Over the course of the last
several years, I have been blessed to come across some amazing people in our
respective professions. People who are
doing some very innovative things in technology, research and movement. One of
those individuals is Eric M. Dinkins PT, MSPT, OCS, Cert. MT, CMP, MCTAAs. Eric is a practicing clinician, educator and
innovator in the movement sciences. In
2014, Eric and a colleauge started a company called motion guidance. A technology designed to assist patients and
athletes in correcting pathological movement patterns. I am honored and humbled to have Eric doing
our guest blog this week.
If the
patient can't feel it, they won't change it
I may have slept through this
lecture in PT school, but early on in my career I often mix balance and
proprioception into the same definition or would at least train them the same.
Although my first job involved the rehabilitation and training of high level
athletes, the implementation of balance and proprioception often overlapped. In
hindsight, the reality is that most high level athletes get better with rest
and some moderately skilled manual and exercise treatment. Not to say that the
treatments weren't skilled, but the vast majority of injuries progressed with
very similar treatments.
But with time and experience,
it was those intermediate, competitive athletes that would see failures; at
least never return play how they considered their pre-morbid level. Often the
return to play would involved continued muscle spasm or that low grade ache
that, while not preventing them from competing, would yield hesitation or
decreased performance. Re-evaluation would demonstrate normal ROM, strength and
functional movement screen. It was at this time that I delved back into what I
may have been missing and how I could clean this up. And I noticed that I was
ignoring that differences between balance and proprioception. Especially in
head, neck and shoulder injuries.
Proprioception involves that
conscious AND unconscious understanding of a joints position in space,
movement, and force sense. It is processed at all levels of the CNS and is
integrated with other body systems like the vestibular, visual and somatosenory
systems. Mechanoreceptors are specialized nerve endings that process this
sensory information and convert this input into action potentials to be sent to
CNS for processing. According to Proske and Gandevia, 2012, the most important
source of proprioception is considered to come from the muscle spindles found
in skeletal muscle. The suboccipital muscles have a high density of muscle
spindles, thought to reflect the exceptional coordination role in head and eye
movement control. Proprioception is also important after movement has occurred
for a comparison of intended movement vs actual achieved movement. This
comparison is vital for motor learning to occur by updating the internal
forward planning model of motor commands.
Proprioception can be altered
or impaired by several factors. Pain, fatigue, joint effusion on the capsule,
and trauma to structures all can change our proprioceptive awareness and
thereby changing the motor control pattern in which our body systems work
together to be most effective. Disturbed feedback, feedforwrad, regulation of
muscle stiffness, postural stability in balance, visual acuity, and joint
stabilization can all be affected with changes to the body's
proprioception. Despite the substantial
importance of proprioception for body function, most clinics have a paucity of
tools to accurately assess proprioception.
Several research articles
have stated that exercise augments proprioception via activation of muscle
spindles. I'm sure this is why so many of my athletes would succeed early on in
my career. Exercise would naturally retrain the proprioceptive losses from
injury and body awareness would return without specific re-training. But
various exercises activate receptors at specific levels of the CNS that can
differ between individuals. Thus leaving some patients without the proper
training to re-educate their proprioception. If not properly re-educated, the
body may continue to interpret certain inputs as a threat and produce abnormal
responses.
This is where I enjoy using motion
feedback (like the Motion Guidance device). Both for clinical assessment of how
people like to move as well, interpretation of if that movement (or lack of) is
abnormal or necessary, and visual feedback for the patient immediately as they
are moving. Many of my patients present in clinic without being able to
reproduce their primary symptom that may warrant them to be in my office
anyway. What is left is an educated guess on what movement patterns, weakness,
overload, environment, etc may be contributing to their pain. Motion feedback allows
me to see a piece of what might be contributing to their pain more accurately
that with the naked eye. And helps bridge the gap between the novice and expert
clinician. It gives clinicians an extra clinical assessment tool for
proprioception, preferred movement patterns, and development of motor learning.
This is most evident in the use of laser feedback regarding Joint Position
Sense. Chen and Treleaven in 2013 researched the use of a laser to determine
accurate JPS in whiplash patients and it was found to be reliable and valid (1).
Simple observations of errors on a target determined whether the subject had
altered cervical proprioception. Balke found similar alterations in changes for
proprioception of the unstable shoulder in 2011(2) . Hande et al also found
knee JPS loss was correlated with both quadriceps eccentric and concentric
strength among patients with PFPS (3) .
Perhaps the most valuable
aspect of attempting to define and objectively measure proprioception is
ultimately how we see, or don't see the body move. Having the ability to
accurately determine a preferred motor pattern or attempt to correct a faulty one
comes down to proprioception. If the patient can't feel it, they won't change
it. There are biofeedback tools that are available to clinicians to improve the
learning curve, such as the Motion Guidance device, the Dynamic Movement
Assessment, or clinicians can use garments, tactile cues or mirrors to assist
in understanding an individuals propriocepetion. But these tools are only
extremely valuable if the information or data collection yields learning by the
patient. The old saying of “you can lead a horse to water, but you can't make
it drink” really applies to this scenario.
As “movement science
specialists”, the sports and healthcare professionals involved in
rehabilitation MUST be able to understand and diagnosed movement. But it goes
further. It is imperative to convert this information into lay terms that the
patient can use to interpret what is necessary to create change in their
movement. This change, whether addressing JPS, weakness, FMP, tissue overload,
etc, is what needs to be owned, understood and acknowledged by the patient.
This is all effecting proprioception! Otherwise, change will not happen. If the
patient can't feel it, they won't change it! One of our job as rehabilitation
professionals is to help our patients learn.
I think Eric would agree, but
as basic as it sounds, to truly change movement, we must change the way that we
think. Move better, feel better, perform
better and last longer. That
simple. If you like what you see, SHARE
THE PASSION! It is the biggest compliment you can give. Follow us
on Twitter @ACL_prevention and tweet about it. #MovingToChangeMovement
and help us spread the passion.
Trent Nessler, PT, MPT, DPT:
Physical Therapist | Author | Educator |Innovator in Movement Science and
Technology. Dr. Nessler is a physical therapist and owner of
Athletic Therapy Services. He serves as a practicing clinician and
movement change consultant for practices and organizations looking to develop
injury prevention initiatives and strategies.
He has been researching and developing movement assessments and
technologies for >10 years is the author of the textbook Dynamic
Movement Assessment: Enhance Performance and Prevent Injury, and
associate editor for International Journal of Athletic Therapy &
Training.
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