Chapter 3: General Neuropathodynamics

This is a Chapter 3 summary of “Clinical Neurodynamics” by Michael Shacklock.

What it is

General neuropathodynamics are abnormalities consistent throughout the nervous system, with specific referring to local abnormalities. These changes may lead to a neurogenic pain experience, in which pain is initiated by a primary lesion, dysfunction, or transitory perturbation in the nervous system. This definition means that dysfunction in the nervous system, it’s surrounding tissues, and innervated tissues can all be related to neurogenic pain.

Definitions of Clinical Problems

When discussing dysfunction, there are several descriptors:

1)      Optimal/desirable: When the neuromusculoskeletal system behaves well and does not create symptoms in situations of high stress.

2)      Suboptimal: Imperfect neuromusculoskeletal behavior which results in potential symptom increasing if an adequate trigger occurs.

3)      Normal: Function of neuromusculoskeletal system is within normal values.

4)      Abnormal: Neuromusculoskeletal system is outside of the normal range.

5)      Relevant: When pathodynamics are linked to the clinical problem.

6)      Irrelevant: When pathodynamics are not linked to the clinical problem.

You will oftentimes have multiple of these components in a clinical situation.

Irrelevant to neurodynamics; relevant to my love life...someday.
Irrelevant to neurodynamics; relevant to my love life…someday.

Mechanical Interface Dysfunction

These dysfunctions deal with abnormal or undesirable forces on the nervous system. There are two main categories with their own subcategories.

1)      Closing dysfunctions – Altered closing mechanisms of the movement complex. Can be reduced (protective response) or excessive (hypermobility/instability).

2)      Opening dysfunctions – Altered opening mechanisms of the movement complex. Can be reduced which creates impaired pressure reduction, or excessive leading to tissue traction.

Pathoanatomical Dysfunction

This type of dysfunction is when interfacing structures of abnormal shape or size exerts undesirable pressure on neural structures. These cases typically have poor responses to therapeutic interventions, simply because clinicians are unable to directly alter pathology. Neurodynamic techniques are often contraindicated in these folk.

Sometimes you have to take pathology into account.
Sometimes you have to take pathology into account.

Pathophysiological Dysfunction

These dysfunctions occur when physiological changes in interfaces lead to pathodynamics in the nervous system. These processes include inflammation, swelling, or bulging disks to name a few.

Neural Dysfunctions

There are five types of neural dysfunctions:

1)      Sliding – reduced nerve excursion. Often relieving positions worsen symptoms.

2)      Tensioning – abnormal elongation mechanics or sensitivity.

3)      Hypermobility – Excessive neural excursion.

4)      Pathoanatomical – Neural symptoms created by nervous system pathology.

5)      Pathophysiological – Abnormal neural physiology leads to pathophysiological dysfunction. Blood pressure changes are an example of this, based on magnitude and time.

Other irritants can influence neural responses. Mechanical irritation can play a role based on C fiber innervation. These fibers can lead to inflammation due to efferent activity. These nociceptors can responds to mechanical movements because they innervate the epineurium and dura.

Mechanosensitivty

The way the nervous system can become a symptom source with movements and postures is by mechanosensitivity. When a nerve becomes mechanosensitive from a force, increased afferent firing travels to the central nervous system. This signal can potentially create a pain experience.

All nerve have some mechanosensitivity, but the amount varies depending on the mechanical trigger magnitude and the nervous system’s health. This aspect can be tested by performing tapping along a nerve tract or performing a neurodynamic test. In abnormal situations, nerve impulses more readily fire leading to potential symptoms. Altered mechanosensitivity can occur in peripheral nerves, nerve roots, the dorsal root ganglion, and the spinal cord.

Mechanosensitivity can also occur from chemical and cytoskeletal influences. Neurofilaments can accumulate in unmyelinated areas. This adaptation occurs to protect neural structures.

Motor Control

Suboptimal musculoskeletal activity can also play a role in nervous system sensitivity.  If motor control is altered via hyper or hypoactivity, neural tissue can be exposed to danger or overprotected.  Motor control can be altered many ways, to include trigger points, muscle imbalance, and paralysis to name a few.

Inflammation Dysfunctions

There are two inflammatory dysfunctions – neurogenic and reduced. Neurogenic inflammation involves substance P and calcitonin gene-related peptide (CGRP) release from C fibers in the dorsal root ganglion. These substances travel to the peripheral nerve’s distal terminals to affect vasodilation and inflammation. This inflammation occurs with increased efferent activity.

Reduced inflammation is when there is a decreased inflammatory response due to decreased efferent nerve activity. You see this dysfunction in those with denervation and hypoactivity, which can lead to poor healing.

The sympathetic nervous system can also play a role in inflammation. This act happens by releasing prostaglandins, adrenaline, and noradrenaline. These changes occur when there is excessive pressure on the nervous system.

Stress can make a huge impact on the nervous system's health.
Stress can make a huge impact on the nervous system’s health.

 

Chapter 2: Specific Neurodynamics

This is a Chapter 2 summary of “Clinical Neurodynamics” by Michael Shacklock.

Intro

Specific neurodynamics include local effects of body movements on the nervous system. So today we will go through each body region discussing these.

The Spine

Here are some interesting tidbits regarding the spine and neurodynamics.

  • When we flex the spine, the spinal canal elongates by about 9 cm.
  • Neck flexion creates significant tension to the lumbosacral nerve roots.
  • Neural structures slide relative to the bony interface differently depending on the location and the movement used.
  • Flexion increases tension, but reduces compression. Extension adds compression, but reduces tension.
  • Lateral flexion increases tension on the convex/contralateral side of the spine. This situation occurs by interface and neural tissue elongation and increased distance between the spine and periphery.
  • Rotation closes on the ipsilateral side and opens on the contralateral side.

The spinal cord tends to move towards various specific segments. These areas are termed zones of convergence, and these areas include C5-6 and L4-5.  For example, tissues above C5-6 will slide toward this zone, as will tissues below this segment. The midpoint at which tissues diverge is at T6. At this point, tissues below T6 will converge towards L4-5, and tissues above T-6 will converge to C5-6.

For those interested, I offer a Therapeutic Microsoft Paint continuing education course.
For those interested, I offer a Therapeutic Microsoft Paint continuing education course.

Gravity can also play a role in neurodynamics. For example, if you perform a SLR in sidelying, the downward side usually has less mobility.  This difference occurs because the neural contents are convex on the downward side and convex on the upper side, increasing tension in the lower leg.

Upper Quarter

Here are some tidbits on the upper quarter

The cervical spine:

  • In the cervical spine, contralateral sidebending usually increases symptoms with median and radial neurodynamic tests.
  • Ipsilateral sidebending usually reduces symptoms, but is not useful in structural differentiation because peripheral nerve tension may not be sufficient.

The scapula and shoulder:

  • Scapular depression consistently produces increased symptoms with upper limb neurodynamic tests.
  • Shoulder abduction creates distal sliding of the nerves proximal to the shoulder and proximal sliding of nerves distal to the shoulder, such that they converge to the shoulder.
  • Shoulder external rotation responses vary.
  • Horizontal extension can increase tension, but is inconsistent and not essential.
  • Shoulder internal rotation increases tension along the radial nerve.

The elbow:

  • Elbow extension increases median nerve bed length by 20%, with convergence towards the elbow.
  • Elbow flexion decreases median nerve tension and increases ulnar nerve tension up to 23%.
  • Pronation and supination create small effects in the nervous system, but can be meaningful at making end-range changes.
Just about anything could make meaningful end-range changes here.
Just about anything could make meaningful end-range changes here.

The wrist:

  • Radial and ulnar deviation produces small changes in the nervous system, similar to pronation and supination.
  • When radial deviation occurs, strain in the median nerve increases at the elbow and decreases at the wrist.
  • Ulnar deviation increases strain at eh elbow and wrist.
  • Flexion decreases median nerve tension, and extension increases it.

The Lower Limb

Here are some tidbits on the lower limb

The hip:

  • Hip flexion increases hamstring tension and posterior pelvic tilt as early as 10 degrees.
  • Nerves converge towards the hip joint with the straight leg raise.
  • Internal rotation increases tension in the lumbosacral plexus and its related nerve roots and also in the sciatic nerve.
  • Adduction increases responses in the SLR.

The knee:

  • Extension accounts for 49% of sciatic nerve bed elongation.
  • Flexion increases femoral nerve tension, but the standard prone knee bend test is usually not indicative of neural issues.

The foot and ankle:

  • Dorsiflexion increases tibial nerve tension; and if done at the end of the SLR, can produce movement at the lumbosacral nerve roots.
  • Eversion increases tension of the posterior tibial nerve.
  • Dorsiflexion/inversion tenses the Sural nerve.
  • Plantarflexion/inversion tenses the superficial fibular nerve. Can also implicate piriformis syndrome for those who have a high sciatic nerve division.
Totally just mooned you.
Totally just mooned you.

Chapter 1: General Neurodynamics

This is a Chapter 1 summary of “Clinical Neurodynamics” by Michael Shacklock.

 Concepts

When we first started working with the nervous system, oftentimes we called pathological processes adverse neural tension. The problem with this name was that it left out nervous system physiology; it was mere mechanical concepts. Hence, we call the movement and physiology of the nervous system neurodynamics.

General neurodynamics account for whole body fundamental mechanisms, regardless of region. Specific neurodynamics, on the other hand, applies to particular body regions to account for local anatomical and biomechanical idiosyncrasies.

The System

There are three parts to the neurodynamic structure:

1)      The mechanical interface

2)      The neural structures

3)      The innervated tissues

The mechanical interface is that which is near the nervous system. It consists of materials such as tendon, muscle, bone, intervertebral discs, ligaments, fascia, and blood vessels.

The neural structures are those which make up the nervous system. These structures include the connective tissues that forms the meninges (pia, arachnoid, and dura mater) and peripheral nervous system (mesoneurium, epineurium, epineurium, and endoneurium).

The nervous system has mechanical functions of tension, movement, and compression. It also has physiological functions to include intraneural blood flow, impulse conduction, axonal transport, inflammation, and mechanosensitivity.

The innervated tissues are simply any tissues that are innervated by the nervous system. They provide causal mechanisms for patient complaints, and are able to create nerve motion. When we have neural problems, sometimes the best treatment is to these structures. You must treat everything affected.

Which is easy to do when you have Brain Salt. For sale soon at zaccupples.com
Which is easy to do when you have Brain Salt. For sale soon at zaccupples.com

Mechanical Functions

The nervous system is capable of performing many mechanical activities:

  • Tension – Typically occur at joint areas; the perineurium guards against excessive tension.
  • Sliding – Neural structure movement relevant to adjacent tissue. Is able to dissipate tension.
  • Longitudinal sliding – Sliding down the tension gradient to allow for tissue borrowing at elongated areas.
  • Transverse sliding – Dissipates tension by enabling nerves to take the shortest course between two points when tension is applied. It is also helpful when nerves are subject to sideways pressure by interfaces.
  • Compression – The nervous system alters its dimensions and position when forces from the mechanical interface are transmitted to the nervous system. The epineurium protects from excessive compression.

Nerve Movement

Nerve movement depends on the nerve’s location relative to the joint. If the nerve is on the convex joint side, elongating forces will occur. Conversely, if the nerve is on the concave side, shortening forces will occur.

Despite these forces, nerves may not always move accordingly. The reason for this paradox of sorts is because neural tissue is borrowed from each end of the nerve tract. Therefore, nerves will displace towards the joints; with the end effect being little movement at the midpoint. This phenomenon is called “convergence.”

Interface Movement

Interfaces have two actions relative to the nervous system:

  • Closing – Reduce distance between the neural tissues and movement complex; creating pressure on the nervous system.
  • Opening – Increases distance between neural tissue and interface; reducing nervous system pressure.

These actions can have profound impacts on the nervous system. Take closing for example. It is possible that if a muscle has increased tone or guarding, pressure could increase along a peripheral nerve and create symptoms.

Unless, you know, you need to do some opening.
Unless, you know, you need to do some opening.

The Nervous System is a Continuum

Any one movement of the nervous system can affect movement at areas further away. Two interesting examples of this occurrence are at the cervical spine and lower back. It has been shown that sagittal neck movement change position and tension in lumbar spinal cord and nerve roots. The other example includes the eyes. When a bilateral straight leg raise is performed, the eyes move inward.

In order to implicate the extent of the nervous system’s involvement requires structural differentiation.  The way this action can be achieved is by moving neural structures in the questioned area without moving the musculoskeletal tissues in the same region. An example of this would be symptoms evoked at the wrist with wrist extension that can be altered by changing head position. Because the nervous system is one piece, a pathological process at one area affects the system in its entirety.

It's like Jenga, only cooler.
It’s like Jenga, only cooler.

Response to Movement

The nervous system moves in a specific order when motion at a joint occurs. First, slack is taken up in early range. Next, sliding occurs in the mid-range, finally, tension builds at end-range.

Slack –> Slide –> Tension

These principles can thus be applied to treatment. A slider involves large movements through the mid-range, whereas a tensioner is performed more at end-range. If someone is incredibly irritable, simply taking up slack in the nervous system can be performed.

Bloodflow

Nerves love three things

1)      Movement

2)      Space

3)      Blood flow

Interestingly enough, peripheral nerve blood flow is regulated by nerves. The major players here are nociceptors and sympathetic fibers.  The nociceptive C fibers create vasodilation, which is counterbalanced by the sympathetic nerve’s vascoconstrictive qualities.

Inflammation

Here we shall discuss neurogenic inflammation. This type is when inflammation is produced efferently by the peripheral nervous system; predominately in the c fibers, dorsal root ganglion, and nerve root.

We can test neurogenic inflammation by stimulating the skin.  If there are changes in vasodilation capabilities from one side to the other, a potential neurogenic problem may be present. Reduced vasodilation may implicate denervation, whereas increased vasodilation may mean a hypersensitive neural tract.

Or as our most recent APTA fellow determined, skinning the patient leads to no neurogenic inflammation.
Or as our most recent APTA fellow determined, skinning the patient leads to no neurogenic inflammation.

Sequencing

Neurodynamic sequencing relies on nervous system non-uniformity.  There are several big points regarding sequencing movements.

  • Movement sequence affects symptom distribution with neurodynamic testing.
  • More likely to create symptoms in area moved first.
  • Greater nerve strain occurs at the site that is moved first.
  • Sliding direction depends on movement order.
  • These principles occur anywhere in the nervous system.

Oftentimes when performing neurodynamic testing, resistance will be encountered. This resistance is usually muscle guarding, but it is entirely possible that nerves provide some of this resistance. Regardless of what is causing resistance, this protective mechanism must be respected. This reason is why usually neurodynamic tests are held for only a few seconds and applied slowly.

Applying these concepts to treatment, we can grade how challenging a movement is to the nervous system. This is where we define sliders and tensioners. Sliders are created to produce a sliding movement to improve pain states and nerve excursion. Tensioners, on the other hand, help improve nerve viscoelasticity and physiology.

Another sequencing aspect that can be beneficial is interface testing within neurodynamics. An example of this test would be having a person contract a muscle during a neurodynamic test. This specificity can be useful in detecting hard-to-find processes.

Why Neurodynamic?

We change the name of this testing to neurodynamics because it accounts for changes in nerve sliding, cross-sectional area and shape, transverse position, axial rotation, viscoelasticity, intraneural blood flow, and mechanosensivity. Calling these tests tension tests only account for one aspect of the nervous system’s capabilities. So to for neural provocation tests, as we are not always trying to provoke symptoms.

P1170043
And that’s the bottom line because Shacklock said so.

Why Everything Works (and Doesn’t Work)

A Great Place to Be

I was recently at my home away from home, IFAST. Every time I go here the following occurs:

  1. I have an amazing time with amazing people.
  2. I learn a ton and realize how little I really know.
  3. Prolific discussions are had.
  4. I end up purchasing WAY too many books as soon as I get home.
Taken from outside my room after my most recent Amazon order.
Taken from outside my room after my most recent Amazon order.

As many of you know, Bill Hartman and I appreciate a PRI philosophy. When I go to IFAST, we inevitably experiment with many different things. This weekend, Bill and I were playing with how many different ways we could achieve full right shoulder internal rotation on my good friend Lance and the lovely IFAST intern Liz. Here was everything that gave these people full motion.

  • Soft tissue mobilization to the infraspinatus.
  • Manually assisted breathing.
  • Tickling the right side of the face.
  • Tapping the left hamstring.
  • Smacking the right glute max (yes, I spanked someone).
  • Having someone think about contracting their right glute max as hard as possible.
  • Having someone watch me breathe with a left sidebend.
  • Reflex locomotion.
If it will keep you neutral, why not?
If it will keep you neutral, why not?

Now of course, that does not mean you should be spanking your patients and clients with shoulder issues (but if you do make sure it is the right glute), but we have to ask why did all of these different techniques–even the weird ones– achieve the same outcome we wanted?

Why Things Work

Joseph Brence, a gentleman whose material I enjoy, recently posted a blog showing several different techniques and polling his readers if these interventions “made sense,” whatever that means to you.

While I am sure most if not all these treatments will achieve certain results, they likely are accompanied with flawed explanations. Why can we have erroneous rationale yet make positive changes?

I think that we get too caught up with what is occurring in the periphery. We can argue all day if we are breaking up scar tissue, mobilizing fascia or joints, stimulating skin, or releasing trigger points—but it does not really matter.

Forget about the periphery for now. Let’s keep things simple. Here is what we think is going on with our interventions. You ready? When I am performing treatment x, I am………………

Applying a sensory input

IASTM is a sensory input, manipulation is a sensory input, myofascial release is a sensory input, and your interaction with someone is a sensory input. All that we do—in therapy, fitness, school, socializing, everything—is a sensory input.

We apply a sensory input, the brain interprets this input, and a multi-system output is or is not elicited. This new output is itself a sensory input, which the brain interprets, thus affecting one’s perception.

Capture

This cycle explains why everything works in simplest terms. However, this process is complicated by the multiple variables that make one technique work for one person but not for another.

Take the examples above that we performed to increase shoulder mobility. What we did not account for was that Lance and Liz were very comfortable with Bill and I, thus are more likely to relax and be more receptive to the sensory input we apply.

Let’s look at ultrasound as another example. The literature is pretty clear that this modality is crap. But we have all had that patient who said ultrasound fixed them the last time and it helps so much. You try everything else to no avail, but as soon as you begrudgingly apply that ultrasound the patient rapidly feels better. The sensory input’s efficacy depends on how the brain interprets said input.

Adding the electrode makes all the difference.
Adding the electrode makes all the difference.

That is why patient interaction is so important. I can fathom someone who performs a treatment that is very much evidence supported, but does not get the outcome desired. Maybe the patient did not feel comfortable with the applied input, or maybe they did not like the clinician. These things matter and this is what makes our jobs so challenging. Everyone’s brain interprets the environment differently, thus requiring an individualized approach.

Ain't no evidence going to help this problem.
Ain’t no evidence going to help this guy’s problem.

What should be in Your Skill-set?

If we operate on the above framework, we can apply pretty much any technique to someone. But again, that does not mean that all techniques will work, and some might be more effective than others.  The short answer is that you need to provide the right intervention to the right person under the right context that has the lowest potential for harm and the largest potential for results. 

It is also desirable and beneficial to utilize sensory inputs that either the patient/client can perform on themselves (i.e. exercise) or that can facilitate this process to occur quickly. The clinician’s ultimate goal should be to render themselves unnecessary for the patient.

But you can still do cool things.
But you can still do cool things.

All that being said, there are things that I look at when I decide to implement or learn a particular technique, in no particular order:

1. Evidence-based.

If there is some substantial support in the literature for or against something, it is a piece worth considering. This does not mean we must live and die by the systematic reviews. Even things such as case studies have merit. After all, it was Pavlov’s dog, not dogs. And it was an animal study at that!

Don’t like that case? Here is another example. Suppose I have a case study which involves a healthy man in his mid-twenties being seen for shoulder pain. I apply a brand new intervention that results in his instantaneous death. Will this influence your thought process in terms of using said intervention? Perhaps a higher level study is needed to make sure that this was not just a fluke. Of course, this will not happen because this case’s outcome is relevant. The big question to be answered by evidence is can I use the literature to support my treatment rationale?

2. The patient believes it will work.

This component is huge. There is more and more research being done on thrust manipulation, but what happens if the patient does not like it? In a clinical prediction rule recently done, one of the criteria was the patient’s belief that the intervention will work. Simply put, patient perception helps maximize the placebo effect and affects the sensory input interpretation.

3. The potential for harm is low.

Hippocratic Oath baby! Do no harm first and foremost. You do not want to ignite one’s pain neurotag if you do not have to, so I try to pick things that will not hurt someone. You want to use the minimal dose necessary to achieve your desired result.

That doesn’t mean I won’t use technique that are uncomfortable; especially if it helps me achieve my goal. This situation is where you have to educate patients that you may be sore during an activity, but safe afterwards.

You are sore, but you are safe.
You are sore, but you are safe.

4. The potential for success is high.

You want to use things that will work on patients. The ability to choose the right intervention comes with your philosophy, evidence, skill level, clinical reasoning, and a multitude of other factors.

5. The intervention works fast.

Suppose we take two manual interventions. You pick one that takes 10 minutes to perform to achieve a desired output. Mine takes me 30 seconds to achieve the same result as you. I will win every time because now I have an extra 9 minutes and 30 seconds to give the patient exercises to facilitate keeping that desired output. If something works incredibly fast and provides more opportunity for motor learning, I am going to use it.

6. The intervention gives the patient or client the power to change themselves.

This is the reason I like PRI so much. They emphasize non-manual interventions over manual. Minimal motor learning is going to occur with passive interventions, so the more active the patient can be the better.

7. I can provide rationale that the patient or client will understand regarding its efficacy.

If you cannot say why you are performing an intervention, you should not do it.

Even Jada to the muah wants your rationale.
Even Jada to the muah wants your rationale.

8. I can perform the intervention with skill and confidence.

This piece goes with maximizing patient’s expectations. If I come across as the cock of the walk with a selected technique, and I have done it enough that I can make it comfortable, that will reflect on the patient. Do all that you can to maximize placebo.

Summary

There are so many different techniques that we utilize, and we all have our biases as to which ones we like. The important thing to understand is that all the interventions we provide operate under a similar framework; sensory input to facilitate a desired output and perception. So when deciding which technique is best to apply, pick the one’s that you can perform the best, that the patient believes will work the best, and allows the patient to take care of themselves as soon as possible.

And each other.
And each other.

Chapter 15: In Conclusion

This is a chapter 15 summary of the book “Movement” by Gray Cook.

The Goal

The goal of movement retraining is to create authentic unconscious movement at acceptable levels. We can develop many methods to achieve our goals, but working under sound principles is paramount. Some of the principles Gray advocates include:

  • Focusing on how we move.
  • Look to movement to validate or refute your intervention.
  • Movement is always honest.
Of course I did my corrective exercise, I swear.
Of course I did my corrective exercise, I swear.

When designing a movement program, we must operate under the following guidelines:

  • Separate pain from dysfunctional movement patterns.
  • Starting point for movement learning is a reproducible movement baseline.
  • Biomechanical and physiological evaluation do not provide a complete risk screening or diagnostic tool for comprehensive movement pattern understanding.
  • Our biomechanical and physiological knowledge surpass what we know about fundamental movement patterns.
  • Movement learning and relearning follows a hierarchy fundamental to the development of perception and behavior.
  • Corrective exercise should not be rehearsed outputs. Instead, it should be challenging opportunities to manage mistakes on a functional level near the edge of ability.
  • Perception drives movement behavior and movement behavior modulates perception.
  • We should not put fitness on movement dysfunction.
  • We must develop performance and skill considering each tier in the natural progression of movement development and specialization.
  • Corrective exercise dosage works close to baseline at the edge of ability with a clear goal.
  • The routine practice of self-limiting exercises can maintain the quality of our movement perceptions and behaviors and preserve our unique adaptability that modern conveniences erode.
  • Some things cannot be fixed, but change what you can.
  • The brain that learns function can learn dysfunction.
  • Be safe, be satisfied, and play.
I can always tell when movement is sassified.
And I can always tell when movement is sassified.

Chapter 14: Advanced Corrective Strategies

This is a chapter 14 summary of the book “Movement” by Gray Cook.

Inputs

Corrective exercise is focused on providing input to the nervous system.  We are allowing the patients and clients to experience the actual predicament that lies beneath the surface of their movement pattern problem. It is okay for mistakes to be made, for these errors help accelerate motor learning. Minimal cueing should be utilized, as we want to patient to let them feel the enriching sensory experience.

Mistakes are good...I wouldn't be here without them.
Mistakes are good…I wouldn’t be here without them.

Motor Program Retraining

There are several different methods in which we can achieve a desired motor output.

1)      Reverse patterning – Performing a movement from the opposite direction.

2)      Reactive neuromuscular training – Exaggerating mistakes so the patient/client overcorrects. Use oscillations first, followed by steady resistance.

3)      Conscious Loading – Using load to hit the reset button for sequence and timing.

4)      Resisted exercise – Makes patterns more stable and durable.

When you can deadlift that much, most anything is stable and durable.

Movement Chapter 13: Movement Pattern Corrections

This is a chapter 13 summary of the book “Movement” by Gray Cook.

Back to the Basics

Mobility deficits ought to be the first impairment corrected. Optimizing mobility creates potential for new sensory input and motor adaptation, but does not guarantee quality movement. This is where stability training comes in. In order for the brain to create stability in a region, the following ought to be present:

  • Structural stability: Pain-free structures without significant damage, deficiency, or deformity.
  • Sensory integrity: Uncompromised reception/integration of sensory input.
  • Motor integrity: Uncompromised activation/reinforcement of motor output.
  • Freedom of movement:  Perform in functional range and achieve end-range.
FREEDOM!!!! Of movement. And if the Road Warrior says we need to move free I listen.

Getting Mobility

There are 3 ways to gain mobility:

1)      Passively: Self-static stretching with good breathing; manual passive mobilization.

2)      Actively: Dynamic stretching, PNF.

3)      Assistive: Helping with quality or quantity, aquatics, resistance.

Getting Stability

In order to own our new mobility, we use various stability progressions to cement the new patterns. There are three tiers in which stability is trained:

1)      Fundamental stability – Basic motor control, often in early postures such as supine, prone, or rolling.

2)      Static stability – done when rolling is okay but stability is compromised in more advanced postures.

3)      Dynamic stability – Advanced movement.

We progress in these stability frames from easy to further difficult challenges.

Assisted → active → reactive-facilitation/perturbations

I would black my face out to if someone was having me do this exercise.
I would black my face out too if someone was having me do this exercise.

Since stability is a subconscious process, we utilize postures that can challenge this ability while achieving desired motor behavior. We can also group the various postural progressions into 3 categories:

1)      Fundamental – Supine, prone, rolling (requires unrestricted mobility).

2)      Transitional – Postures between supine and standing such as prone on elbows, quadruped, sitting, kneeling, half-kneeling.

3)      Functional: Standing variations to include symmetrical and asymmetrical stance, single leg stance.

The only legit way to practice single leg stance.

Movement Chapter 12: Building the Corrective Framework

This is a chapter 12 summary of the book “Movement” by Gray Cook.

A Whole Lotta P

When we build our corrective framework, we must take into account the 6 P’s:

1)      Pain – Is there pain with movement? Staying away from pain improves motor control.

2)      Purpose – What movement pattern are we targeting with corrective exercise and what problem are we addressing (i.e. mobility, stability, dynamic motor control)?

3)      Posture – Which moderately challenging posture is the best starting point for corrective exercise that allows for reflexive activity?

4)      Position – Which ones demonstration mobility/stability problems and compensatory behaviors?

5)      Pattern – How is the dysfunctional movement pattern affected by corrective exercise?

6)      Plan – How can you design a plan based on findings?

The goal when designing the correction is to stay in the middle ground of the autonomic nervous system while providing a rich sensory experience.  Movement pattern dysfunction is a behavior that needs to be addressed and changed.

Movement Chapter 11: Developing Corrective Strategies

This is a chapter 11 summary of the book “Movement” by Gray Cook.

Autonomics

All exercise affects tone and tension. This influence is the basis for movement. The autonomic nervous system determines movement as threatening or not, which determines requisite tone. It is important to nudge movement towards further nonthreatening yet advanced stimuli.

 

FMS Corrections

Proceeding to correct under FMS protocol is determined by screen results and changed via exercise.  We first correct mobility, next reinforce stability, then retrain movement patterns. Stability training in particular follows a sequence:

1)      Challenge posture and position.

2)      Build mid-range strength.

3)      Develop end-range stability.

Movement patterns are corrected in the following hierarchy:

ASLR & Shoulder mobility → rotary stability → pushup → Inline lunge → hurdle step → Deep squat

 

SFMA Corrections

The SFMA corrective pathway is nonlinear unlike the FMS. The breakouts will tell you which direction to go to restore optimal movement.

The options are also increased. Often to gain mobility, you would utilize various manual therapies or other modalities. To alter stability, taping, orthotics, braces, or anything else to increase motor control may be utilized.

Movement patterns are corrected in the following hierarchy:

Cervical spine → Shoulder multi-segmental flexion & extension→ Multisegmental rotation single leg stance → Squat

Depending on how movements present, certain therapies are utilized:

DN – manual therapy and corrective exercise.

DP – Manual therapy and modalities.

FP – Modalities and manual therapy.

FN – General exercise.

Modalities? No FN way...See what I did there??? Ah hell with it.
Modalities? No FN way…See what I did there??? Ah hell with it.

Exercise Categories

There are several exercise types that can be utilized depending on one’s goal:

  • Functional: Purposeful exercise that displays carryover to other activities. Can be general (for movement patterns) or specific (for certain skills). These generally enhance physical capacity.
  • Corrective: To create a functional base, normalize tone, and allow movement freedom.
  • Conditioning: Create positive neurophysiological adaptations in structural integrity/performance over periods longer than a single exercise series.
  • Movement prep: Work on patterns needed for activity.
  • Skill training: For specific skills.

Movement Chapter 10: Understanding Corrective Strategies

This is a chapter 10 summary of the book “Movement” by Gray Cook.

Mistakes, I’ve Made a Few

When we are talking corrective exercise design, people often make 4 mistakes:

1)      Protocol approach: Exercise based on category.

Problem – 1 size fits all.

2)      Basic kinesiology: Target prime movers and some stabilizers.

Problem – fails on timing, motor control, stability, and movement.

3)      Appearance of functional approach – Use bands and resistance during functional training.

Problem – If the pattern is poor, adding challenges to it can increase compensation. There is also no pre-post testing.

4)      Prehabilitation approach – Prepackaged rehab exercises into conditioning programs as preventative measures to reduce injury risk.

Problem – Design is based on injuries common to particular activities as opposed to movement risk factors.

Several, so it seems.

There are also certain mistakes that are often made when utilizing the FMS and SFMA:

1)      Converting movement dysfunction into singular anatomical problems.

2)      Obsessing over perfection in each test instead of identifying the most significant limitation/asymmetry.

3)      Linking corrective solutions to movement problems prematurely.

The overarching rule is to address these movement deficiencies first, as we do not want to put strength or fitness on top of dysfunctional movement.

 

The Performance Pyramid

When designing an exercise program, we look for three areas to improve performance: Movement, performance, and skill.

performance pyr

It is important that program design is based on the individual’s needs and has these qualities in a hierarchal fashion. For example, if one performs excellent on functional performance capabilities but has poor foundational movement, injury risk may increase.

 

Program Design

When implementing corrective exercise, it is important to provide the correct stimulus amount. We want the individual challenged, but not struggling for dear life.

  • Too easy – >30 reps with good quality.
  • Challenging, but possible – 8-15 reps with good quality and no stress breathing. There is a decline in quality secondary to fatigue towards the end of rep ranges.
  • Too difficult – Sloppy from the beginning and only worsens.

Rarely does increasing difficulty equate to increasing resistance. Oftentimes you may advance the exercise position, decrease the base of support, or add more movement complexity.

You may have to remove some activities that feed into dysfunction from one’s current programming, lest you wish to not change the movement pattern. Often how quickly one changes his or her ability to move depends on how diligent one is with corrective exercise.

Realize that corrective exercise should only be supplemental and temporary to what one is doing. It is supposed to be corrective in nature, not preventative.  Moreover, movement scores can decrease with hard training, so continual reassessment is important.

I do active leg lowering and wall ankle dorsiflexion while I'm taking NO Xplode bro.
I do active leg lowering and wall ankle dorsiflexion while I’m taking NO Xplode bro.

The corrective exercise pathway should proceed as follows:

1)      Exercise selection is driven by screen and assessment.

2)      A thought out framework gives you the best possible choices.

3)      Retest, note positive or negative changes, and then use results to modify next session.

4)      Reassess once an obvious change is noted to see what the next priority is.

Ain’t no need to question the Authority