Limb to Trunk Rapport

Starting Off on the Wrong Foot

 

In last month’s blog, the topic was pelvic control—one of the two primary differences between static and dynamic integration philosophies. This month we’ll address the second characteristic of dynamic integrated movement, which features another major divergence from static practices. We’ll talk about how the limbs (arms, legs and head especially) ‘should’ move relative to the trunk, or how distal parts ‘should’ move relative to proximal parts.

 

The early history of rehabilitative exercise was characterized by ‘isolate and localize’ thinking (Isolate vs Integrate blog May 2020). This inaccurate vision of human movement was likely created by the way we learned anatomy, where ‘origin and insertion’ language short-circuited a more realistic assessment of, and a more dynamic vision of, how people actually move.

 

Origin & Insertion Thinking

 

When learning our anatomy ABC’s, we described movement relationally. ‘This moves relative to that’ is common to all three movement visions—isolate/localize, static integration and dynamic integration.

• • In our ‘isolate and localize’ days, we were either unaware of limb to trunk relationships or took proximal stabilization in the presence of limb movement for granted. Assumed stability.

• • • Supine, prone and side lie straight leg raises—the leg/insertion moves relative to an unconsciously immobile pelvis/origin.
    • Glenohumeral internal and external rotation with theraband, bicep curls—the arm/insertion moves relative to an unconsciously immobile thorax/insertion.
    • Cervical ROM exercises or static isometric strengthening—neck moves/thorax ‘shouldn’t’.

 

• • We are now in our ‘static integration’ phase, where we are (somewhat) aware of limb to trunk relationships, and where we are actively encouraging deliberate stabilization of the proximal part. Intentional or trained stability.

• • • We now know that the pelvis ‘would’ move when you lift a leg (as above) so we now train our charges to be intentionallystabile. Same origin and insertion thought process as ‘localize and isolate. Same abdominal muscle control of the pelvis as ‘localize and isolate’.

 

• • We now know (or should know) that the scapula ‘would’ be dragged into anterior tilt and the thorax ‘would’ be pulled into flexion when you reach an arm forward—so we train our folks to straighten their back, pull their scapula down and back and intentionally stabilize while moving the arm.

• • • Same origin and insertion thought process as ‘localize and isolate’.

 

• • The upper thoracic area naturally flexes and extends when a toddler looks up/down and LR. But we have discouraged this natural integration (see SFMA guidelines for assessing cervical movement).

• • • We have labeled any movement other than the neck as ‘substitution’, ‘compensation’ or ‘cheating’.

 

• • Static integration thinking is essentially a re-boot of origin and insertion concepts, with intentional vs assumed stabilization as the primary difference.

• • • We even have a nifty mantra that encapsulates this mindset:

 

‘Proximal stability facilitates distal mobility’

 

Minority Report

 

But maybe instead of trying to understand movement through the study of inert anatomical structures (featuring people who have donated their body to science), we could look at living people as they actually move (especially people who move well—dancers, yogis, martial artists, athletes, etc). For these folks, the head/neck and arms/hands most commonly move as an extension of a dynamically moving thorax.

• • We encourage progressing to a ‘dynamic integration’ phase of understanding, where proximal structures are not automatically immobilized in the presence of limb movement. Dynamic or ‘proportional movement’ stability.

• • • The pelvis can move to assist the movement of the leg. (Kicking a soccer ball, large side step, swinging a leg when walking).
    • Both scapula and thorax are encouraged to move to assist movements of the arms. (Throwing, punching, reaching forward, across, behind or overhead).
    • The thorax is encouraged to move to assist head and neck movements. (Star gazing, checking your blind spot, contemplating your navel).

 

Stabilization Through Movement Re-Distribution

 

This concept of proportional or appropriate movement distribution is a paradigm shift for us. We have historically taken the position that if we want something to be stabilized, we need to prescribe exercises that strengthen the muscles around that joint.

• • Multifidi stabilizes the lumbar spine.
  • Longus colli stabilizes the cervical spine.
  • Infraspinatus facilitates glenohumeral centering/stabilization.

 

Thinking of these scenarios relationally, maybe we could ask why these areas are hypermobile or unstable in the first place:

• • If the lumbar spine is hypermobile/unstable, look for hypomobile areas elsewhere.

• • • Simultaneously coordinate TrA/multifidi with hip and thoracic mobility work.
    • Relate the exercise functionally to bending, turning, walking, pushing/pulling and other potential lumbar hypermobility stresses.

 

• • If the neck is degenerative, encourage a re-direction of movement stresses elsewhere.

• • • Simultaneously coordinate longus colli/rectus capitus with thoracic mobility work.
    • Relate the exercise functionally to looking (up/down, LR, etc), eating, drinking and other potential cervical hypermobility stresses.

 

• • If the GH joint is unstable, invite proximal structures to assist.

• • • Simultaneously coordinate the rotator cuff with dynamic scapular and thoracic mobility work.
    • Relate the exercise functionally to reaching, throwing, tucking in a shirt and other potential glenohumeral arthrokinematic stresses.

 

‘Proximal mobility facilitates distal mobility’

 

This is consistent with other emerging rehab principles.

• • Regional interdependence.

• • • ‘This is connected to that’, and limitations or dysfunction distally can have negative effects locally.
    • Addressing these distal issues can have positive effects locally.

 

• • Relative flexibility.

• • • Shirley Sahrmann’s ideas of ‘path of least resistance’. Movement happens in looser places, while lack of movement elsewhere encourages further stiffening along ‘path of most resistance’.
    • Need exercise that simultaneously mobilizes the stiff part while stabilizing the loose part.

 

Bottom Line

 

So if you are prescribing cervical mobility exercises, then longus colli strengthening exercises, you are sending mixed messages. If you are having your patients develop their six pack TrA, then doing hip mobility work, you are missing an opportunity. If you are pumping up the rotator cuff, then doing thoracic mobility work, please think again. In all these scenarios, according to the transfer principle of motor learning, the two functions (stabilization of the targeted joint and mobilization of potential allies) need to be done simultaneously.

 

Just like pelvic control, limb to trunk relationships need to be better understood in the rehabilitation community. Reflexly following static integration concepts and prescribing static integration exercise is no longer the only option—there is another choice. Time to up our game and educate ourselves on another, more realistic and more effective movement paradigm.