One of the students has just send a message saying she's selling her place on this course .... hence I hope Ive got in there first to buy it off her !!!
Well I'm now on a role with my Functional Approach. Prof Lederman's course was actually very informative ... not so sure I agree with the whole 'you don't kneed to know your anatomy approach, just the function of the body parts' ... but I definitely like his approach to rehabilitation through active movement apposed to passive static treatment on the plinth.
Have a Nigerian patient who's English isn't very good with a suspected annular strain. Due to the communication barrier Ive not been able to HVT here TSpine ... but I think functional active rehabilitation will be able to help her hence I tried it out for the first time ... it was only a matter of minutes til she tired and didn't want to participate any more ... not sure how to engage her in the activity but I'm determined to make it part of her recovery.
Prof. Eyal Lederman
Copyright 2009 Neuromuscular Rehabilitation in Manual and Physical Therapies
This workshop explores how manual and physical therapists can help individuals to recover their movement control. Musculoskeletal injury, pain experiences and central nervous system damage are all associated with diverse neuromuscular and movement control changes. The aim of this workshop is to provide the theoretical and practical basis for neuromuscular rehabilitation for these conditions.
This workshop is intended for manual and physical therapists of all disciplines, (physiotherapists, osteopaths, chiropractors, sports massage therapists, etc.) who work with patients whose conditions involve the neuromuscular system. The workshop will also be useful to Personal trainers, Alexander Method teachers, Pilates instructors, Postural Integration teachers, Rolfing practitioners, sports trainers and individuals who experience losses in movement control.
A functional approach in rehabilitation
A functional approach in rehabilitation is the key concept underpinning the management described in this workshop.
Functional movement is defined here as the unique movement repertoire of an individual. Some of this repertoire is movement behaviour associated with daily needs and demands such as feeding, grooming, going places, etc (general skills). Some of this repertoire is partly shared by others and some may be unique to particular individuals; they include physical hobbies, sports and occupational activities (special skills). For some people, their functional repertoire will include playing tennis, for another standing on their head (Yoga) or playing the piano and so on. Once a person learns a movement or a new skill it becomes a part of their movement repertoire and therefore, their behaviour. Movement which is outside the normal repertoire of an individual will be termed here as “extra-functional” (Fig. 1).
Functional rehabilitation is defined here as the process of helping a person to recover their movement capacity by using their own movement repertoire (whenever possible). Hence, for a person who has motor losses at the knee and is unable to walk or run, the rehabilitation will be in walking, then running, jumping and stair-climbing, etc. If this person plays tennis, this activity will also be used in the rehabilitation programme.
However rehabilitation is likely to be less effective if the remedial movement patterns or tasks are outside the individual’s experience (extra-functional). For example, it would be less helpful for a tennis player with a leg injury to be given rehabilitative exercise such as football, or leg presses in the gym or leg exercise lying on the floor (Ch. 2). For this particular patient, rehabilitation that incorporates tennis tasks is more likely to be useful. For a person who is suffering from lower back pain and enjoys Yoga, a functional rehabilitation would consist of the shared functional activities but may also include some of the upright postures from Yoga. A less suitable rehabilitation approach would be to prescribe tennis to this individual. This may seem obvious, however, movement rehabilitation often prescribes extra-functional tasks such as core stability training on the floor, bracing the trunk or strength training with equipment. The question is how effective these activities are in recovering functional movement.
The Introduction of extra-functional activities during rehabilitation raises some problems. Extra-functional activities or exercise require learning a new task at a time when the patient is experiencing pain and/or loss of movement ability. This might not be the best time to enter a new exercise regime. Learning requires set-aside time, intense mental focus and physical effort. Often it means the patient has to be dependent on others for instructions and guidance during the training. A functional approach which aims to use the patient’s own movement resources does not require additional learning; the cognitive demands are less taxing and do not require protracted training. Also the set-aside time for practice is more manageable for the patient. Furthermore, the rehabilitation programme seldom relies on any specialised exercise equipment. The remedial movement challenges are an integral part of the person’s daily activities and therefore, can be practised anywhere and at any time. A functional approach is easy to apply and it empowers the patient to self-care.
There are exceptions to the functional approach in rehabilitation. There are circumstances where the patients will require specific exercises for particular motor losses, challenges which are not provided by their functional repertoire. There are also situations where the individual is physically unable to perform functional activities. When and why the rehabilitation should stray from this model will be discussed throughout this workshop.
Rehabilitation levels: Skill and ability level rehabilitation
Movement rehabilitation and motor normalisation following injury occurs naturally for most individuals. Following injury most humans will take physical actions that will support their spontaneous and unaided recovery. This would happen without any special knowledge or understanding of the underlying physiological principles underpinning their recovery. In this form of rehabilitation the individual is attempting to, partially or fully, execute the movement that has been lost. Attempting to walk becomes the rehabilitation for the person who lost the ability to walk. Similarly, if an individual with an arm injury is unable to reach; their repeated attempts in that pattern would often be their rehabilitation. The focus in this form of movement recovery is on the overall skill of performing the particular movement. This will be loosely referred to as skill rehabilitation.
However, this approach does not always lead to the intended results. Individuals who are in pain or have motor losses may develop movement patterns that circumvent their losses. A patient may present with walking difficulties due to losses in the control of balance and coordination. Using the similarity principle, one would imagine that by encouraging the patient to increase their walking, “walking would train balance and coordination during walking”. However, what may happen is that the patient will get better at using their compensatory pattern; walking slowly, using wider gait, shorter steps, rather than truly improving their control of balance and coordination during walking.
Balance and coordination are part of several control building blocks that make up skilled movement. These building blocks are called sensory-motor abilities. A therapeutic approach that targets the various motor abilities will be termed in this text as “Re-Abilitation”. At this level of rehabilitation the aim is to recover control losses associated with particular abilities. Hence, in the walking scenario described above, the rehabilitation would aim to challenge balance and coordination in dynamic and upright postures (Fig. 2).
Skill rehabilitation and re-abilitation are both clinically important and are often used in combination. However there may be a shift of focus towards one of these particular approaches depending on the individual’s condition and their phase of recovery.
The code for neuromuscular adaptation
Neuromuscular rehabilitation is a straightforward process – anyone can do it. Indeed, we all do it all the time. Every day we take actions that result in movement and behaviour changes; we can self-modify our motor control. Furthermore, the neuromuscular system has the capacity for self-recovery and to reorganise in response to injury. It means that within our behaviour there are certain elements that facilitate the recovery of movement control.
In functional rehabilitation we identify five such elements that optimise neuromuscular adaptation: cognition, being active, feedback, repetition and similarity (Fig. 3). Hence in order to learn a new task, modify our behaviour or help our system recover we need to be aware of what we are doing (cognition) and we have to actively perform the action that we aim to recover (being active). In order to correct our movement we rely on internal information from our senses or depend on guidance by someone (feedback) and we have to practise the task many times (repetition). Furthermore, the practice has to closely resemble the movement we aim to recover (similarity). Hence, to play the piano a person needs to practise the piano. However, strength training with finger weights or practising push-ups is unlikely to benefit playing the piano. The practice has to be task-specific.
The recovery of motor control can be facilitated by introducing the adaptive code element into the rehabilitation programme. It will promote a functional recovery that is more likely to benefit the patient in their daily activities. The results are more likely to be maintained in the long term and could help to reduce the overall duration of the treatment programme.
Developing a neuromuscular rehabilitation programme
Much of the rehabilitation promoted in this workshop is the marrying of the three concepts discussed so far:
1. The focus on functional movement,
2. The principle of skill/ability level rehabilitation
3. The code for motor adaptation.
Through a simple three steps process the therapist decides which level of rehabilitation will be used and applies the motor adaptation elements to the treatment programme. Many of the remedial challenges are selected from the patient’s own movement repertoire. It really is that simple.
The beauty of it all is that these principles can be applied to any condition in which the neuromuscular system is implicated:
Conditions with an intact motor system
• Neuromuscular changes associated with musculoskeletal injuries, sports injuries, post surgery, back pain and other musculoskeletal pain conditions
• Conditions where certain behaviours impede recovery or may lead to injury or pain
• Non-traumatic pain conditions such as trapezius myalgia, chronic neck pain and painful jaw
Conditions where there is damage to the central nervous system (CNS):
• Stroke, head trauma and post CNS surgery and all the degenerative conditions
The main difference in managing these conditions is in the magnitude of losses, the duration of recovery and extent of potential recovery.
Summary
• Neuromuscular rehabilitation aims to help the individual recover their movement control
• Functional movement is the movement repertoire of an individual
• Functional movement is individual-specific
• Functional rehabilitation uses the patient’s own movement repertoire to help them recover their movement losses
• The rehabilitation promoted in this workshop has three basic recurring concepts:
1. It aims to be functional
2. It uses the skill/ability level rehabilitation concept
3. It uses the learning/adaptation code to optimise motor control changes
