), sensory accuracy (proprioceptive acuity) and intentional clarity (what’s my target) are the three indispensible aspects of human integrated movement—we can and should be including all three.

In this month’s blog, we will continue to address motor control exercise and the last two phases of motor learning—the associative phase and the autonomous stage.

The first phase, the cognitive phase, was addressed in last month’s blog. This was described as the ‘ground floor’ stage of rehab-related postural or movement optimization. This phase is characterized by:

• • Exploration of options—recognizing the benefit of examining more than one choice in order to make an informed decision.

• • • Like the optometrist, we use a strategy of presenting a variety of possible solutions.
    • We want to provide a contrast between the ‘good’ movement we are proposing and the ‘bad’ movement they are doing.

• • Training attentional focus—acknowledging the need to proprioceptively distinguish the differences between choices.

• • • We use specific language as a strategy to direct internal attentional focus.
    • We use descriptive language to give specific instructions on ‘what to do’.
    • We use inquisitive language to give specific instructions on ‘what to pay attention to’.

• • Encouraging patient self-evaluation—accepting that they are the ones that need to make the choice or set the target.

• • • We bring them into the decision making process and give them a stake in the outcome.
    • We provide the actionable information, then they decide what action to take.
    • These are motor learning strategies called attention to task and autonomy.

Autonomous Phase

 

During the cognitive phase, we proposed solutions while our patient selected and established their provisional target.

• • This is how I want to align my foot over my knee.
  • This is the shape of my lower back that feels best.
  • I would rather anchor my arm to my back than to my neck.
  • My neck pain is reduced when I move it less and invite more thoracic participation.
  • I’ve got the basic idea—now it’s time to solidify it.

Conceptual vs Embodied Knowledge

As mentioned last month, coming to an intellectual awareness of ‘how to move better’ is not enough—our patients will need to move beyond that conceptual understanding to an embodied understanding of how to move.

An embodied understanding means:

• • I can now walk and chew gum at the same time.

• • • I don’t have to think about it so much.
    • I’ve experienced the sensations produced by the target movement, skeletal shape or muscle activation pattern enough that I can relegate sensory awareness to more of a background gestalt.

• • I have ‘unfired and unwired’ my old problematic muscle activation patterns and have made room for something else to grow.

• • • Previously habitualized, but suboptimal, movement or postural patterns have been recognized as the misery producers they are.
    • I have consigned old motor habits to the dust heap of personal history.

• • I have ‘fired and wired’, ‘linked and synced’, the more appropriate muscles.

• • • Newly acquired muscle activation patterns have now been practiced enough that synaptic transmission has been eased and neuronal sprouting has established new connections.
    • Neuroplasticity does its magic and an optimal new muscle synergist cooperation has been established.

• • I am able to take my shiny new movement pattern and use it in my daily life.

• • • I am now extrapolating what I learned during exercise into specific functional contexts, and am reaping the rewards of my diligence.
    • This ‘exercise to implementation’ phenomena is called transfer.

So this is what we are aspiring to—the autonomous stage. This is the ‘penthouse’ phase of motor learning—the ‘I’ve made it’ stage. I have established a new normal or created a new habit that is clearly superior than my old one.

I might still need to refresh my memory or fine tune some of the details with my custom-designed movement practice to prevent inertia from dragging me down again, but in essence ‘I’ve got this’.

But how do we get there? How do we move our patients from the early cognitive phase and a conceptual understanding to the autonomous stage and an embodied understanding?

Associative Phase

 

The associative phase constitutes a ‘bridge phase’ between the early learning of the cognitive phase and the movement mastery (more or less) of the autonomous phase. As in the cognitive phase, there are certain stratagems we can use that make it more likely that that our patient can transition from a conceptual to an embodied understanding—and from exploratory exercise to finished product:

 

Application of Constraints

Applying a constraint during movement training means setting up the conditions in which movement and effort is directed away from undesirable areas and funneled to more appropriate places.

• • This strategy provides a means by which we can fine tune a movement—to prevent hypermobile places from moving or to encourage hypotonic muscles to work.
  • We can make stiff places looser and weak muscles stronger, without risking stress on sensitive or over-worked tissues.

 

Practice Variability

Practice variability means taking a particular movement pattern and adding additional or complicating factors.

• • Positional Variations. Performing the same movement in a variety of positions or relationships to gravity (prone, supine, hands/knees, floor sit, chair sit, stand, etc.).

• • • This assists with patient pattern recognition and pattern reproducibility.
    • We want our patient to utilize our thoughtfully designed ‘corrective pattern’ throughout any possible position changes.

• • Variation of Intent. Performing the same movement but relating it to different functional intents (orientation, manipulation, locomotion, etc.).

• • • We want our patient to utilize the ‘corrective pattern’ throughout the whole gamut of human activity.

 

Practice Specificity

Practice specificity in movement training is designed to ensure ongoing accuracy.

• • The specificity principle urges us to make our exercise look like the motor behavior we are trying to influence.

• • • Make the exercise’s skeletal relationships, muscle activation patterns and cognitive processing similar to our target pattern.

• • ‘Aim small to miss small’ suggests that we do our best with each repetition—that quality is more important than quantity.

• • • Football coach Vince Lombardi famously stated “practice doesn’t make perfect, perfect practice makes perfect.” 

 

Link to Functional Context

This is related to practice variability, but is not exactly the same. The strategy of linking our exercise to specific functional contexts is a key aspect of the ‘transfer principle’. Examples:

• • Lengthen the hamstrings by practicing pattern-specific bending from split stance standing.
  • Strengthen the gluteals by simulating a push off movement in gait.
  • Mobilize the thorax in the context of looking along the horizon.

 

Intensity

This doesn’t just mean how hard you work, but how many other complicating factors are in play:

• • Objective progressions.

• • • Add more weight, more repetitions or done for longer periods.
    • This is classically what we think of as elements of intensity.

• • Speed and spontaneity.

• • • Make a movement faster.
    • Introduce an element of ‘flow’ or undulation.

• • Adding an external motor focus.

• • • Do the movement while talking or playing catch with a ball.

• • Adding an external sensory focus.

• • • Do the movement while reading something or while listening intently to the lyrics of a song.

 

Finito

Concluding this two part discussion of the three phases of motor learning, you might ask yourself a few questions:

 

• • Are the various motor training strategies presented here widely implemented throughout our beloved profession?
  • Are there any of these described elements of motor control exercise that you commonly use in your practice?
  • Would it really be that difficult to introduce some of these elements into the way we teach exercise?

• • • Can our profession truly claim to be doing doctorate level work when we still use exercise paradigms that were developed in the 1960’s?

There are three distinct phases of motor learning, each with its own unique characteristics and requirements. Therefore, we will need distinct exercise strategies, appropriate to each phase, for learning to optimally transfer from exercise to ADL.

In this months’ blog and next, follow brief descriptions of the phases motor learning—applicable whether learning a new skill or re-learning an old/established skill in a more optimum way. The three phases are cognitive, associative and autonomous. The cognitive phase is featured this month.

 

Cognitive Phase

This is where we start—with exploratory movement, using trial and error. We have determined a ‘provisional target’ that we think would benefit our person—now we want to train our person to recognize, execute, reproduce and utilize our suggested ‘corrective pattern’.

We know that normal, everyday movement is not primarily willful, or cognitive. We don’t think about everything we do, movement-wise. From sitting posture and gait patterns to knee alignment and spinal stabilization, most movement is habitualized and relegated to auto-pilot.

But our proposed solutions, our new and improved movement patterns, cannot be habitualized and filed immediately into the sub-conscious. They need intermediary steps, and the cognitive phase is the first one. When doing movement training, or exercise for motor control purposes, we start by exploring options, training attentional focus and encouraging patient self-evaluation. In essence:

• • What are my options—what are the key differences between them—what is my preferred choice?

 

Exploration of Options

When I go to the optometrist, we work cooperatively. He has gadgets that approximate lens correction, but he doesn’t stop there—he doesn’t assume that his choice is my choice, but provides me with options.

Together, we go through a process by which I can see differences in quality between varying strength or shaped lenses. He suggests based on clinical judgement. I evaluate based on internal sensory criteria. I decide which ‘correction’ I like best.

Training complex and integrated movement or postural patterns is very similar. We suggest movement-based solutions to movement-based problems and provide our didactic reasoning. We then proprioceptively ‘show’ our patients contrastsbetween their sub-optimal and possibly tissue damaging behaviors and our more elegant and comfy propositions. Examples might include:

• • Patellar pain descending stairs, where we see the affected knee go into valgus and shear too far forward.
  • Low back pain when bending, where we see lumbar flexion hypermobility and a lack of hip flexion mobility.
  • Cervical pain when looking up, where we see no thoracic contributions and obvious localized movement stresses at C4-5.

 

In all these scenarios:

• • We bring our patients attention to their ‘pattern at fault’.
  • We propose a solution and demonstrate a ‘corrective pattern’ or a ‘provisional target’.
  • We have our patient feel the difference between the two experientially.
  • We ask our patient to determine a preference.

 

But how do we get from exploration of options to determination of preference?

 

Training Attentional Focus

Inherent in any exploration of options is recognition of differences. My optometrist doesn’t provide me options that are identical; he wants me to recognize the qualitative difference between choice A and choice B. Lucky for him, vision is pretty easily accessible for most everybody. Unlucky for us, it is not visual differences we want our patients to focus on, but proprioceptive differences.

Sadly, many people wander around in a proprioceptive haze. They don’t know where to ‘look’ to distinguish the difference between knee alignment and non-alignment, or between lumbar hypermobility and stability. Often, we need to teach them where, or how to,  focus their attention.

Depending on your clinical target, you might ask your patient to notice:

• • Bony relationships or patterns—is there a shape to be recognized?
  • Muscular effort—is there someplace unfamiliar that needs to step up, or is there someplace else that is working unnecessarily?
  • Distribution of movement—is there someplace that’s moving a lot and another place that’s not moving at all?
  • Differences left to right—are my imbalances linked to my discomfort?

 

Setting up optimal conditions for learning is helpful:

• • Minimizing unnecessary noise (voices, TV, music) and closing the eyes to highlight proprioceptive information—the Weber-Fechner Law (another time).
  • Minimizing effort to make muscle engagement more obvious/accessible.
  • Going slowly to give ample time to recognize what’s going on.

 

Using specific language to provide a guided tour of the movement and how they are doing it.

• • Inquisitive Language. Asking questions to direct their inquiry to specific key themes.

 

• • • What is the shape of your back when you bend?
    • Is your weight more toward the big toe side or the little toe side of your foot?
    • Does your shoulder blade move up or down when you reach your arm forward?

 

• • Descriptive Language. Describe to your patient in proprioceptive terms both what to do and what to pay attention to.

 

• • • Feel your low back flatten to the ground when you roll your pelvis upward.
    • Notice the difference in where your effort is when ‘anchoring your arm’ to your neck vs to your back.
    • Notice differences in hamstring length between your two sides while rotating your pelvis in plantar grade.

 

So we have displayed our wares and have trained our patient in recognizing proprioceptive contrasts. They can now execute our ‘provisional target’ and can perceive differences between it and their habitual whatever. Now we move to close the deal.

 

Encouraging Patient Self-Evaluation

The last step in the cognitive phase, and before moving on the associative phase, is establishment of preference—or encouraging patient self-evaluation. In neuro rehab, this is called autonomy—meaning people learn better when they have some say over what they are doing. Give them a choice and let them decide.

• • What do you want the shape of your back to be?
  • How would you rather anchor your arm?
  • Does it feel best to have your foot rolled inward, outward or in the middle?
  • Does your low back feel better coming up from bending with back extension or with hip extension?

 

This preference can’t be imposed, though it can be anticipated and even encouraged. But ultimately, it is the person you are working with who needs to do the work—to get some skin in the game:

• • To pop open the hood and try out the movements.
  • To ‘listen’ to their body and to proprioceptively recognize differences in contrasting options.
  • To make the decisions and to benefit from the consequences.

 

In a Nutshell

 

So these are the characteristics of the cognitive phase:

• • Slow and small and eyes closed helps to minimize distracting sensory chatter.
  • Directing your patients inquiry into unfamiliar patterns by using inquisitive and descriptive language.
  • Providing options (including clarifying their habitual and sub-optimal choice), contrasting options and ranking options on a subjective scale of good/better/best.

 

In the next phase, we stress different exercise strategies—more advanced and appropriate for the associative phase of motor learning. To be addressed next month.

 

 Damage Control

 

My wife and I were having dinner the other day when she gave a quiet moue of distress—she had just bit her tongue. Been there, done that, don’t like it. But it did get me to thinking about how absolutely mind boggling it is that we are not always biting our tongues. Your tongue is a big old soft muscle, with very little space between it and those hard, cutting, puncturing and grinding objects called teeth. Upping the ante, they are pressed and ground against each other by a muscle that produces the greatest force per square cm in your body—your mighty masseters.

 

And, it’s not like your tongue can just find a safe hidey-hole and get out of the way while your teeth repeatedly crash together either. Your tongue is always out there in the thick of the action—actively herding your delicious mouthful of apple and almond butter into that kill zone between upper and lower teeth. It’s like running your Tonino Lamborghini Casa armchair through a wood chipper 3 times a day for decades and still expecting it to be comfortable.

 

Developmental Learning

 

Amazingly, this ability of your tongue to dodge danger is learned. It wasn’t instinct and it wasn’t hard wired. Sucking and swallowing was, so that’s good—it allowed you to consume nutrients right out of the ‘gate’ without having to learn to coordinate your jaw and tongue muscles beforehand. But if you wanted to progress past mothers milk and mashed up sweet potatoes to corn on the cob and biscotti, you were going to need more than just gums.

 

When did you learn to avoid biting your tongue? Early on in life and pre-verbally. You developed this movement skill as a result of an environmental need and without the benefit of a teacher. How do you learn this? The school of hard knocks obviously—insult your tongue enough and your CNS quickly figures out how to ‘map out’ the dangerous areas/times. What else is learned this way?

 

• • Falling over without hitting your head—balance.
  • Rolling from your back to your belly or moving from sitting to hands and knees—transitional movements.
  • Lifting your head from prone to look to the horizon—orientation.
  • Getting that spoonful of applesauce (eventually) into your mouth or throwing that wooden block at your dad’s face—manipulation.
  • Crawling, walking and climbing onto the top of the couch—locomotion.

 

• • • Figure basically anything a two year old can do falls in this category of developmental learning.

 

Intentional (Willful) Learning

 

After that initial pre-verbal learning phase, we start to learn all sorts of movement skills that are taught to us by someone else. For this type of learning, unlike developmental learning, there is a necessary cognitive component. Early examples include:

 

• • Dressing yourself.
  • Tying your shoes.
  • Brushing your teeth.

 

This type of willful learning continues through school and into adulthood:

 

• • Throwing a curveball or dancing the macarena.
  • Typing on a keyboard or playing the piano.
  • Driving a car or ice skating.
  • Writing your name or riding a bike.

 

Some of these types of movements remain ‘willful’ or are always deliberate:

 

• • Gestures like shrugging your shoulders, winking at your heartthrob or flashing Spock’s ‘live long and prosper’ sign.
  • Putting on mascara or shaving your legs.
  • Driving a screwdriver or swinging a hammer.

 

Bodies on Autopilot

 

But most intentional movement eventually becomes sub-cortical—they evolve to become more or less automatic.

 

• • Your hand and finger movements while playing the piano, tying your shoes or signing your name are now ‘programmed’ and semi-unconscious.
  • You can drive your car while engaging in conversation, ride a mountain bike on a rocky single track or swing a hockey stick without falling on your backside.
  • You can walk AND chew gum.

 

Nearly all our developmentally learned movements and most of our willfully learned movements have long since become habitualized. And, to a large degree, this is a good thing. Motor habits are beneficial, even necessary. They make it so we don’t have to reinvent the wheel every time we thumb through our pile of junk emails or walk up a set of stairs.

 

On the Other Hand

 

However, habitual movement and postural patterns are not always beneficial. In ortho related rehab, we have to deal with these ingrained motor habits in two primary ways:

 

• • Our patient has suffered a traumatic injury and their CNS has reacted by creating compensation or substitution patterns. These patterns may be initially helpful and necessary, but shouldn’t become the new normal.

 

• • • Because these patterns quickly habituate, part of our job is to anticipate these compensatory motor adjustments and to ensure that they don’t put down permanent roots.

 

• • Our patient suffers from ongoing repetitive stress injury or some degenerative spinal condition. Habitual sub-optimal or invariant movement and postural patterns ARE the repetitive/degenerative stress.

 

• • • Our job is to help our patient to recognize these patterns and to learn/adopt more optimal solutions for their particular complaint.
    • How do we get them to do this?

 

Phases of Motor Learning

 

If you are working in ortho rehab, the opportunity for developmental learning has likely long since passed. Therefore, what we are mostly doing in this setting is (initially) willful or intentional learning:

 

• • Bend differently so you don’t stress your lumbar spine.
  • Throw differently so you don’t impinge your shoulder.
  • Walk differently so you don’t compress your trochanteric structures.
  • Look over your shoulder differently so you reduce cervical hypermobility stresses.

 

But these are activities that (eventually) need to become sub-cortical or automatic. The game is then to teach the movements in ways that expunge the old/sub-optimal pattern and transfer the new learning into daily activities. We would like them to habituate to a new and improved normal. The strategies by which we do this will be covered in subsequent blogs, where we will talk about the three phases of motor learning:

 

• • Cognitive.
  • Associative.
  • Autonomous.