Functional Rehab Essentials for the Fit Pro

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WWW.Cor-Kinetic.COM

 

Over 4 hrs of content for only £49

 

 

This brand new product from Cor-kinetic is designed to give the fitness professional a better understanding of the rehabilitation process and their role within it.

Forget the crap you see on the internet about the 3 best ways to do X or how to get rid of pain in seconds rubbish. If you really want to understand the science behind what you really need to know in the 21st century then this is for you.If you are more interested in sketchy science, bro science and fantastical (and therefore questionable) results then it is probably not.

It is not about magic answers but instead the key considerations that will make you credible to both your client and their medical professional.

This product takes the science, the evidence and the research and seeks to explain the findings and implications for YOUR business simply, clearly and concisely.

If you want to become a trusted fit pro, build another element to your business and grow your knowledge base then this is definitely for you.

Below we have some short video previews of some of the content.

 

Content

 

Lesson 1 – What the hell does functional mean?

 

Lesson 2 – The role of the fit pro in rehab

 

• Where do you fit in?
• What can you do?
• How to communicate with the others in the rehab process

 

Lesson 3 – Pain & the modern understanding

 

• Pain and brain
• Hurt does not equal harm
• Other factors that affect the pain experience

 

Lesson 4 – Pains affect on movement

 

Lesson 5 – Variables

 

• Key variables that are manipulated in successful rehab exercise

Lesson 6 – Graded exposure

 

• The key to successful rehab – Getting the overload just right and the factors involved

Lesson 7 – Functional strength for rehab

 

• Strength is not just weight
• F = MA
• Strong for what?

Lesson 8 – ACL case study. Bridging the gap between the research and the gym!

 

• Mechanisms of injury
• Movements involved in injury and rehab
• Evidence & research
• Key considerations

Lesson 9 – ACL rehab program video

 

• Designing a program
• Graded exposure to performance and return to play

Lesson 10 – Hip mobility progressions for rehab

 

• An example of improving hip capacity
• Cor-Kinetic rehab process

Lesson 11 – Lunge assessment case study.

 

 

*CLICK HERE*

to buy

 

Thinking critically about your continuing education!?

Continuing education (CE) outside of a professional qualification is always going to be a good thing. The more we can learn and expose ourselves to information the better.  I am always reminded of a profound statement from a friend a few years ago in which he said:

“Have you got 10 years experience or 1 years experience, 10 times”

This can sometimes sum up some peoples evolution within their chosen profession.

As well as a lack of learning, problems can also arise when we don’t evaluate the information we are learning sufficiently. Learning is not just about sitting in a room and diligently making notes from a well respected or even revered ‘guru’ but critically evaluating the information, the evidence presented and its plausibility.

In fact being critical about the information all around us on websites, blogs, articles, journals; conferences etc is important. This blog just happens to be about the sometimes murky world of continuing education but myths continue to be perpetuated in the worlds of therapy and fitness in many forms and at an institutional level sometimes. That is why we have seen the emergence of many critical thinking websites and articles dedicated to myth busting. It does not matter if you are a personal trainer, physio, osteopath or massage therapist, some basic critical thinking skills will benefit you.

On a simple level with a basic understanding of science, does what you are learning make any sense? I have listened to many theories presented in vast technical detail but when you peel away the layers of the onion the basic idea underneath does not hold water or when subjected to rigorous scientific trial does not produce the desired or expected results.

Science

To be able to evaluate the basic science we first must have a grasp of the basic sciences behind the body, its anatomy and function. Continuing education can prey on this area sometimes. In both the fitness and therapy worlds magical wonder courses offering instant miracle cures or earth shattering results are often more attractive than those offering quality science, evidence, hard work, limitations and a dose of reality.

Any idea or technique has to be underpinned by basic science. I think sometimes we take the view that if we don’t understand it is because we are less intelligent than those teaching it. In fact I have felt like this myself in the past, especially if the teacher has obtained a certain status in their chosen field.

It maybe however that it actually just does not make sense and to disguise this it is layered in ever more complex wrappings. Einstein said:

“If you can’t explain it simply, you do not understand it well enough”

Although we can delve in to the minutiae of any concept it is often the best teachers who can make you understand the complicated in a simple digestible manner at first.

Cult of CE

Here we get to the cult of CE. I have a basic rule, if it seems to be to good to be true, it is!

If it is a wonder ‘secret’ that no one else knows or offers to provide miracle cures to debilitating problems but cannot offer plausible science or evidence then we have to say, why is that? Often however people are hooked by the extraordinary efficacy and rapid gateway to the status of miracle worker instead of asking the hard questions.

Often they offer close to 100% success rates but anyone who has worked with the body knows we can easily make problems worse as well as better and often do. If the ‘method’ (Disclaimer: The reference to ‘method’ is not meant to reflect any particular ‘method’ or organization, just merely for want of a better term) does not work for the patient or client then it is their fault rather than the fact the ‘method’ may not be right for that person.

No one ‘method’ will be right for everybody all of the time.  We may need many skills to help many people. The biggest skill of all is to know when to pass someone along to be helped by someone with a different set of skills.

We also must realize reams of testimonials are simply not evidence of a ‘method’ working.  A facebook page or website piled high with testimonials and case studies is simply no substitute for evidence. It is often not the ‘method’ I object to but the claims that surround it. If you claim it, you prove it! The onus should be on the person making claims to prove it not to be disproved by others.

The same people who go for this kind of ‘method’ would laugh at the faith healer in a church who offers miracle cures but I fail to see the difference as they are often based on a belief and claims rather than evidence or science.

Obviously it would be great if we all lived in a world where we were honest and upfront about our limitations but, newsflash, we aren’t. We can also be blinded by our own conformation biases both when teaching and using  ‘methods’ we are earning money from and have spent good money on. It has to come down to the individual to critically evaluate the information being taught. Often we see opinion served up as hard evidence and fact both from ‘guru’ types and their disciples, who if challenged appeal to the authority of their chosen ‘guru’.

It has to come back to the individual to be critical of what they are doing with their clients and patients. We should be critical of ourselves first and foremost before turning our critical eye on others. Often followers of a ‘guru’ or ‘method’ are quick to turn their critical thoughts onto other ‘methods’ but less willing to turn it on themselves.

Adam Meakins of thesportsphysio.wordpress.com has a well written and honest blog on being critical here.

Critical thinker? Or just an arse?

Being critical

When undertaking any education we have to say to ourselves:

Are the techniques and opinions presented well supported by firstly scientific plausibility and then some evidence relating to the proposed efficacy?

Unfortunately ‘in my experience’ just does not cut it and neither do testimonials. A basic scientific rationale is good but we have to be aware of modern evolutions in thinking. An example might be ‘overpronation’ presented as a problem that needs to be addressed but we simply do not know what ‘normal’ pronation is to be able to say what is ‘over’ and if this is a problem anyway. This boils down to an assumption or theory rather than being based in science or evidence.

What is the quality of research presented?

Firstly is there any? Theories based on ideas key to a ‘method’ don’t really count in this respect. Without some form of research or evidence these amount to little more than nice stories.

Then we have to look at quality of evidence. Not all research is equal in method and the conclusions and evidence do not always nicely tally up. If you read around the subject is there also a weight of associated evidence or a dearth of available information? If it does boil down to experience or opinion then this should be made clear rather then presented as hard evidence. The people I respect most often do this.

P.S Case studies and testimonials don’t count!

Does the information presented evolve and change as new information and research comes to light?

If your chosen CE provider has stayed still for the last ten years pedaling exactly the same message whilst the rest of the fitness or medical community has forged boldly on then in my opinion they are lazy or arrogant. New studies and research come to light everyday offering new perspectives on a host of subjects. Can we just discount them? My personal opinions change regularly. This is not about being wrong but now having better information than before. That’s called evolution. The most important thing is the critical and introspective thought process than being right or wrong at any given moment.  This is certainly not an easy thing to do or something I personally have always done. Maybe each of us has our own critical epiphany somewhere along the way.

Same old, same old!

The worst perpetrators are those that continue to peddle the same old information even though there maybe a weight of evidence contradicting some of the underpinning foundational ideas behind a particular approach.

This is where CE can become more of a business than education business. Many ‘methods’ excel at marketing, a necessary evil, but this can often hinder change and evolution that is vital for progress.

Sometimes CE is a little bit like having a brand loyalty such as shopping at the same supermarket. Loyalty can go a long way to stopping us running a critical eye over what we are being taught; especially if there is a social aspect or community feel from being amongst ‘like minded’ people. Multiple levels and arbitrary certifications can keep people coming back for more rather than exploring different approaches.

Often we can get individuals who are very good at knowing the intricacies of a system or ‘method’. We could confuse that with being knowledgeable about a broader understanding of the body and related research.  If you take the individual outside of the ‘method’ are they quite as impressive? Good knowledge of a ‘method’ is different to having good knowledge!

I sincerely believe that there is merit in the teachings and experiences of many educators and ‘methods’. If you can critically evaluate the information it allows us to be able to take what is useful and based in science and evidence and maybe discard what is not. The problems start when we accept hook, line and sinker a ‘method’ without question. Any educator who does not like being questioned is simply not worth his salt. If they cannot offer you explanations or evidence from where they formed their opinions then that is a deal breaker in my opinion.  I run CE courses myself and I encourage critique. In fact I sometimes tend to get the most critical thinkers it seems!

We can build our own personal opinions and technique toolbox based on our own education, scientific knowledge and an appreciation of the current evidence base rather than being a (fill in the blank) “……. practitioner”. Learning how to think critically and applying a critical mindset, is well, critical to this. Just paying your money and simply accepting the information is lazy learning and allows the perpetuation of information without a solid and plausible science and evidence base.

An awareness that everything that glitters is not gold is the first step to having a more critical mindset. Of course the opposite end of this is being so critical than you never move from your narrow bandwidth of beliefs. In fact we can use critical thinking to reject anything that does not fit with our current mindset. We also have to realize the limitations of our current evidence base and look to expand this rather than be limited by it.

If we were to never hypothesis or theorize we would never push things forward. These theories do have to based on science and look to be validated by evidence if we want to make claims about their efficacy.

The more critical we become then the better the information that is served up in our education will have to become.

‘I want to believe, I really do, you just have to help me’ would be a great slogan for a T-shirt for the next CE I attend, and I will be attending some I assure you.

Thinking critically about continuing education.

Continuing education (CE) outside of a professional qualification is always going to be a good thing. The more we can learn and expose ourselves to information the better.  I am always reminded of a profound statement from a friend a few years ago in which he said:

“Have you got 10 years experience or 1 years experience, 10 times”

This can sometimes sum up some peoples evolution within their chosen profession.

As well as a lack of learning, problems can also arise when we don’t evaluate the information we are learning sufficiently. Learning is not just about sitting in a room and diligently making notes from a well respected or even revered ‘guru’ but critically evaluating the information, the evidence presented and its plausibility.

In fact being critical about the information all around us on websites, blogs, articles, journals; conferences etc is important. This blog just happens to be about the sometimes murky world of continuing education but myths continue to be perpetuated in the worlds of therapy and fitness in many forms and at an institutional level sometimes. That is why we have seen the emergence of many critical thinking websites and articles dedicated to myth busting. It does not matter if you are a personal trainer, physio, osteopath or massage therapist, some basic critical thinking skills will benefit you.

On a simple level with a basic understanding of science, does what you are learning make any sense? I have listened to many theories presented in vast technical detail but when you peel away the layers of the onion the basic idea underneath does not hold water or when subjected to rigorous scientific trial does not produce the desired or expected results.

Science

To be able to evaluate the basic science we first must have a grasp of the basic sciences behind the body, its anatomy and function. Continuing education can prey on this area sometimes. In both the fitness and therapy worlds magical wonder courses offering instant miracle cures or earth shattering results are often more attractive than those offering quality science, evidence, hard work, limitations and a dose of reality.

Any idea or technique has to be underpinned by basic science. I think sometimes we take the view that if we don’t understand it is because we are less intelligent than those teaching it. In fact I have felt like this myself in the past, especially if the teacher has obtained a certain status in their chosen field.

It maybe however that it actually just does not make sense and to disguise this it is layered in ever more complex wrappings. Einstein said:

“If you can’t explain it simply, you do not understand it well enough”

Although we can delve in to the minutiae of any concept it is often the best teachers who can make you understand the complicated in a simple digestible manner at first.

Cult of CE

Here we get to the cult of CE. I have a basic rule, if it seems to be to good to be true, it is!

If it is a wonder ‘secret’ that no one else knows or offers to provide miracle cures to debilitating problems but cannot offer plausible science or evidence then we have to say, why is that? Often however people are hooked by the extraordinary efficacy and rapid gateway to the status of miracle worker instead of asking the hard questions.

Often they offer close to 100% success rates but anyone who has worked with the body knows we can easily make problems worse as well as better and often do. If the ‘method’ (Disclaimer: The reference to ‘method’ is not meant to reflect any particular ‘method’ or organization, just merely for want of a better term) does not work for the patient or client then it is their fault rather than the fact the ‘method’ may not be right for that person.

No one ‘method’ will be right for everybody all of the time.  We may need many skills to help many people. The biggest skill of all is to know when to pass someone along to be helped by someone with a different set of skills.

We also must realize reams of testimonials are simply not evidence of a ‘method’ working.  A facebook page or website piled high with testimonials and case studies is simply no substitute for evidence. It is often not the ‘method’ I object to but the claims that surround it. If you claim it, you prove it! The onus should be on the person making claims to prove it not to be disproved by others.

The same people who go for this kind of ‘method’ would laugh at the faith healer in a church who offers miracle cures but I fail to see the difference as they are often based on a belief and claims rather than evidence or science.

Obviously it would be great if we all lived in a world where we were honest and upfront about our limitations but, newsflash, we aren’t. We can also be blinded by our own conformation biases both when teaching and using  ‘methods’ we are earning money from and have spent good money on. It has to come down to the individual to critically evaluate the information being taught. Often we see opinion served up as hard evidence and fact both from ‘guru’ types and their disciples, who if challenged appeal to the authority of their chosen ‘guru’.

It has to come back to the individual to be critical of what they are doing with their clients and patients. We should be critical of ourselves first and foremost before turning our critical eye on others. Often followers of a ‘guru’ or ‘method’ are quick to turn their critical thoughts onto other ‘methods’ but less willing to turn it on themselves.

Adam Meakins of thesportsphysio.wordpress.com has a well written and honest blog on being critical here.

Critical thinker? Or just an arse?

Being critical

When undertaking any education we have to say to ourselves:

Are the techniques and opinions presented well supported by firstly scientific plausibility and then some evidence relating to the proposed efficacy?

Unfortunately ‘in my experience’ just does not cut it and neither do testimonials. A basic scientific rationale is good but we have to be aware of modern evolutions in thinking. An example might be ‘overpronation’ presented as a problem that needs to be addressed but we simply do not know what ‘normal’ pronation is to be able to say what is ‘over’ and if this is a problem anyway. This boils down to an assumption or theory rather than being based in science or evidence.

What is the quality of research presented?

Firstly is there any? Theories based on ideas key to a ‘method’ don’t really count in this respect. Without some form of research or evidence these amount to little more than nice stories.

Then we have to look at quality of evidence. Not all research is equal in method and the conclusions and evidence do not always nicely tally up. If you read around the subject is there also a weight of associated evidence or a dearth of available information? If it does boil down to experience or opinion then this should be made clear rather then presented as hard evidence. The people I respect most often do this.

P.S Case studies and testimonials don’t count!

Does the information presented evolve and change as new information and research comes to light?

If your chosen CE provider has stayed still for the last ten years pedaling exactly the same message whilst the rest of the fitness or medical community has forged boldly on then in my opinion they are lazy or arrogant. New studies and research come to light everyday offering new perspectives on a host of subjects. Can we just discount them? My personal opinions change regularly. This is not about being wrong but now having better information than before. That’s called evolution. The most important thing is the critical and introspective thought process than being right or wrong at any given moment.  This is certainly not an easy thing to do or something I personally have always done. Maybe each of us has our own critical epiphany somewhere along the way.

Same old, same old!

The worst perpetrators are those that continue to peddle the same old information even though there maybe a weight of evidence contradicting some of the underpinning foundational ideas behind a particular approach.

This is where CE can become more of a business than education business. Many ‘methods’ excel at marketing, a necessary evil, but this can often hinder change and evolution that is vital for progress.

Sometimes CE is a little bit like having a brand loyalty such as shopping at the same supermarket. Loyalty can go a long way to stopping us running a critical eye over what we are being taught; especially if there is a social aspect or community feel from being amongst ‘like minded’ people. Multiple levels and arbitrary certifications can keep people coming back for more rather than exploring different approaches.

Often we can get individuals who are very good at knowing the intricacies of a system or ‘method’. We could confuse that with being knowledgeable about a broader understanding of the body and related research.  If you take the individual outside of the ‘method’ are they quite as impressive? Good knowledge of a ‘method’ is different to having good knowledge!

I sincerely believe that there is merit in the teachings and experiences of many educators and ‘methods’. If you can critically evaluate the information it allows us to be able to take what is useful and based in science and evidence and maybe discard what is not. The problems start when we accept hook, line and sinker a ‘method’ without question. Any educator who does not like being questioned is simply not worth his salt. If they cannot offer you explanations or evidence from where they formed their opinions then that is a deal breaker in my opinion.  I run CE courses myself and I encourage critique. In fact I sometimes tend to get the most critical thinkers it seems!

We can build our own personal opinions and technique toolbox based on our own education, scientific knowledge and an appreciation of the current evidence base rather than being a (fill in the blank) “……. practitioner”. Learning how to think critically and applying a critical mindset, is well, critical to this. Just paying your money and simply accepting the information is lazy learning and allows the perpetuation of information without a solid and plausible science and evidence base.

An awareness that everything that glitters is not gold is the first step to having a more critical mindset. Of course the opposite end of this is being so critical than you never move from your narrow bandwidth of beliefs. In fact we can use critical thinking to reject anything that does not fit with our current mindset. We also have to realize the limitations of our current evidence base and look to expand this rather than be limited by it.

If we were to never hypothesis or theorize we would never push things forward. These theories do have to based on science and look to be validated by evidence if we want to make claims about their efficacy.

The more critical we become then the better the information that is served up in our education will have to become.

‘I want to believe, I really do, you just have to help me’ would be a great slogan for a T-shirt for the next CE I attend, and I will be attending some I assure you.

Pain and prediction.

This article is a standalone piece and also kind of serves as the third piece of ‘The brain, movement and pain’ series already released earlier on this blog site.

This follows the loose ‘brain model’ of

Patterns

Perception

Prediction

In this model the brain uses stored neural patterns that are triggered by and compared with feedback to make a prediction of an outcome. Although we may not need any specific feedback to make a prediction, just stored memories.

This piece focuses on the brains prediction to create an output and/or action. In our opinion movement and pain would fall into these categories.

This piece focuses more on pain than movement. Pain is certainly not an area of Cor-kinetic’s expertise but a definite area of interest.

The problems may occur when the prediction of the brain is not a beneficial one. This could be when the prediction of danger or threat is not in proportion to the actual reality of threat to the tissue, especially after previous pain or injury. Pain can be the result of this prediction to limit possible damage even after the state of the tissue has improved.

This is by no means a comprehensive look at the pain experience, just some thoughts. Pain is caused and modulated by many contributing factors often with no single factor to blame in isolation.

Pain

Pain is an exceptionally tricky subject. We know much more about pain than we really know what to do about it and the fact that it is so prevalent provides a significant problem.

Often reconceptualizing a problem can help us change our approach as a few enlightened souls have blazed a trail in the understanding of pain. They have provided new perspectives on the previous Cartesian view that had or could be argued still is, the dominant understanding of the pain process. One such pioneer would be Ronald Melzack and his seminal “neuromatrix’ model. *Click Here* for full paper

(Updated model from, Pain, Melzack and Katz 2013)

It would seem the key to a modern understanding of pain is that it is an output of the brain rather than an input from the body. This starts to separate the connection between damage to a tissue and amount of pain experienced or even nociceptor activity and the pain experienced. The central processing of stimulus, potentially painful or not, within the brain is key to the level of pain experienced by the individual. In fact we may not need any stimulus from the body at all to create pain as we will further discuss.

Lorimer Moseley explains this far more eloquently in, Reconceptualising pain according to modern pain science. Physical Therapy Reviews (2007)

“it is clear that experimental studies do not show an isomorphic relationship between pain and nociceptor activity, nor between pain and the state of the tissues. Rather, they show a variable relationship that is modulated by many factors”

Pain and pathology

The fact that pain can persist many months or years after an injury also confounds the current opinion that pain levels correlates with state of the tissue.  This also questions the constant search for pathology to link with the current pain state of the patient.

Boden et al (1990) performed, Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation, that is scans on individuals with no pain. They found that one-third displayed ‘substantial abnormality’. This raised to 57% for those over sixty. More surprisingly 35% of the subjects between 20 & 39 years old had bulging or degeneration of a lumbar disc.

Borenstein (2001) also looked at MRI as a predictor of lower back pain of asymptomatic individuals. “The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study.”

They found:

“The findings on magnetic resonance scans were not predictive of the development or duration of low-back pain. Individuals with the longest duration of low-back pain did not have the greatest degree of anatomical abnormality on the original, 1989 scans”

A recent study by Graves et al (2012), ‘Early imaging for acute low back pain: one-year health and disability outcomes among Washington State workers’, actually found that:
“Among workers with LBP, early MRI is not associated with better health outcomes and is associated with increased likelihood of disability and its duration”

It lead to a 2-fold increase in the liklehood of work disability benefit 1 year later.

Surgical procedures in response to disc herniation only provides complete relief from pain and sciatic symptoms in 60% of cases. Patients are also rarely helped by vertebrae fusion to provide support for the back. (Melzack, Full article here – Pain 2013)

This highlights the variable relationship with pain and tissue state as discussed by Moseley. An early correlation with tissue state did not lead to a better outcome. Did the link to’pathology’ in fact increase the duration of the pain experience? Again this widens a predictable link between tissue state and pain and also brings into play the patients cognitive evaluation of the situation.

Although we have tried to find many biomechanical or anatomical ‘flaws’ or ‘anomalies’ within the human condition to blame or attempt to predict for various chronic pain. It has proved an elusive game that has not been reliably supported by high quality research and still remains rife with opinion presented as fact.

Pain as an output

To widen the gap between pain and the state of the tissue and make us further evaluate the idea of pain as an output of the brain we must start to look at pain that cannot involve any input from the body. A perfect example would be ‘phantom limb’ pain.

‘Phantom limb’ is when amputee patients still get pain in their limb that has been amputated. It is not an uncommon experience. Nikolajsen & Jenson in “Phantom limb pain” (2001) found more recent studies reported incidences of phantom limb pain of 60 -80%.

Melzack and Katz in their article “Pain” (2013) when discussing phantom limbs state:

“all the qualities of experience we normally feel from the body, including pain, are also felt in the absence of inputs from the body; from this we may conclude that the origins of the patterns of experience lie in neural networks in the brain; stimuli may trigger the patterns but do not produce them”

Macabe et al (2006) in “Simulating sensory–motor incongruence in healthy volunteers: implications for a cortical model of pain” looked at

“Conditions that occur in the absence of a discernible peripheral causal pathology or appear disproportionate to the size of the injury”

such as

“Repetitive strain injury, complex regional pain syndrome-type 1 (CRPS), fibromyalgia, focal hand dystonia and phantom limb pain”

They sought to induce pain in health individuals through motor-sensory central nervous processing. They found:

“Twenty-seven subjects (66%) reported at least one anomalous sensory symptom at some stage in the protocol despite no peripheral nociceptive input.”

Both of the examples above bring into question the current hegemony of pain only stemming from damaged tissue, pathology or structural abnormality. In fact we see pain in these examples without any ‘noxious stimulus’ in some cases without any stimulus or input to the brain at all.

Melzack and Katz in their article ‘Pain’ add:

“In short, phantom limbs are a mystery only if we assume the body sends sensory messages to a passively receiving brain. Phantoms become comprehensible once we recognize that the brain generates the experience of the body. Sensory inputs merely modulate that experience; they do not directly cause it”

Pain as a prediction

So we come to the real subject of the piece. That is introducing pain as a ‘prediction’ of the brain that requires no input from the periphery. This can be why pain can persist long after tissue may heal or in the absence of pathology, and why some people despite MRI findings that we would associate with pain, experience little or no pain.

In Norman Doidge’s book “The brain that changes itself”, Doidge talks to the Indian neuroscientist Ramachandran who has been instrumental in understanding neuroplasticity and phantom limb pain.

Ramachandran discusses chronic pain patients and his belief “motor commands are wired into the pain system” or possibly this could be pain association is wired into the motor program (neurosignature/tag) for certain movements. This may happen after an injury has occurred and to protect the injured tissue the motor command changes. Motor changes in response to pain or injury has also been discussed by Hodges in his ‘Moving differently in pain’ (2010) article.

“When we guard we prevent our muscles from moving and aggravating our injury, if we had to remind ourselves consciously not to move, we’d become exhausted and slip up, hurt ourselves and cause pain” (Ramachandran)

“The brain that changes itself” Norman Doidge. Penguin, 2007, p193.

This causes a neuroplastic change within the functional organization of the brain, creating a ‘”pathological form of guarding”

He goes on to say

“now suppose, thought Ramachandran, the brain preempts the mistaken movement by triggering pain before the movement takes place, between the time when the motor centre issues a command to move and the time when the move is performed” (Ramachandran)

“The brain that changes itself” Norman Doidge. Penguin, 2007, p193.

Understanding pain as an output is vital to this viewpoint. ‘Guarding’ of a movement in the author’s opinion can be both a motor and a pain output. The body can choose to limit movement both through the range or direction of a movement and a pain response.

Where this becomes a problem is once the tissue has healed.

“Ramachandran came to believe that in these chronic pain patients the pain command got wired into the pain system, so that even though the limb had healed, when the brain sent out a motor command to move the arm, it still triggered pain”

The brain still sees the body part as a problem.  Taking this one step further we could start to get pain or discomfort with the thought of moving the affected body part or even discussing it. It would depend on the ‘wiring’ of pain into the many neural patterns involved with painful area in multiple parts of the brain.

One of Lorimer Moseley’s key points in “Reconceptualising pain according to modern pain science“ is

“iv. that pain can be conceptualised as a conscious correlate of the implicit perception that tissue is in danger”

Here we see a consensus on the state of the tissue being unimportant compared to the perception of the state of the tissue or the perception of the tissue being endangered.

This perception could be based on previous events that have occurred to the tissue, such as injury or pain, or movement that the brain may feel is endangering to the tissue. This opens up a whole world of possibilities of previous movement/pain experiences or prediction of future experience having an effect on the pain output from the brain. The damage to the tissue at the site of pain experienced as a cause or link to pathology becoming further removed from the pain experienced. Any correlation further diminishing as more time elapses (Moseley 2007) However we must be mindful that the pain experienced is still very real to the person experiencing it.

Memory-prediction model

One theory of how the brain works is via a memory-prediction model. It is further discussed in this article.

The brain, movement and pain. Sportex July 2013

Faced with so many variables and unable to process them all the brain uses prediction based on previous events and learning experiences.  Bayesian probability theory may give some insight into how this model may work.

“To evaluate the probability of a hypothesis, the Bayesian probabilist specifies some prior probability, which is then updated in the light of new, relevant data“

Bayesian probablility. Wikipedia.

An example of this could be that you hear a song on the radio you know and are singing along. You use your prior memory of the song to predict the upcoming words. We see the same thing in game shows when we fill in the missing letters to a word or fill in the missing word to complete a well-known phrase. The examples available to use to explain the memory-prediction model are countless.

We see this neural process at a base level with rats in response to a reward or sanction associated with pressing a button.

In this way we can start to see a link between past events and the current prediction of threat or danger to a tissue or tissue state.  Especially with a memorable event such as pain.

The prediction is influenced by what has happened in the past. Both on a direct level in terms of storage and recall of specific actions or outputs and also in the overall processing of input and subsequent output commands through our individual ‘neuromatrix’ shaped by both genetic and learned factors.

If we perceive the state of a tissue, regardless of the actual state, as damaged or likely to be further damaged by a motor action, a prediction of a future tissue state, then a pain output could be used to prevent the motor action or a pain association used as an efficient way to limit or modify movement at a motor planning stage.

The problem here maybe that it is not the painful movement or pathology (if present or relevant) is the real problem. Instead it is the perception and subsequent prediction of further damage by the brain. It is much harder to change a learned response. In fact Ramachandran calls this ‘learned pain’. The pain is a habit and as we all know habits can be hard to break.

Pain ‘memories’

Melzack discusses ‘somatic memories’ in his paper, “Pain ‘memories’ in phantom limbs: review and clinical observations”  Even though the limb is no longer present, pre amputation pain persists in the ‘phantom limb’.

Melzack Says
“The results suggest that somatosensory inputs of sufficient intensity and duration can produce lasting changes in central neural structures”
The injuries are varied encompassing:
“cutaneous lesions, deep tissue injuries, bone and joint pain and painful pre-amputation postures”
The pain does not exist within the periphery, it cannot. Instead neuroplastically altering the brain in the specific representations relating to the limb. The question is does this happen in less extreme examples than complete deafferentation?

David Butler in “The sensitive nervous system”, NOIgroup Publications, 2000, says:

“Overuse, lack of use, minor injuries and associated cognitions will also alter representations. Amputation simply serves as a dramatic example”

Here we see previous pain experiences affecting future pain experiences. On a less extreme level than complete deafferentation do we regularly see our pain ‘memories’ neuroplastically reorganizing our brain, therefore altering its future perceptions and subsequent predictions of threat to a tissue? The brain output may range from minor alterations in movement right up to debilitating chronic pain.

The ‘’forward’ model

A predictive model has also been hypothesized in motor control theory. The ‘forward’ model of motor control.

Fleischer discusses the ‘forward model’ in his paper “Neural Correlates of Anticipation in Cerebellum, Basal Ganglia, and Hippocampus”

“A forward model provides the nervous system with a prediction of what the body state will be like in the near future”

He adds

“Optimal motor control theory requires the presence of a forward computation of what the effect of a motor command will be given the current state and motor commands”

And

“Alternatively, a forward model can allow the production of movements that are faster than using only feedback control”

It is important to appreciate the Cerebellums link with the cerebral cortex where our somatotopic representations are stored and the constant information flow between the two areas when moving. We compare intended movement from the motor areas with reported movement from the periphery using the information to alter motor commands to achieve the desired task.

Here again we are seeing the implications of feed forward model rather than a feedback. A need to be able to predict what will happen that can only be based on previous experience. In both pain and movement control often the feedback model rules such as in the force-based model of biomechanics or Cartesian view of pain.

Implications for biomechanics

A question we have to ask ourselves is the implication for a structural biomechanical model. A structural ‘anomaly’ may not be able to alter a movement in the predictable way we anticipate when we factor in a ‘forward’ model of motor control. If we consider pain as a prediction and associated to a motor command rather than as a result of the movement and actual affect on the tissue it must force us to possibly rethink the biomechanical/Cartesian feedback perspective. A question is “has the movement caused pain or pain altered the movement?” Changing subconscious perception of the tissue maybe most important rather than specific movements deemed as abnormal or damaging by the practitioner.

Better representations, better predictions?

Our neural structures and their organization appears to be important in how we predict future events if we include the memory-prediction model in our considerations.

Our somatotopic representations have been implicated in chronic pain states by Butler, Moseley, Flor and Ramashandran amongst others.

Moseley and Flor in “Targeting Cortical Representations in the Treatment of Chronic Pain: A Review” (2012) explain:

“A large body of evidence shows that chronic pain is associated with disruption of a range of body-related cortical representations. There is some evidence that this disruption contributes to, or maintains, chronic pain”

We may use these representations to predict future levels of threat or danger to a tissue and significant changes have been documented in these areas with people in chronic pain. Has pain altered the representation or has the altered representation contributed to pain? This is a tough question to answer but both scenarios must be considered.

Targeting cortical representations has been proposed and implemented by Moseley and Flor and by the NOI group with their graded motor imagery program http://www.gradedmotorimagery.com/

Falla et al in “The role of motor learning and neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders”  (2010) state:

“In novel motor-skill acquisition, cortical neuroplastic changes are often accompanied by behavior deemed to be advantageous, such as an increase in motor performance”

They add

“Rehabilitation efforts that attempt to maxamise the extent of cortical neuroplastic changes stand to provide the greatest potential for rehabilitation success”

Moseley and Flor also add

“Treatments that target sensory and cognitive representations using sensory and motor strategies show clear functional and symptomatic benefits”

Breaking the cycle

In our opinion it may be breaking the prediction that helps change a persistent pain response although specific ‘hows’ is not really the focus of this piece. This could involve becoming aware of behaviors, emotions and movement strategies to break the subconscious ingrained output associated with pain.

This could be as simple as consciously relaxing before moving in some cases. Anecdotal success has been gained via using this method. Just being able to modify pain through simple sequential changes to a motor action may give the patient back some level of internal locus of control and have an effect on their emotional state as well as altering prediction of threat.

Pain education and the bio-psycho -social model may also have implications for changing prediction or perception of pain and threat.  Helping reevaluate the link between what the patient is experiencing and the actual harm to their bodies.

Subtle shifts in context may have an affect on the specific motor command that has a pain component ‘wired’ in. This could be body position, location or emotional state.

Non-painful movement as close to the painful movement as possible may allow us to keep or build movement confidence without reinforcing pain association. Subtle changes in limb position may alter the pain response and reduce protective mechanisms associated with movement and pain. This may need to be regressed to any non-painful/threatening movement of the afflicted area depending on the severity of the pain output.

Conclusion

It is important to start to disassociate pain from tissue state, pathology, nociception and biomechanics. Pain is an output of the brain that can occur without any input from the body. This however does not mean any of these components cannot cause pain but pain is certainly not exclusive to them, as many seem to currently believe.

A prediction of pain based on prior learned experiences that may change the functional organization of the brain may create a feed forward model of pain during movement. This can also be modulated by many factors such as stress and illness affecting our individual ‘neuromatix’ and amplifying the pain experience.

Targeting our cortical representations may enable us to make different, hopefully better, and long lasting change in predictions that don’t involve protecting perceived threat to tissue via limiting movement or increasing pain output. This could be done through the visual system & imagery, motor skills and subtly altering the context of a given pain situation.

Biomechanics BS. Can you ‘predict’ injury or pain?

The perspective that the body is an interconnected unit that displays regional interdependence is a valuable one. That different parts interact in different ways during different activities and influence ROM (range of movement) in other areas of the movement chain should seem a fairly easy link to make when looking at the whole body during different context dependent movements. We often eschew the value of the integrated system in favour of the isolated joint/muscle model.

However if we start to critically evaluate this concept of interdependence can we make assumptions about the specific nature of the segmental relationships? Have we the evidence to reliably predict joint to joint relationships or a causative link to injury or pain if we don’t conform to the predicted relationship and biomechanical ideal? As a former biomechanical enthusiast it has been the sheer weight of evidence that has caught my attention and forced me to question these ideas. The evidence has proved hard to ignore even in the face of my previous beliefs about what I though I knew!

I have decided to focus on one area, the foot and much blamed pronation, in this blog to provide an in depth look at some of the evidence.

Often biomechanical theories rely on reliable anatomically perfect structures that perform uniformly from person to person and deviation from this ‘normal’ has often been suggested as causative of injury and pain. Examples of this with regards to the foot and pronation would be length length differences (LLD) and differing ‘foot types’.

The ‘Chain reaction’ theory of movement when looking at walking or running gait, relies on the foot causing a reaction that is then felt throughout the chain. It is a valuable narrative for proposing a theoretical model of how different body parts may interact but does appear to rely on certain prerequisites to occur.

One of these prerequisites is that ‘optimal’ calcaneal motion and pronation of the foot occurs and for this movement to be transferred to the tibia, femur and then further up the kinetic chain. Some advocates of this approach have attempted to reliably ‘map’ throughout the body the complex regional relationships even promoting causative ‘injury prediction’ based on ‘sub optimal’ mechanics further down the chain.

Some of the questions the critical mind may ask about this approach are:

“What is optimal movement to begin with?”

“Are deviations just normal variations?”

“Have sub optimal mechanics reliably been shown to be causative of injury or pain?”

“Does pain change our biomechanics or do biomechanical variations cause pain?”

“Do you have evidence to back your view up?”

Pronation

Pronation of the foot is a pretty important thing for many reasons that are not really the focus of this blog, such as adapting to variable surfaces and force attenuation. The effect of pronation higher up on the chain is certainly a murky area and not definitive by any means.

To understand whether the foots affect on the body is optimal for the required affect on the rest of the kinetic chain, first we must define what optimal or even adequate is.

Dr Kevin Maggs in his excellent “The Definitive Guide to Pronation: Clinicians Version”, which provided a great resource for this article, has this to say on the matter.

“We have no definition of what “normal” pronation is, so how can we possibly define what ‘over’pronation is? This type of ambiguity is frustrating for clinicians and patients”

Could it involve? (of pronation):

Range.

Velocity.

Sequencing.

Time during cycle spent in.

Or all of the above?

What is normal?

The basis of ‘normal’ foot function has its origins in the work of Root and Weed in the 60’s and 70’s. They conceived the theoretical ideal foot that should function around a neutral STJ (sub talar joint) position, which they described as being oriented at 41 degrees, nicely between the frontal and transverse planes. This creates a torque converter where rotation around the frontal plane axis of the STJ through calcaneal eversion creates a 1:1 equal reaction in the talus into talus adduction in the transverse plane. This ‘coupling’ motion is then transferred into internal rotation torque of the tibia and higher up the chain to the knee and hip and beyond. Because of this 1:1 ratio excess motion of pronation will create increased tibial motion. This increase of torque has been theorized as a potential injury risk. Equally a lack of pronation will not cause the movement required for tibial internal rotation and a decreased reaction up the chain. A force based model seems not to take into account the variable motor control we may have over various segments to control excess force.

This all hinges on the fact that we should have a foot that conforms to this ideal. Deviations from normal foot function have been previously hypothesized for a number of pathologies such as in Tiberio’s “Pathomechanics of Structural Foot Deformities” (1988)

Ian Griffiths in his article “Overpronation:Accurate or parachronistic terminology?” Sportex Dynamics 2012, says of Weed and Roots observations:

“Feet that did not fit these criteria were then deemed as ‘abnormal’ with the assumption being that they may provide less efficient walking and running gait patterns, and be more prone to injury due to compensations that may occur during activity.”

He goes on to say

“It should be noted that this has never been suggested in any research, instead just gaining popularity within both medical and lay communities insidiously”

So lets take a look at what the science says with relation to the 1:1 ratio of the  ‘torque converter’ or ‘mitre’ of the STJ.

There are two issues here. Firstly is there a 1:1 ratio and of STJ to tibial motion and 41 degree oblique axis?  Secondly does any one conform to the median ‘neutral’ of 41 degrees if it does exist?

Lets start with the ratio. Dr Maggs says

“For example, Powers (2002) found that the ratio of rearfoot eversion to tibial rotation during walking is closer to 2.5:1, and McClay (1996) found it to be 1.5:1 while Nawoczenski (1998) found the ratio to be 1.8:1 for running.  Ratios of up to 2.5:1 of rearfoot motion to tibial rotation are far from the 1:1 ratio most of us were taught in school”

Lundgren, “Invasive in vivo measurement of rear, mid and forefoot motion during walking” Gait Posture. 2008, has the axis about 30 degrees (using probably the most accurate method!). Average ROM for the participants of his study had 11.7 deg of frontal plane motion at the STJ vs 7.2 of movement in the transverse plane between the talus and tibia. Not a 1:1 ratio of transfer from the STJ to the tibia.

Lundgren’s data in fact shows far more motion between the talus and navicular. He showed an average of 21 deg of motion in both the frontal and transverse planes at the mid tarsal joint, an equal motion (although is this important?)! The talonavicular joint is under looked at in pronation mechanics in my opinion.

Reischl and Powers, Relationship between foot pronation and rotation of the tibia and femur during walking, Foot Ankle Int. 1999 found:

“The lack of a relationship between peak foot pronation and the rotation of the tibia and femur is contrary to the clinical hypothesis that increased pronation results in greater lower extremity rotation”.

In this study the magnitude and timing of peak pronation did not correlate with tibial or femoral rotation.

So here we are seeing a trend in the research that indicates a predictable reaction between the foot and body is certainly not clear. In my opinion this makes it extremely hard to even postulate, let alone reliably predict or prove causative, the effect the foot may have on the rest of the kinetic chain. This does not invalidate their relationship but certainly makes it more complicated. Especially when designing and educating using complex predictive biomechanical models of movement or injury.

On to the next point. How many conform to the median of 41 deg, if it did exist? Well again Dr Maggs review of the data from a number of studies found variations in subjects axis from 20 to 68 degrees. Hardly a tight grouping around the 40-50 degree mark. This shows the large variation in axis height and the unpredictable nature of how this affects the tibia, femur and higher up the chain. The higher the axis above 41 deg then the more the transfer of rotational torque to the tibia in theory. In practice this does not seem to be the case. This would indicate the body is able to control movement through more proximal control strategies and is not a simple slave to the movement at the foot.

Dr Maggs adds

“If the research can’t agree on how, why or how much the foot movement influences the rest of the lower extremity, maybe it’s because the foot doesn’t influence the lower extremity as much as we’ve been lead to believe”

If we cannot agree on how it directly influences the bits directly above how the hell can we predict what it will do in even more distant structures?

Assessment

Measuring pronation also provides a troublesome area. With so many differing methods from video analysis to force plates to hands on assessment it seems we have no gold standard. Again making it harder to define a normal pronation process with which to then compare an abnormal against.

Manz HB in “Alternative techniques for the clinical assessment of foot pronation”. J Am Podiatr Med Assoc 1998 says:

“On the basis of a critical evaluation of the literature, it would appear that arch height and footprint indices are invalid as means of categorizing foot morphology”

STJ neutral has long proven difficult to assess in a reliable fashion.

Picciano Am, in the “Reliability of open and closed kinetic chain subtalar joint neutral positions and navicular drop test” J Orthop Sports Phys Ther. 1993 found that:

“The results reveal that both OKC and CKC STJN yield poor intratester and intertester reliability and the NDT yields poor to moderate intratester reliability and poor intertester reliability”

It appears to be pretty tough to be able to accurately and repeatedly measure pronation even amongst experienced professionals. Does that mean we should discount it, no. But it is difficult to then use that measure to predict or prove causative of injury elsewhere in the body. If that evidence is available then I am all eyes. Until then it is a nice story and a valuable way of starting to connect the body in upright function. Something we have not done enough of previously.

Association with injury

So there must be a provable link to injury both in the lower extremity and further up the chain if we place so much emphasis on deviations from ‘optimal’ pronation.

It is important we look at prospective studies rather than retrospective studies with respects to this. A prospective study allows us to link who might develop pain from a biomechanical variation rather than possible developing a biomechanical variation because of pain. If indeed they develop pain at all because of any variations measured.

In fact Wen in “Injuries in runners: a prospective study of alignment” Clin J Sport Med. 1998 found:

“Minor variations in lower extremity alignment do not appear conclusively to be major risk factors for overuse injuries in runners”

They looked at a number of variations in alignment. Arch index (AI), heel valgus (HV), knee tubercle-sulcus angle (TSA), knee varus (KV), and leg-length difference (LLD) were all measured. No variations appeared to be causative. We have to ask our selves the question “when does a variation become a limitation?” I suspect this will be highly individual.

In “A prospective biomechanical study of the association between foot pronation and the incidence of anterior knee pain among military recruits” Hetsroni et al J Bone Joint Surg Br. 2006 found:

“No consistent association was found between the incidence of anterior knee pain and any of the parameters of foot pronation”

Powers in “Comparison of foot pronation and lower extremity rotation in persons with and without patellofemoral pain” Foot Ankle Int. 2002 looked at:

“Abnormal foot pronation and subsequent rotation of the lower extremity has been hypothesized as being contributory to patellofemoral pain (PFP)”

He found that

“These results do not support the hypothesis that individuals with PFP demonstrate excessive foot pronation or tibial internal rotation compared to nonpainful individuals”

Conclusion

Based on the available evidence it seems hard to reliably predict what reaction the foot may have on the tibia and therefore even harder to predict what affect it may have further up the chain on other areas of the body.

Global movements are brain based patterns rather than simple force based bone reactions and this means we probably have a way of self organising to achieve the task with our individual structure, motor learning and previous movement experiences.

We do not fully understand what should be happening with regards to pronation to compare against what should not be happening and the subsequent affects elsewhere in the body.

Any models of movement prediction, mapping or injury causation are at best a guess using foot pronation. This does not mean that foot pronation does not have any importance or impact on the whole kinetic chain but it is certainly not a consistent or predictable reaction amongst individuals.

Variations in structure and function are normal and do not seem to be consistently attributable to injury or pain. This view appears to be supported by the available prospective studies.

Popular current clinical methods of assessment of pronation appear not to be reliable, accurate or repeatable. To use these methods to make predictions or causative links in other areas of the body would also seem to be difficult if we follow the evidence rather than assumptions.

The foot remains an important and under assessed area of the body in relation to movement. The question of the influence of the foots affect on the body and the bodies affect on the foot needs to be further explored before making links between movement elsewhere in the kinetic chain and causative of injury and pain.

One of the topics that regularly comes up in our courses is how relevant are more static/clinical tests to our everyday dynamic and function related movements. We have decided to address this in this blog.

We also have a special treat. A sneaky link to Cor-Kinetic founder Ben Cormack’s new article in July’s Sportex Medicine *Click Here*

This is essentially a clinical vs. functional model comparison. A course participant once said traditional tests tell him all he needs to know about how people move, specifically the Thomas test. Obviously this is an anecdotal comment but the question is, does a more scientific viewpoint back this up?

The answer to the question “Should we still be using the Thomas test?” is probably not if you want to know how well people move when away from the treatment table.Schache et al in the British Journal of Sports Medicine performed a relevant study in 2009. It looked at the “Relation of anterior pelvic tilt during running to clinical and kinematic measures of hip extension”

Their objective was 

“To assess the relation of anterior pelvic tilt during running to peak hip extension range of motion measured during running and hip extension flexibility measured clinically”

They used the widely used modified Thomas test to clinically assess hip extension while dynamic assessment was performed using motion analysis software.

The conclusion the team carrying out the research came to was

“Static hip extension flexibility, measured using the Thomas test, was not found to be reflective of these dynamic movements (running). The ability for clinicians to interpret the results of the Thomas test with regard to the sagittal plane movement patterns of the pelvis and hips during running may therefore be limited”

They also add

“As a result of the findings from this study and the work of others, it is advised that clinicians need to be extremely cautious about making predictions about the dynamic sagittal plane movements of the pelvis and hips based on the outcomes of the Thomas test”

This research paper is fairly emphatic that the correlations between static and dynamic measures of hip extension are low, and any use of the static measure to ascertain a dynamic measure is a “prediction”

What happens dynamically and functionally is not a simple reflection of what happens on a treatment table. Often people say “it works fine for me” or “so and so uses it so I use it” Are these good enough justifications in the face of more scientific evidence? We would suggest no. Just because you do something currently or have been taught a clinical methodology does not mean that we should not explore other assessment methods that pertain to functionality.

Lets have a look at some more science. Mcgill and Moreside in their paper “Improvements in hip flexibility do not transfer to mobility in functional movement patterns” in the journal of strength and conditioning in 2013, looked at the transferability of increased passive hip ROM to functional movement patterns.

They found

“These results indicate that changes in passive ROM or core endurance do not automatically transfer to changes in functional movement patterns”

Not only do static, passive clinical tests seem to have low correlation but also passive exercises/stretches to improve dynamic hip ROM. Both are regularly used in clinics the world over but with seemingly little effect in assessing or changing our movement. Are we “asking the right questions for the right answers?” One reason for both pieces of research showing little correlation from the static to dynamic scenarios is that they are differing motor patterns. We often look at movement as being local structure (bone and tissue) based. It is becoming more apparent that specific movements are just that, specific, and controlled by the brain rather than being limited by local tissue length or structural orientation.Our brains work on a memory prediction model that uses feedback from the sensory systems such as the proprioceptive, visual and vestibular to auto associate stored movement patterns according to the situation. These systems will recognize visual horizon, orientation against gravity, joint compression, angle and torque, tissue tension and length. All these factors make dynamic movement very different from clinical testing therefore eliciting a very different efferent response, in terms of motor pattern, from the system.
Controlling our centre of mass (COM) during dynamic movement also provides a huge challenge to the body that cannot be recreated with a prone clinical environment. Add in balance and speed variables and we can see the highly specific nature of movement. On a simple biomechanical level as soon as we step away from the table we also add in the component of translation as well as rotation to movement. This is something that is hard to recreate on a treatment table. This added movement variable would also create changes in feedback and motor control.In fact Schache et al suggest the lack of correlation between static and dynamic hip extension.
 
”may be determined by complex dynamic neuromotor patterns rather than static flexibility alone”Flexibility is context dependant because it is controlled efferently through the Gamma motor neuron system and intrafusal fibre (muscle spindle) gain. This in turn drives the Alpha motor neuron to operate our extrafusal (Skeletal muscle) fibres. Flexibility or stiffness levels in a movement are a brain output that relies on the context of what is being received through input of the sensory systems. Flexibility is not a skill in itself, and therefore should not be trained as such, but a component of successful movement. We need to be able to achieve the right amount at the right time in the right movement.Mcgill and Moreside also suggest

“training and rehabilitation programs may benefit from an additional focus on ‘grooving’ new motor patterns if new found movement range is to be utilized”

If we are to do this we must incorporate the most authentic patterns possible to ensure crossover. What this does not mean however is that input needs to always be functional but at some point functionality has to be addressed to ensure maximal motor pattern exposure for storage and recall from the motor cortex.

One of the most valuable measures that can taken our opinion is the difference between what happens passively in terms of ROM and how much of that range can be accessed within a more functional situation.

One of the tough things to find is an objective measure of a subjective creature. Variations in motor pattern strategies and structure mean that literally no two people operate in the same way. This is similar to the fact we do not look or talk the same and have variations in height, foot size and width. The question is does median data reflect actual human structure and operation? The subtalar (STJ) joint is a great example of this with multiple variations in both structure and function. This means very few people correlate to median STJ axis location with a wide variation of location in experimental studies and therefore variation in ‘normal’ foot function (Manter 1941, Kirby 2001, Lundberg 1993).
A number of pathologies related to deviations from this ‘average’ or median have been hard to consistently prove as causative. An example of this would be knee pain (Powers 2002, Hetsroni 2006)
When we compare the individual against a specific set of biomechanics, such as gait for example, we have to be careful in blaming any deviation from objective median data for a cause of pain. This deviation more than likely is just a personal variation.

Schache et al also found:

“Peak hip extension ROM was found to have a positive correlation with relative leg length. This meant that subjects with increased relative leg lengths tended to run with reduced peak hip extension ROM. This may well be a product of having different sized people running at the same absolute velocity on a treadmill”

So the subjective natural structural variation of human beings has an effect on the objective data we may compare them against. This is without factoring in the complexity of different learned motor patterns, running styles and previous injury history.

Schache et al in their testing state:

“it is apparent that the sagittal plane movement patterns of the pelvis and hips differ across a group of subjects running at the same speed”

At Cor-Kinetic we look more at the comparison of the system against itself e.g. left Vs. right. The variation between segmental capabilities, especially in cyclical activities such as running, in an integrated system may provide more clues to increased workload and avoidance strategies of the brain and body than objective comparisons of a median ROM from the subject. The same would be true of segmental contributions within a throw or a swing. If one part, especially a large resource such as a hip, does not contribute then does another part have to contribute more. This could lead to real or perceived tissue threat. The body will achieve the task desired in any way that it can, generally the path of least resistance.

If my left hip has much larger ROM and quality of motion during segmental assessment than my right then this will create asymmetrical motion and possibly increased actual or perceived stress/threat to the system. Now we know asymmetry is a normal but how much asymmetry presents a problem? When does our personal variation in movement become a limitation? Again it is hard to be objective in a subjective situation that is dependent on the threat assessment or stress load toleration of the individual.

Cor-Kinetic use a set of functional criteria to help us create the most authentic environment possible to be able to “ask the right question for the right answer”. This means to try to elicit the response from the brain that correlates to the movement being tested and helps us formulate the best treatment strategy. An ability to assess using functional criteria means that we have vital pieces of information about the individual for increased treatment success. Objective injury prediction has proved hard to come by.

Functional criteria include:

Moving COM
Upright
Active
Dynamic
Integrated
3 Dimensional
Proprioceptive authenticity – Biomechanics/movement patterns

References

Hetsroni et al, A prospective biomechanical study of the association between foot pronation and the incidence of anterior knee pain among military recruits. British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.88B7.
2006.

Jundberg A, Svensson OK: The axes of rotation of the talocalcaneal and talonavicular joints. Foot 3: 65, 1993.

Kirby K. Subtalar joint axis location and rotational equilibrium theory of foot function. J Am Podiatr Med Assoc 91(9): 465-487, 2001

Manter JT: Movements of the subtalar and transverse tarsal joints. Anat Rec 80: 397, 1941.

Moreside J, Macgill S. Improvements in hip flexibility do not transfer to mobility in functional movement patterns. J Strength Cond Res. 2013 Apr 15

Powers et al. Comparison of foot pronation and lower extremity rotation in persons with and without patellofemoral pain. Foot Ankle Int. 2002 Jul;23(7):634-40.

Schache A et al, Relation of anterior pelvic tilt during running to clinical and kinematic measures of hip extension. Br. J. Sports Med. 2000;34;279-283

5 key steps for breaking into professional sport.

At Cor-Kinetic we often get asked how we are able to be involved with so many elite sports organisations. I was asked this question last week and made me stop for a moment to think about. I then decided to put some points down to help those looking to break into sport and fulfill some of their ambitions.

One of the things that many people want to achieve in their careers as trainers or therapists is working in professional sport or with elite athletes. It brings with it a special kind of kudos and has exciting moments such as competitions and events. In fact being involved is probably the next best thing to competing. The adrenaline rush and shared highs and lows. The team spirit or bond with an athlete. Getting the opportunity to travel to can also be an exciting experience.

At Cor-Kinetic we have been lucky enough to have had success within the world of professional sport. We have educated a large number of medical and training staff across the premierships of both football and rugby and national teams within these sports. For a full list of teams we have worked with *Click Here*.  Some of my favourite personal moments have been with individuals such as title fights live on sky sports (winning and drawing) and even a single-handed cross Atlantic row!

I thought that in this blog we would give you our 5 part recipe for success.

1. Get educated

If you want to be involved you have to ask yourself have you got the skill set? If you are not at a required standard you are not going to be on a level playing field with the other people you are competing with for the limited roles available. This is the first and probably the most important step to turning your dreams into a reality. Without a solid knowledge base in a chosen field it is very difficult to put the next stages into action. This is the foundation for everything else to be built on top of. The more you learn also the more you can achieve in whichever role or job you are in. Unlike a job you can never lose knowledge. Investing in yourself always pays off.

Check out our EMS (Elite Movement Specialist) Course. *Click Here* Also our in depth Mentorship program *Click Here*

Both courses are designed to make you a specialist and add the edge needed to stand out from the crowd.

2. Fulfill a need. Become a specialist.

Specialism and expertise are highly sought after commodities. Just saying you are better than the rest or get results is not enough. If you had 20 people all of the same standard would you pick the person who brought a different skill set and added something extra? A good team is about having different strengths. How many people have a trainer, S & C or physio background? Well lots, so the question you can ask yourself is what can you add to your existing skill sets to make you different, needed and get noticed? Our specialism is in the functional movement of the body and how this can be used for pain, assessment, rehabilitation and performance. This has led to us being contacted by many clubs looking to add knowledge of this specialty to their skill sets or hire us on a consultancy basis to bring knowledge as and when needed. To be invited into some of the country’s top training facilities is a great experience even if it can be a little daunting with such expertise around.

3. Get connected

Not always what you know but who you know? Well it is really the mixture of both. How are people going to find out about you? Online tools such as Linkedin are perfect. You can target the right people in the right places quickly and efficiently. Twitter and Facebook tend to be a little more general. Facebook seems mainly about your friends and funny photos. Twitter can also be a good resource for building a really targeted connection base if you put in the time and effort to build it.

4. Have something to say

So once you have the audience what are you going to say to them? Just telling people how good you are does not cut the mustard at the top-level of sport where evidence based practice is often king. This kind of goes full circle back to the first two points. With the right education and specialism then you can say and do things that people will sit up and take notice of and they may feel that they need at their club or as part of a training team for an individual athlete. You can do this in the form of articles, blogs, video, tweets, lectures, workshops and presentations. With the right subjects that are pertinent to the sports environment there is no better way to get people’s attention. Sending a CV into a club or athlete may mean it just ends up in a pile with all the others. Are people able to Google you and get some hits? Having a presence on the internet is so important in today’s technologically driven world. It allows people to know you before they get to know you! It may even  lead to them to coming to you not the other way around. At Cor-Kinetic we have never once contacted a club. All our work has come through information we have put out there and then backed up by some minor advertising. If someone sees and advert it can then lead to an internet hit and then interaction with your content. That’s why your contact list is so important because it allows you to target your advertising. The last two premiership football champions have both used our educational services with members of their first team medical staff. Most of this was word of mouth. Do the right things and people will talk about it. The world of sport is pretty tight-knit. The biggest complement is when people say that they talked to someone else about you and decided it was also for them. That is the mark of a good job. This is also true of client or patient referrals.

5. Persevere

Rome wasn’t built in a day. It takes time to build up an education, contact list and library of information. You will not get a return straight away on the hard work you put in. People need to see more than just one piece of information to have trust in what you have to say is for them. Your information needs to regular, consistent, well thought out and get to the right people. There will always be people who knock what you have to say and will comment on your content. This is actually healthy and helps to build your understanding of a subject through explaining your point of view and also expanding your knowledge base through interaction with other people’s knowledge base.

So good luck!!

WWW.COR-KINETIC.COM

Check out our EMS (Elite Movement Specialist) Course. *Click Here* Also our in depth Mentorship program *Click Here*

The Cor-Kinetic “Movement Neuromatix”- A multifactoral approach to movement.

The ‘movement neuromatrix’ model is designed to show our movement as more than just the mechanical operation of bones, joints and muscles. All of the inputs we have listed in our model below have an affect on how our brain recognizes and responds to movement.

The movement of the body should be seen as the physical expression of a neurological process, a brain ‘output’. The graphic in the middle of the diagram below represents the movement ‘output’ and is influenced by the surrounding ‘inputs’. Often we see movement purely as an ‘output’ of the body rather than being influenced by the many ‘inputs’ that the brain receives and uses to determine our motor or movement ‘output’.

It has been influenced by Melzack’s “neuromatrix” which introduced a multi factorial model for pain and the many contributing ‘inputs’ that shape the pain experience. One of the largest departures from traditional views of pain, is that in the ‘neuromatrix’ pain is an ‘output’ of the brain rather than than simply an ‘input’ or signal from the body.

Melzack describes this:

“I have labeled the entire network, whose spatial distribution and synaptic links are initially determined genetically and are later sculpted by sensory inputs, as a neuromatrix”

Everything that flows through our ‘neuromatrix’ is shaped by it. ‘Inputs’ only trigger ‘neurosignatures’ or ‘output’ patterns from the ‘neuromatrix’ rather than the ‘input’ creating the ‘neurosignature’ at source An example of this is pain being created in the periphery and transported to the brain and ‘neuromatrix’ rather than sensory input triggering a pain “neurosignature’ and resultant pain ‘output’ from the ‘neuromatrix’. Other ‘inputs’ to the ‘neuromatrix’ such as stress levels can influence and modulate the pain ‘neurosignature’ ‘output’. We could also have a pain ‘output’ in lieu of sensory ‘input’ from tissue and structure.

Our “movement neuromatrix” is designed to highlight one single output of the neuromatrix, movement. It is not a revision, adaptation or a replacement. More a focus and opinion on one of the many outputs from the ‘neuromatrix’. The addition of ‘movement’ to the title is to highlight this focus.

In fact we could even see the process behind  the ‘movement output’ as the reverse of how we perceive the pain process. Pain is mainly seen as an ‘input’ when in reality it maybe more of an ‘output’. Movement is often seen as an ‘output’ ignoring the many ‘inputs’ and contributing factors.

We believe movement is similarly influenced by a multitude of contributing factors that are modulated by the brain to produce our unique movements.

This model works on the premise the brain is the controlling factor in our movement. In fact our brain is able to rewire itself, strengthening the connections it uses regularly and eroding the ones it doesn’t.  This is a process described as neural pruning.

“Axon branches more active in releasing neurotransmitters persist at specific neuromuscular sites, whereas less active axon branches retract, resulting in the canonical elimination of polyneuronal  innervation“

Jackie Yuanyaun Hau et al.

This is a fancy way of saying, “use it or lose it” in terms of our neural connections, one of the major principles of neuroscience and neuroplasticity.

This rewiring is a based on a multiple inputs that include our memories, structure, sensory systems, vitality and environment that create our unique ‘movement fingerprint’ or neural circuitry that defines an individuals movement potential. This all happens in the cerebral cortex where the sensory and motor systems, which rely on each other for successful movement, live. These cortical areas are now being seen as vital to understanding both our movement and pain.

“Without constant and accurate feedback from our touch maps, our motor maps can’t do their job. And so a feedback loop of mutual degradation is set up: Your touch map worsens so your motor map worsens, which worsens your touch map more”

The body has a mind of its own. Sandra and Matthew Blakeslee.

“One aspect of the changes that occur when pain persists is that the proprioceptive representation of the painful body part in primary sensory cortex changes. This may have implications for motor control because these representations are the maps that the brain uses to plan and execute movement. If the map of a body part becomes inaccurate, then motor control may be compromised – it is known that experimental disruption of cortical proprioceptive maps disrupts motor planning“

Lorimer Moseley, Professor of Clinical Neurosciences and Chair in Physiotherapy, School of Health Sciences, University of South Australia.

Our movement is made up of our previous experiences collected over our lifetime, both internal and external. To see the body as a purely mechanical structure misses the great depth of experiences that constitutes the ‘movement neuromatrix’ and the role the brain, nervous system and memory play in our movement. We are able to now understand the influence of our previous movement problems on our future problems at a motor control level by looking at the brain and its various inputs. Research has shown that a big predictor of future injury is past injury!

“Adaptation to pain has many short term benefits but with potential long term consequences“

Hodges 2011

Our daily demands and postures, previous movement problems and sensory inputs are major players in dictating what happens in our future movement. Previous pain causes changes within the brain to our motor and sensory cortex that then controls our movement potential. Getting out of pain is the gold standard of rehabilitation but rarely is previous movement assessed or restored, often we take a symptom or pain reduction approach. This altered movement can then potentially create movement issues and pain at a local and global level at a later date. This means a move away from a more biomechanical or postural biased model that may look at specific structures, such as the feet, to blame for the problems the body may experience. The available research does not consistently support specific pathomechanics in relation to the pain experienced.

“Although pain provides a potent stimulus to change the movement strategy to protect the painful or injured part, resolution of pain or injury does not necessarily provide a stimulus to return to the initial pattern”

 Hodges 2011

In fact pain can be the body’s opinion of a tissues health based on all of the information contained within the neuromatrix rather than actual damage.

This means that assessing in a low threshold way, such as a treatment table, may not allow you to create the right environmental factors to find the movement problems associated with an injury or restriction.

Our Cor-Kinetic SAID principle of assessment tells us that the body will give us a Specific Answer to an Imposed Demand. As the demand of the assessment changes so will the response to the demand. This can be especially important with elite level athletes and the more athletic population in general.

We believe the brain works on a model of:

Patterns – Memory recognition of situation

Perception – Interpretation of sensory feedback

Prediction – Response-Including reduced movement or pain

Only by feeding the body the right patterns of sensory information, which comes from movements authentic to peoples movement needs, can be expect to get the true response or prediction from the body that would happen away from an assessment/treatment situation in their functional situations. Problems can often be simply an opinion or prediction of what is going to happen in response to a motor command/ planning or movement situation. Much of what happens in terms of sensory processing is simply an interpretation or perception that can change on a minute-by-minute basis. Nerve signals are amplified or attenuated at a central level according to others factors included within the “movement neuromatrix”

“Pain is an opinion on the organism’s state of health rather than a mere reflective response to an injury. There is no direct hotline from pain receptors to ‘pain centers’ in the brain”

 VS Ramachandran

Our sensory systems are also key players in our ‘movement neuromatrix’

All of our senses have an impact on the way that we move to successfully process the large volume of available information our body needs to navigate our environment. Mismatches in this sensory information can cause sub optimal movement and pain. The sensory system is not just our movement information but also, and possibly more importantly, our visual and vestibular systems.

“it remains possible that in a sensitized or disrupted neurological system such as in neuropathic pain, sensory-motor incongruence might contribute to, or maintain, pain”

Moseley and Flor 2012

Our internal health including stress hormone levels, diet, hydration and breathing will also affect our movement and pain levels. These are also included with the ‘movement neuromatrix’ when considering movement ability.

Only by interacting with the ‘movement neuromatrix’ through effective movement, sensory and health based assessment within an authentic environment can we truly understand the individual and their movement potential.

References

Blakeslee S, The body has a mind of its own, Random house, Sept 2008

Hodges P Walker K, Moving differently in pain, PAIN 152 (2011) S90–S98

Jackie Yuanyuan Hau et al, “Regulation of axon growth in vivo by activity based competition” Nature, 2005 Vol. 434 21

Kandel E et al, Principles of Neural science, fifth edition, November 2012

Lederman E, The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain, CPDO Online Journal (2010), March, p1-14. http://www.cpdo.net

Melzack R, Pain and neuromatrix in the brain, J Dent educ, 2001 Dec, 65(12):1378-82.

Moseley G, Flor H, Targeting cortical representations in the treatment of chronic pain, Neurorehabilitation and neural repair, XX (X) 1-7

Moseley L et al, Cortical changes in chronic low back pain: Current state of the art
and implications for clinical practice, 3rd International conference on movement dysfunction 2009

Moseley L, A pain neuromatrix approach to patients with chronic pain, Manual therapy 2003, 8(3) 130-140

Ramachandran VS et al, Touching the phantom limb. Nature. 1995;377:489-490.

Ramachandran VS and Blakeslee S, Phantoms in the brain, New York: William Morrow, 1998

Can functional movement be too much?

I thought I would have a bit of a Jerry Maguire moment with my latest blog post!

Over the last few months I have certainly gone through a period of change with regards to how I understand the human body. Anybody who regularly reads my blog may have sensed that! I have begun to appreciate the brain as the command centre for all that we do, moving away from a more functional/biomechanical approach I had previously. This has been facilitated by some pioneering characters around me who I am thankful to for opening my eyes, even if it can feel sometimes that they don’t want others to come along for the ride! I have certainly suffered my own bouts of cognitive dissonance along the way.

My overiding end game will always be to get people back to moving optimally (for them) in their function. Many of my movement assessments have remained consistent, such as gait, as I am still interested in how they perform movements that relate to the movements they want to perform in related positions relative to the things that act on them e.g. gravity, ground reaction, mass and momentum! It is not so much the biomechanics I am assessing more the brains ability to control the meaty bits (muscle) rather than the mechanical motion of the bones, joints and muscles.

I now realise however that many things can also impact on movement such as the visual and vestibular system (if these bits don’t go, the body won’t either!) emotion and memory of previous injury. Pain also has changed for me, it is no longer simply a result of poor biomechanical motion but instead interlinked with many factors in the brain that can often have nothing to do with our structure or feedback systems at all. But this is not the time or place to go into that now.

One point is that in some circles people are starting to see pain as multi-faceted with many contributing factors. Melzack’ s Neuromatrix theory (1999) has thrown a new light on pain and pain science. Movement is similarly multi factorial and we are now starting to see the contributing factors as a “movement neuromatrix” with many of the contributing factors coming from outside of the biomechanical realm. We are seeking to simply outline these factors that would influence a “movement neuromatrix”, both internal and external.

(Melzack 1999)

A new way of thinking has allowed me to understand why a functional/biomechanical approach has allowed me to achieve success in the past and also explains some of my failures as well.

One conclusion is that for some people complex functional movement can be far to much for their bodies to handle. At best we maybe ineffective but could we be making things worse?

We know that if we give someone a movement task to achieve they will find a way to achieve it with the movement ability that they have. Often times by using the movement pathways that are available to them and that they use regularly. By feeding them these “functional” patterns we may not have changed anything, merely reenforced the movement they had previously. The more complex a movement involving many joints the more ability of the body to use different bits it can use rather than the target joints we would like it to use more of. If we do succeed in making it look better through hands on techniques or coaching the movement does it stay this way when we are left to our own devices without outside help? Does the person have the hardware (brain and neuron connections) to run the software (movement pattern) successfully? An analogy I like to use is that of trying to run a PS3 disc on a tape computer from the 80’s!

A purely feedback based approach dictates that the hardware (brain) is set. But the exciting and fast moving world of neuroscience tells us differently.

Our hardware relies on a few principles of neuroplasticity (the ability of the brain to change). This is that “neurons that fire together, wire together” and the principle of “use it or lose it” Simply put this means that neurons associated with movements we use often will strengthen their connections with the other associated neurons and neurons associated with movements we don’t lose their connection strength. This is a process known as neural pruning. These neurons will be associated with firing up the muscles at the right time to create the reactions we want. These neural associations also create the neural representations of body parts we have in our cerebral cortex that have been referred to as maps. Our movement is governed by our maps. If our map is poor then our movement will also be poor. Our map is regulated by the way we move and also then dictates the way we move. If it is poor, blurry or smudged (Blakeslee 2010, Butler 2006), the terms some have used to described eroded maps, then we create a cycle of faulty movement that is hard to break. The maps have also been associated with chronic pain through the incongruence between predicted and actual propriceptive feedback and an altered body schema (Harris 1999, Mcabe et al 2005). Mismatching feedback from our senses when integrated, such as in the cerebellum, has been hypothesised by many as a cause of chronic pain.

An example I have used previously is that of the flat foot, the map for the foot may not have strong connections associated with creating an arch (if you feel this is creating a problem!). Helping some one do this hands on or with complex exercise may not be enough to change the hardware and may explain why the predominant foot posture prevails. We can create movements that facilitate a supination reaction in the foot but do we do it within the parameters of the function? We know that external tibial rotation creates supination of the foot in gait. If I have to create much more external rotation than would ever happen in gait to create supination, either through hands on manipulation or exercise, will that have a crossover into my desired function e.g. gait? Will it become the predominant motor pattern within the brain when in subconscious function? Maybe not if we don’t have the right sensory or motor maps to understand and create it.

We may have to use a more targeted methods in specific areas away from function to increase the sensory feedback and therefore motor control. It may not look like function but may have a functional response within the hardware (brain) that allows us to use complex software (authentic functional patterns) and get the desired outcomes. In fact an inability to perform specific targeted movements at a joint may be an indication of sensory and motor changes through neuroplasticity within the sensory motor cortex (Moseley 2009, Moseley and Luomajoki 2010) Will the body choose to use areas it cannot control effectively when faced with a complex task, such as an integrated functional movement, if it has the ability to compensate through many joints it can use to achieve the task?

We must not confuse increasing the hardware through joint motion by just applying a specific pattern to a joint. Our motor control is a general ability to perform many motions not an ability to perform a clinical and contrived motion or “corrective exercise” at a joint as directed by some practitioners as being indicative of good function or problematic if not performed correctly. Our focused joint mobility exercises should look at increasing our feedback to the somatosensory areas which will help increase our cortical mapping through neuroplastic rewiring. The key is in the reintegration to the gross functional motor pattern. Putting the joint back into a functional context with the rest of the body to allow it to play its full roll in global range of motion and force dissipation and creation. This must also be done at differing loads, speeds, movement variations and levels of stability. We know that the body may not choose to use movement it has available if unable to control it (motion and stability). Again this is a skill that can be enhanced through movement education in an authentic context, such as a functional position.

Many solely brain based approaches may assume that once we have the hardware we can run any software. But we still have to apply, learn and refine that software program to make it better and that’s where functional movement comes into its own!

As always this is just my opinion on the way certain things may work within the brain and body. Certainly not evidence based in a traditional sense. We must remember however that evidenced based is based on evidence for the questions we have asked, not the ones we haven’t yet and is biased by the view of those asking the questions. If that is based on a traditional anatomical understanding of the body then the answers will be related to the bias!

References

Blakeslee S & M, The body has a mind of its own, Random house, Sept 2008

Butler D et al, The sensitive nervous system, NOI group publications, 2006

Doidge N, The brain that changes itself, Penguin group, January 2008

Forencich Frank, Topiary physiology, Go Animal

Harris AJ. Cortical origin of pathological pain. Lancet 1999;354(9188):1464e6.

Luomajoki H Moseley GL, Tactile acuity and lumbopelvic motor control in patients with back pain and healthy controls, BR J Sport MED 2011 Apr;45(5):437-40

Melzack R, Pain and the neuromatrix in the brain, Journal of dental education, volume 65 No12

Moseley G, Flor H, Targeting cortical representations in the treatment of chronic pain, Neurorehabilitation and neural repair, XX (X) 1-7

Moseley G, et al, Cortical changes in lower back pain:current state of the art and implications for clinical practice, Manual therapy 16 (2011) 15-20

Moseley G L, A pain neuromatrix approach to patients with chronic pain, Manual therapy (2003) 8(3), 130-140

McCabe CS, Haigh RC, Halligan PW, Blake DR. Simulating sensory-motor incongruence in healthy volunteers: implications for a cortical model of pain. Rheumatology 2005a;44(4)

McCabe CS, Haigh RC, Halligan PW, Blake DR. Re: sensory-motor incongruence and reports of ‘pain’, by GL Moseley and SC Gandevia. Rheumatology 2005b;44:1083e5. Rheumatology 2006; 45(5)

McCabe CS, Haigh RC, Ring EFJ, Halligan PW, Wall PD, Blake DR. A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome (type 1). Rheumatology 2003;42 (1)

No motor learning attached to walking, really??

It would seem my previous blog has generated some discussion on whether walking is simply an innate skill or there is motor learning attached to the process. For me it quite simple, but hey I am a simple guy.

Firstly we must not confuse learning with being taught. No one teaches you how to walk. But it is a self-driven learning process.

In fact is it driven by a desire to walk? The sensory motor stage of development as described by Piaget between 0-2 years involves learning by trial and error. As discussed in the previous blog failure is biological necessity.

Piaget also talks about goal-orientated behavior to bring about a desired result when we get to around 12 months. Right around the time we start to look to walk!

Well walking is just that, a goal orientated behavior. It is a better way to move around the world, just like those we see around us. It maybe an innate desire, who knows, but it is not a desire realized without the need for motor learning.

Lets look at what innate means:

Innate:

1. Possessed at birth; inborn.

2. Possessed as an essential characteristic; inherent.

3. Of or produced by the mind rather than learned through experience

There has always been a discussion about whether walking is innate or not. So I suppose it is a matter of opinion. But not a fact.

So do we possess the ability to walk at birth? Well no, or we would walk out of the womb or soon after! Fish are born with the ability to swim. Humans are not born with the ability to walk.

Our reflex ability’s are the sucking reflex , clasping reflex, Moro reflex, Babinski reflex and Root reflex. We do have a stepping reflex but this is not walking which comes with motor learning. This is a simple reflexive action rather than a complex and coordinated skill.

Learning to walk IS a complex skill. In fact all movement is a skill that has motor learning periods associated to it. Motor learning is important and nowhere more so than in performance training where the skills being learned become exceptionally complex. But the same rules of motor learning still apply. People may be better at complex skill initially because they have previously chunked general movement patterns associated with that skill in previous motor learning experiences but generally the more reps they do the better they get (although not always!)

Although there may be elements of walking that are pre-encoded as research as suggests, even blind children learn to walk, and demonstrated by basic reflexes such as the stepping reflex. It is not a purely innate skill such as breathing or swallowing which we are able to do as soon as we are born however. Blind children will still have to go through the same motor learning process as their sighted peers if not more so. The environment we learn and experience will also play a part. Think of feral children who move like the animals that have adopted them.

The fact is we do not just get up and walk. We go through stages of motor learning to get there. Even without the rolling and crawling (which also involve simple reflexive components) that comes before, we first practice standing and swaying finding our balance, then take one of two steps and fall. We get up and try again practicing the complex motor skills associated with locomotion. Next time we make more steps.

Even the observation of people walking is involved with the motor learning process. Imitation through mirror neurons is vital to human development. This process I believe shows we are learning through experience, which by definition would not make it purely innate.

Associated reflexes maybe hardwired but the gross skill certainly is not just there and available as it later in our lives after we have been through this process. That’s why we start of waddling and swaying and then refining until we are more proficient at the skill. We do this through a learning process. A motor learning process.

We make neural connections and then myelinate the pathways to improve the firing rate and strength of the motor pattern. This is Hebbian learning. “neurons that fire together, wire together” So we practice like any learner of a skill that is new. This is not a purely innate or reflex based scenario.

The first stage of motor learning is the memory encoding or cognitive stage where we are cognitively aware of the task that needs to be performed. The performer may be more concerned with what to do rather than how to do it.

This maybe described as a desire to walk. This maybe something we are born with. But certainly does not replace the motor learning stage.

In the associative stage the participant is now concerned with performing and refining the skill. The conscious decisions become more automatic and can concentrate more on the doing of the task.

The autonomous stage is when the action being performed is automatic. Walking without conscious thought is a good example of this.

This process is vital for efficient operation in the brain. Moving without conscious effort decreases the need for conscious attention on the task. This means the task can be moved back down the brain from the frontal executive areas associated with conscious thought and put into action in older areas such as the cerebellum and spinal cord.

Looking at reflex’s does not give any credit to the brain and its role in everything we do and how we learn. It is a simple and limited way to understand the body.  A bit like just seeing muscles as simple reactors to bone motion which gives no credibility to the understanding of motor patterns, their development or neuroplasticity as a concept. If you are being taught this way are you being kept in the dark?