Motor Control and Stability

Posted on February 22, 2012 by admin

This is one massive topic! However it’s something to consider with pretty much every patient/client you see, as we perhaps have more influence over this than anything else we do, either through movement or manual therapy. It’s also important because a loss of motor control/stability is so common, even if at a low level. The changes in proprioception after any injury are incredible, so it’s worth checking out. If you go in depth it can get a little intense, but there are some simple observations that I use to help guide me to what my patient needs.

The thing that really led me down this path was the contrast between a joints ROM when performing non-functional tests compared to functional tests. For example, I would assess someone’s hip internal rotation in supine: full ROM. The I would ask them to walk, squat or do an excursion test and they didn’t appear to have any range! So why would the body not use the available range? Well, there are probably many reasons, but the ones that spring to mind for me are either:
1. The motion is being limited by another plane/joint
2. There is a lack of stability (motor control) so the body will not allow you to go into an uncontrolled ROM.

If you have completed either the Diploma in Functional Performance or Functional Therapy you will know the process of clearing all the other joints/planes. If the body still won’t let use the ROM you know is available, then I am thinking it’s a stability problem. You can use simple balance-reach tests to compare one side to the other and 99/100 times you will find a lack of stability on the affected side. The situation where you can get caught out is when you are dealing with a good athlete: they may be so adept at compensating that you have to push them harder to find the problem.

This kind of presentation is most obvious with lower back pain, shoulder pain and knee pain, although I am sure it can appear any time. The good thing is, once identified the patients/clients tend to respond really quickly. Pivot matrix, balance reach matrix etc. are awesome in this scenario and the change will be instant, which the patients love. Within a week you can progress to much more challenging exercises, and often the pain scores are starting to come down too.

A similar scenario is when you know there is strength in the range, but the body just isn’t using it. My favourite example of this was a patient who undergone a hip replacement about 3-4 months previously. He’d been through all the usual re-hab and had experienced an uncomplicated recovery, apart from the fact that when he walked and was weight bearing on the affected leg the opposite side of the pelvis dropped dramatically. He had been given lots of hip abductor exercises (clams, resisted clams etc.) and had progressed to the strongest theraband, but there was no corresponding change in his gait! I met him because I was taking over from someone who had gone on holiday. I did an assessment and he showed me his exercises, but that hip drop was still massive! All that strength and yet no motor control.

My strategy was to do some more functional type exercises to try and get the body using the strength I knew it had. We went through some pivot exercises for about 10 minutes using a few different variations and I then asked him to walk across the room without his walking stick. He now walked with a mild hip drop (about 80-90% improved) and couldn’t believe it. It would take a bit of practice to keep this effect, but he can repeat the exercise daily, so that’s no problem. It just goes to show you don’t necessarily have to wait weeks and months to see positive change.

If you look out for these types of presentations it won’t be long before you see them. The results of using functional exercises with them are spectacular. Enjoy!

Neil Poulton

Posted in Articles for Personal Trainers, Articles for Therapists, Exercise Therapy, Functional Assessment, Functional performance, Injury rehabilitation, Manual Therapy | Tagged , , , , , , , , | Leave a comment

Conscious vs Subconscious Movement

Posted on February 22, 2012 by admin

When I was a personal trainer and was beginning the journey to where I am now, there was a lot of emphasis on posture, alignment and control of movement with learned cues. However, since learning with John Hardy. Gary Gray and Dave Tiberio, I have come to realise this conscious cueing is not the best plan and there is a better way of achieving the desired effects.

The ones I hear most often are “keep the spine in neutral” (whatever that means!)and “keep your shoulder blades retracted”. I am always getting patients who have been given these kind of postural cues from varius sources, and I’m sure they do more harm than good.

The way I go about achieving the desired movement or position is through subconscious movement through an alternative goal. For example, if you assess someone and decide they are missing right hip adduction, and want to help them increase this joint motion through an anterior lunge, the conscious way would be to ask him to adduct the right hip more as he lunges forward. This strategy may lead to a little more hip adduction, but it will tend to be a highly compensated movement. The client is concentrating so hard on one joint movement he will try and achieve it regardless of what means for the position and movement of the other joints. I also believe you will get far less carry-over into their gait pattern with this strategy, as the movement hasn’t been authentically driven and it is impossible for that person to walk down the road thinking about achieving the correct amount of hip adduction.

The alternative strategy: I would avoid telling the client specifically what I am trying to achieve as I want to avoid conscious over-riding of the movement pattern, which results in massive compensation and poor carry-over. I would ask him to do the same anterior lunge but would not even mention the right hip. Instead I would give them a simple goal to focus on away from the hip, but which will drive authentic hip adduction through that right hip. My preferred choice is to ask the client to drive the right hand left lateral overhead as he completes his anterior lunge. If this is not possible for whatever reason (right shoulder impingement, for example) he can drive the left hand towards the floor, or as a last resort you can stand him close to a wall and ask him to drive his pelvis towards the wall as he performs his lunge. I say this one is a last resort as you are bringing the driver closer to the hip, which you might want to avoid if you can.

There are many reasons this subconscious strategy is of benefit, but for me the most compelling reasons are how fast results tend to be with this method, and how good the carry-over is into their normal function. If you assess your client’s gait or movement, drive subconscious movement through the joint and then re-test you should see a lasting change immediately. Another reason it is a great strategy is that this type of movement can so easily be turned into a manual therapy approach consistent with the HMACIV and therefore gait.

Neil Poulton

Posted in Articles for Personal Trainers, Articles for Therapists, Assisted Dynamic Stretch, Functional Assessment, Functional performance, Injury rehabilitation, Manual Therapy | Tagged , , , , , , | Leave a comment

Looking After Yourself

Posted on February 22, 2012 by admin

This post came to mind because a while ago I made the mistake of not looking after myself. In particular my left thumb! Now I know that may sound a little trivial, but it’s a reality a lot of therapists face as we work with our hands all the time and life becomes difficult if you can’t use them.

If you are trained as a therapist, such as a physio, osteo, chiro, massage therapist etc, it is likely that you had it drummed into you that when treating your first priority is the position you are in, and the way you use your own body, so that you can avoid injury and treat long term without wearing yourself out. Backs and thumbs are the two most common areas therapists have trouble with.

I have always tried to look after my thumbs when treating with traditional manual therapy, but I made the mistake of forgetting about them when doing some more of the functional manual therapy: assisted dynamic stretch (ADS). I had experienced pain for a few weeks and was struggling to work out exactly what was causing it. Then one day I was working on a few shoulders and I realised I hadn’t been taking as much care of my hands, and my thumb was really painful while working on the scapular. There are plenty of ways of working, particularly when you are doing more functional manual therapy, so it is possible to adapt to reduce the pressure on the thumbs.

I’m hoping my experience will save pain in the thumbs for a few of you, so here is what I suggest. When you are performing ADS:

* Think about your whole body position so you can use your body weight rather than excessive force on your hands
* Think about the position of your hands and where the force you are applying is going
* Try to adapt your position so that the force is going through larger or multiple joints, so that you are not excessively stressing one small joint
* If it’s stressing a joint, and you can’t find a way to avoid it, stop. Change to an exercise solution or an alternative manual therapy solution.

As most of you who have done the Diploma in Functional Performance or Diploma in Functional Therapy are using hands-on solutions regularly I feel it is really important you start to think about these things so you don’t end in a painful position as I did! The thumb pain was resolved with a little treatment, but I have learnt to change my technique/treatment habits to protect myself in the future.

Neil Poulton

Posted in Articles for Personal Trainers, Articles for Therapists, Assisted Dynamic Stretch, Functional Assessment, Functional performance, Manual Therapy | Tagged , , , , , , | Leave a comment

Building An Exercise

Posted on February 19, 2012 by admin

All of us know loads of exercises, we have been using them for our own training, performance training and for rehab for many years. At first a lot of the exercises come to most of us from watching others – either people in the gym or colleagues. I remember learning exercises by body part as part of my sport science degree, and then from prominent industry experts when I was working in gyms. The process was always the same: watch the exercise, learn the teaching cues and then correct others’ technique.

However, it occurs to me now that this might be a bit backwards!It’s probably a process we’ve all been through, but we are learning random exercises with no structure (or at least I was). Now when I am prescribing exercise I really want to build the exercise based on that individual patient, not simply give out pre-determined exercises.

I often see patients who have been given exercises by someone else, or found them on the internet, and although there is nothing wrong with the exercise in itself it is totally inappropriate for that individual. For example, given standard exercises for whiplash – which are fine for some and make others much worse – there’s no thought process. Now I believe that the exercise has to be for the individual, and not the other way round.

So how do we build exercise?

The starting point has to be an understanding of function. You need to know what is happening in the individual’s desired function eg gait, kick a ball, jump etc. I most commonly work with gait as a basis as that is what my patients need. Then we need to know the goal of the exercise eg range, strength, power, stability etc. Then it’s time to put it all together, build the exercise around the desired function and then tweak the parameter to suit the goal.

Here’s an example:

Limited right hip internal rotation in gait, causing the foot to spin out when it is a back foot (we’ll assume I’ve cleared all other joints/planes).

Well, we know the function is gait, so we need to know what is contributing to this function, we’ll stick to the hip so it doesn’t get too complicated. If we are looking at a back foot motions we know the hip will be going through extension, abduction, and internal rotation. We know the goal is range as internal rotation is limited. So let’s build!

We want the exercise to challenge end range, so I would keep the right foot (limited side) on the floor to allow the foot to be relatively fixed. I would start the exercise with right foot forward and drive the left foot either anterior or right anterior lateral. This creates a fair amount of extension and internal rotation, but limited abduction if any. I would then add bi-lateral arms, right rotation at shoulder height, timed to hit end range immediately after the hip reaches end range. You can then tweak the arms to add more hip extension or more abduction as you think necessary.

This is a totally different process, but you end up with the perfect exercise for that individual and you have far more control over the exercise. Because you built it with your thought process, you can tweak it infinitely to meet the needs of your client.

Neil Poulton

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Loads of Shoulder!

Posted on February 19, 2012 by admin

A few months ago I had a few weeks when all I seemed to treat was shoulders. On some days, out of about 10 patients I might have seen 7 with shoulder pain! Crazy! And I learned a few things from a couple of them. One patient in particular was memorable as she came up with a strategy of her own, and it was really effective.

If you have read my shoulder masterclass blog posts, you’ll know the types of strategies I use. But recently one of my patients added a very simple but very effective way of improving the proximally driven shoulder abduction exercise.

To quickly recap, I get the patient holding onto a bar at about shoulder height in abduction. Then I get them to drive their pelvis in the frontal plane, driving away from the wall and back repeatedly. While they are doing that, I work on their scapular movements, either speeding up or slowing down the scapular, depending on what the patient requires.

As I have always found this strategy to be effective I had never really looked to change it or improve it. Though having said that, it is hard for some people to get good range because they cannot drive their hips far enough. In this situation I usually let them escape into the transverse plane, which allows them to achieve a greater range in abduction, which is fine. But then recently my first patient of the day, who had been having this problem, said: “If I drive my opposite arm overhead towards the wall I feel I will get much more range”. Why the hell didn’t I think of that? So simple, but awesomely effective! Always happy to learn. :-)

So I used it with a couple of patients in the afternoon (I had plenty of practice as it turns out) and it was great. If they can do it the old way I leave well alone, but if they struggle we use the overhead driver. It will be interesting to use the next time I have a patient with back pain as well, as often they can’t do this one. Maybe this will make it easier for them?

One of the other shoulder patients had a problem when practising martial arts. As he hit end range he got pain in the posterior shoulder. We reduced it by about 80% with the proximally driven motions (I used flexion and abduction in this case) and then we used IASTM to work around the shoulder while we gradually increase the speed at which he was punching. Once he was punching pain-free we loaded up the shoulder in a press up and by the time he left he had no pain, had full strength/power and should be able to complete his second degree black belt at the end of the month. Lush!

Neil Poulton

Posted in Articles for Personal Trainers, Articles for Therapists, Exercise Therapy, Functional Assessment, Injury rehabilitation, Manual Therapy | Tagged , , , , , | Leave a comment

Understanding Knee Abduction

Posted on February 19, 2012 by admin

I recently started teaching a new group of Functional Therapists, and over the first weekend we covered modules 1 and 2: Observing and Predicting Human Motion and Mastering Movement and Muscles of the Lower Limb. Part of this first weekend is to bring everyone to the same understanding of how bones move, how joints feel and how muscles react to those joint motions.

One of the hardest things to get your head around when you start is how to name joint movements, and again there are a few that always trip you up because they are a little counter-intuitive. The one that springs to mind is knee abduction, so we’ll use that as our example.

Throughout Functional Therapy we are trying to gain a greater understanding of gait as a foundation movement, and so at the knee we go through the motions in all three planes as a front leg and a back leg. As a front leg, the knee is flexing, abducting and internally rotating, and it is the abduction at this point that causes so much confusion.

If we are talking about the right leg, then we know that in the frontal plane the tib and fib are tilting left and the femur is still tilting right, which gives you a knee joint motion of abduction through both bones moving in opposite directions. Sounds simple when you write it like that, but the confusion comes when you look at the knee motion in function.

I think this is partly because in anatomy and human movement we are taught that frontal plane motion is measured from the mid-line of the body, with movement towards the mid-line being adduction and movement away from the mid-line being abduction. Makes sense for some motions, but it doesn’t work in the case of knee abduction. In this case the limb moves towards the mid-line of the body, which would suggest the knee is adducting, but we are not talking about where the limb moves to, we want to know what the tibia is doing relative to the femur. So the mid-line of the body is irrelevant, it’s the mid-line of the knee joint that is important.

This is a brilliant insight from John Tran who described the knee motions like this and it makes perfect sense. If you draw a line vertically on the front of the knee, movement that moves the tibia to the outside of this line would be abduction, and movement to the inside would be adduction. Makes understanding adduction/abduction much easier, particularly when you are looking at the knee in function.

So, in future I will be using this thought process in explaining motion at the knee, or any other joint motions that cause confusion. All thanks to John Tran. :-)

Neil Poulton

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Type I and Type II Motion in the Lumbar Spine

Posted on February 18, 2012 by admin

I have spoken many times before about using Type I and Type II Motion in the thoracic spine. I have to say it is one oif the most useful things you can use, whatever the patient’s pain or dysfunction. Although this may get used in response to an injury, the most direct use for it will be for neck pain and lumbar spine pain. However, if you have cleared the hips, feet and thoracic and there is still pain or dysfunction, you may want to drive motion through the lumbar more directly.

For this I use a Type I/Type II Motion Matrix specifically for the lumbar spine. This was something I picked up from Gary Gray and is absolute genius to be perfectly honest! As with all techniques it is knowing when to apply it appropriately – when it is appropriate it works brilliantly. As with all techniques I use, the exercises have to be performed pain free.

The lumbar spine seems to respond better to Type I Motion when it is in mid-range of sagittal motion, and Type II when it is in a relative end-range of either flexion or extension.

So here are my strategies. I use a step to help drive the sagittal and frontal plane motion and I use the step forward to drive the lumbar from the bottom up, and hand drivers to drive the sagittal and transverse plane. I also use a relatively heavy weight in the same side hand that is on the step. This helps drive the lumbar in the frontal plane from the top down. I told you it was genius!

Examples:

Type I Motion

I start by asking my patient to stand on the step for this one as it drives the lumbar spine really well via the pelvis. To create the Type I motion at the lumbar, step off with the right leg. This anteriorly tilts, right tilts and left rotates the pelvis, causing extension, left lateral flexion and right rotation of the lumbar spine. However, because the anterior tilt creates a fair bit of extension, I would suggest driving the left hand into right rotation at around hip/knee height to create a little flexion to keep the lumbar spine in mid range.

To create the opposite Type I motion, you can simply reverse everything :-)

Type II Motion

If you are trying to create Type II motion, right rotation and right lateral flexion. This time you step onto the step with your right leg. This gets you a posterior tilt, left tilt and left rotation of the pelvis, which gives you flexion, right rotation and right lateral flexion of the lumbar spine. Because this is Type II motion, I want to be towards end range so I usually drive the left hand into right rotation at knee height. This further flexes the spine and gives a top-down driver of right rotation, which complements the bottom-up driver. Again, I would use a weight in the hand that is on the step, so right hand this time. Again, reverse everything to create left Type II motion.

These exercises can be very gentle if you keep up the speed and the range down, and should always be pain free, but you can increase as the client is able. They are also a great way to assess which motions the person has trouble with. As you watch them go through each motion you can see if there is a limitation in any particular plane or with either Type I or Type II motion. Most people will prefer one or other of the motions, which gives you a great place to start when trying to improve lumbar spine motion.

Neil Poulton

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Planning a Treatment

Posted on February 18, 2012 by admin

If you keep notes and you use the SOAP notes format:
* Subjective
* Objective
* Assessment
* Plan
you are supposed to write a plan as the last part of your notes. In my experience, the plan varies in detail from practitioner to practitioner. However, although I see the need to plan, I also see a great need to constantly assess and adapt treatment to the needs of the individual patient.

I tend to have a plan in my head, which is based on the whole of the last treatment:
* Their response to the previous treatment
* The tasks they have found difficult/painful this week
* The response to the treatment that day
* Progression relative to the healing of the injury

All of the above are in my head all the time while I am treating. My main goal depends on the patient, their injury and what is achievable in that session.

My difficulty with the SOAP notes plan is that there is often a week between treatments. How do you know the effects of the treatment from the first week to plan your next treatment? I personally tend to use the plan to provide reminders of where to go strategically, rather than getting too specific as a week can be a long time in the life of an injury or dysfunction.

I also find that with Functional Therapy I am able to make quite rapid changes in 30 minutes and that in conjunction with their exercise programme I might need to totally re-assess their current state on the next appointment, because my initial assessment is already out of date. I often even see kinds of changes during a single session so I would have to re-assess one joint having worked on another, and thus made changes to the whole kinetic chain.

For example, a hip that seems to be completely locked down may free up once I have finished working on their foot, therefore my “plan” to work on their hip would now be a waste of time. Therefore, I favour continual assessment over the reliance upon a single initial assessment to make a plan.

Although I am sure many practitioners think like this, it’s not often talked about and I have often seen very detailed plans for patients. I think an over-arching plan is important, but there needs to be a working flexibility that allows you to adapt not just between sessions but within sessions. Assess, treat, assess, treat is the only way for me, as you never know what effect treatment will have on function.

In the long run it will save a lot of time and it has the added advantage of helping you build a functional profile of the patient, which is invaluable when trying to resolve complex and long standing dysfunction.

Neil Poulton

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Movement is Driven – but from where?

Posted on February 18, 2012 by admin

I was talking to a friend of mine recently who is looking at movement analysis techniques using various gizmos that I don’t understand. This resulted in me thinking through various movements, considering how we analyse movement, and how we determine what we think a joint is feeling. Anyone who has done a FASTER course will know that there are 5 ways of achieving any one joint motion, for example, 5 ways of achieving hip flexion, hip internal rotation etc.
So how do we decide? Well, if you’ve been with us for a while you will have seen the Diploma develop over the last few years. In particular there has been a shift in thinking towards the bones move, joints feel, muscles react concept. This allows you to more easily see what is going on, even in planes that are not easy to see at some joints.

Someone smart also once said that force can neither be created nor destroyed, which means that you are looking at what is driving the motion and, therefore, where the force is coming from. This allows us to understand movement even if we can’t see what is happening in a particular joint or plane of movement.
If we stick to gait for now, we know that as a front leg it is the ground reaction force that is the primary driver for the lower limb and up to the lumbar spine. As a result we can use this information to decide which motion is occurring in each of the three planes.
As a general rule you are looking at the bone that is closer to the driver moving faster. However, as with all rules there are exceptions, and in particular in the foot you have to be careful as the shape of some of the joint surfaces allow this rule to be broken.
Let’s look at an example: we’ll use the front leg load in the right knee for this.
Bones Move
We know that as a result of the motions at the foot that the tibia is anteriorly rotating, tilting left, and rotating left.
Joints Feel
It’s easy to see from this that in the sagittal plane the knee will be flexing as both bones are moving in opposite directions to create flexion. Again in the frontal plane both bones are moving in opposite directions to create abduction. Things get a little more tricky in the transverse plane. It’s hard to see from the outside if there is internal or external rotation, and because the bones are both rotating to the left there’s no obvious explanation there. So we have to look at where the movement is being driven. The force is coming from the ground up. This means we can assume the tibia is rotating faster than the femur, giving us internal rotation in the transverse plane.
Hopefully, that’s easy to see but let’s go through the back leg in gait, just to be thorough.
Bones Move
The tibia is anteriorly rotating, tilting right and rotating right. The femur is anteriorly rotating, tilting left and rotating right.
Joints Feel
Now in the sagittal plane the tibia and the femur are both anteriorly rotating. However, the driver now is not the ground reaction force, but comes from the opposite leg swinging through and the forward momentum of walking. As a result, the femur will be rotating faster, resulting in knee extension. In the frontal plane they are moving in opposite directions so it is easy to see the knee is going through adduction. Again, in the transverse plane they are both rotating in the same direction. This time they are both rotating to the right, however with the driver coming from the top down we can assume that the femur will be rotating faster. This will result in the knee feeling internal rotation in the transverse plane.
This simple example shows both how the driver change influences the bone movements and how we determine what the joint feels. If you go through that thought process at each joint and each plane of motion you will have a very powerful assessment and treatment tool.

Neil Poulton

Posted in Articles for Personal Trainers, Bone movement, Functional performance, Joint Feeling | Tagged , , , , | Leave a comment

What a Joint Feels

Posted on February 17, 2012 by admin

Recently I wrote about how movement is driven, and I went through how the bone movements lead you to what the joints feel. Remember: bones move, joints feel, muscles react. The example I used showed how we determine what the joint is feeling even when the proximal and distal bones are moving in the same direction. In that scenario at the knee we determine which is moving faster by asking which one is closer to the driving force of the movement.
The one thing I didn’t explain was how we name a joint movement. In the example I used, the knee felt internal rotation with both movements. However, in the first movement all the bones were moving left and in the second all the bones move right, but you get internal rotation with both. The reason this is possible is because in one case the driver is coming from below and in the other the driver is from above.
As we know, there are 5 ways of getting a joint motion. The above are just two of the ways of getting internal rotation. The other three are proximal still/distal moving, distal still/proximal moving and both moving in opposite directions. But, how do we name the joint movement?
Well, in anatomical terms, a joint movement is named by what the distal bone does on the proximal bone. So, in the case of the knee, if you imagine that the femur (proximal bone)is still, it is the tibia movement that will determine the name of the joint movement.
If we stick with the example of right knee internal rotation and we keep the femur still, it’s what the tibia does in the transverse plane that we need to consider. If in this scenario the tibia rotates right, the knee will feel external rotation, and if the tibia rotates left the knee will feel internal rotation. Simple as that!
It becomes more complicated when you are trying to look at functional movement with both bones moving in all three planes, but in my mind I always bring it back to the simple bone motions and then decide which motion the joint is feeling.

Neil Poulton

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