The Role of the Rehab Professional
What is our role in orthopedic related rehab? Should we use tissue treatment techniques or teach movement optimization strategies? My father-in-law was a retired auto mechanic who drove an early 80’s Pontiac and spent his time with an ancient Model T. Why does he drive a 30 year old car? Because he can’t work on anything but the older models since auto manufacturers began installing computers in cars in the mid 80’s.
He could twiddle a wrench or adjust a spark plug gap with the best of them, but doesn’t have the tools or knowledge to work with control systems. Having come out of PT school in 1983, I was trained somewhat mechanistically. We mobilized joints to improve joint play and arthrokinematics. We utilized release techniques to improve fascial mobility and range of motion and prescribed exercise to stretch or strengthen individual muscles.
Beyond Tissue Treatment—Teaching Movement Optimization
What we didn’t think of then, and are still in our infancy in terms of clinical application of now, was how to affect the control system. This is not to say that the strategies mentioned above are not helpful or that you shouldn’t use them. But you can have more in our toolbox than tissue treatment techniques. Keep in mind that for each joint that is mobilized, for each fascial plane that is released, for each muscle that is strengthened, there needs to be a corresponding change in neuro-motor behavior. The computer needs to be re-programmed to assimilate the new possibilities you have created.
The habit-driven nervous system is resistant to change. Postural, movement and muscle activation patterns are not set in stone but they do want to bring the skeleton back to homeostasis—to return to what feels like home. Some people can take your intervention and run with it. Their CNS automatically adjusts and there is a permanent change, but these are the lucky few. For most people you need to follow up, to spell it out in the language of the nervous system—experiential movement, proprioceptive sensation and functional intention.
Mobilizing the thoracic spine won’t automatically reduce scoliosis or kyphosis. Doing myofascial release on the hip flexors doesn’t automatically reduce lumbar hyper-extension and strengthening the VMO doesn’t automatically improve patellar tracking. Fortunately, you are not limited to just working with the hardware. Affecting a change in tissue property and coaching them up to re-program their own software are not mutually exclusive—you can be both healer and teacher.
APTA Vision Statement
The APTA House of Delegates in 2013 adopted a new vision for the physical therapy profession, one that could easily be embraced by all the rehabilitation professions. “Transforming society by optimizing movement in order to improve the human experience”. The optimizing movement part is right up our alley, but you risk frustration if you think you can make someone move better—you don’t have the access codes needed to re-write the program, to change the way people move and act in the world.
Who does? Our patients! But you can add to your job description by assisting your patients in recognizing their sub-optimal movement—encouraging people to be aware of what they are doing and how it is affecting their musculoskeletal health and function. You could be providing conditions in which an individual can experience different movement options, then select from various options those that work best. You can do things to people to help them, but you can also do things with people by coaching them.
Embracing this role, there are two primary questions you should be asking. One, what am I going to teach—how can I define optimal movement? Two, how am I going to teach movement optimization—what characteristics or tricks of the trade can I use to make my exercise informational? Both questions have commonly/historically been ignored or glossed over with vague generalities in school and con ed. Maybe it’s time for some definitive answers, for specificity—it’s time to make the leap from knowing the mechanics of anatomy to understanding and facilitating the control of integrated movement.