by Dr Matt Fontaine
Ensuring the Proper Rehab Sequence:
A major key to corrective rehabilitation of musculoskeletal pain syndromes is to retrain proper movement. Several factors can cause compensated movement in the body including overuse or repetitive stress injuries, stress, poor posture etc. All of these create stress on our structural frame causing the nervous system to adapt and change the body’s movement patterns. This is neurological adaptation to change. If tissues become tight due to overuse, the body will lose flexibility in those tissues and the joints those tissues cross. If a joint becomes immobile, then the body is forced to compensate and move from other joints above or below the fixated or dyskinetic joint. Then there is the issue of joint stability and mobility. Often times a joint or set of joints lacks proper mobility, and the muscles involved in a certain movement can’t properly stabilize the joints to handle the load and force of that movement. This forces the nervous system to find other ways to move to accomplish nearly the same gross motor patterns. The nervous system can adapt, but that adaptation comes with a price. And that price is often faulty movement, muscle imbalance, increased likelihood of injury, degenerative arthritis and pain.
It is important to note that the nervous system learns movement. It also has movement patterns that are “hard wired ” into the computer or CNS- Central Nervous System. Pavel Kolar, a pediatric PT has devised a system of rehabilitation he calls Dynamic Neuromuscular Stabilization (DNS). It is founded on the principle that the developmental stages from fetal posture of an infant progressing to an upright posture involves hard wired stored programming in the nervous system. Essentially humans have motor programs that are involuntarily controlled by the CNS that train the muscles to coordinate, facilitate, and stabilize upright posture. An infant rolling over in a crib is an involuntary movement directed by the CNS with the main function being to train and integrate the core with the extremities in the progression of supporting an upright posture. A detailed description of Dynamic Neuromuscular Stabilization is beyond the scope of this article. Suffice to say that as we develop from infants to toddlers and young children, our nervous system develops engraining us with movement patterns. When injury and other circumstances causes a disruption in these “engrained, involuntary” movements, we begin to move improperly. Move improperly long enough and injury and pain will ensue. The big key here is that after childhood, many of us sit too much and don’t move properly in our day to day activities. Subsequently these engrained neurological movement patterns become sluggish. Below is a simplified synopsis of how to best approach correcting faulty movement and not olnly resolving pain, but optimizing human movement and performance.
The following sequence ensures a complete treatment strategy for the musculoskeletal patient. Many times patients have had some of the treatments listed below, but rarely have they successfully completed all six stages, and in the proper order. For example, consider the patient who sees and orthopedist or their primary care physician and receives a cortisone injection. That works great for acute inflammation and pain. But then what? The patient needs follow up with the other five stages to completely recover from the injury and help to rehabilitate the injury with the goal of future injury prevention. Or what about the patient who has been to physical therapy. Most of these patient receive a good deal of exercise instruction, but are often lacking in adequate amounts of manual therapy to address the joints and overactive soft tissues.
When only acute care is given or when manipulation in combination with ART is missing, the patient fails to make a complete recovery. What the patient needs is proper manual therapy to address joint fixation, compression or misalignment AND soft tissue release, such as Active Release Techniques(ART), to address overactive muscles. During a proper sequence, once these issues are addressed in stages 2 and 3, then the patient can safely and effectively be progressed through corrective exercise.
Which leads us to stages 4,5, and 6. First and foremost, the patient must be given exercises that will ensure they can activate muscles that have become weak. Mostly these muscles are critical for proper joint stabilization during movement. Once this is accomplished, the patient can then safely progress to stage 5, focusing on increasing the speed of muscle contraction. As coordination of movement improves, they patient can then progress to the final stage.
In stage 6, the patient can focus on improving mass movements. This is where the athlete or active individual will retrain proper squatting and deadlifting patterns, or learn to do overhead press movements, throwing movements etc. while they have already gained the ability to stabilize and support the joints through a loaded movement, or through a movement with high velocity.
Proper sequencing ensures that all key issues are addressed. Missing any of these stages will result in inadequate and incomplete recovery. This is often one of the major causes that lead to chronic muscle and joint pain. But this doesn’t have to be the case.
At Capitol Rehab of Arlington, our doctors and staff understand the importance of this proper sequence.
1. Treat acute symptoms: pain and inflammation. The medical model works great. Anti-inflammatories can be helpful. Passive modalities like electrical muscle stimulation can help ease tightness from overactive muscles, ultrasound can help speed healing, Rest, ICE, Compression and Elevation(RICE), active rest are all essential in an acute stage.
2. Manipulate/mobilize fixated/ compressed and misaligned joints. This is often essential to reduce nerve irritation which may be causing muscle weakness and or pain.
3. Release overactive muscles with Active Release Techniques. Learn more about overactive muscles here.
4. Improve motor control: rehab tracks( a series of exercise progressions) are prescribed which focus on retraining the ability to activate muscles for joint stability.
5. Increase speed of contraction: Moving from stabile to labile surfaces(BOSU, stability balls, Airex foam pads, balance work) further challenges the patient/athlete to optimize proper body movement.
6. Improve mass movements for a full return to sport.
For more information on the importance of addressing muscle imbalance, read the article on The Janda Approach to Musculoskeletal Pain and A Comprehensive Approach to Resolving Muscle and Joint Pain Syndromes.
