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).
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!