Mechanic or Coach: The Role of the Rehab Professional

 

My father-in-law, a retired auto mechanic and professional curmudgeon, drives an early 80’s Pontiac and whiles away his time with an ancient Model T. Why does he drive a 30 year old car? Because in the mid 80’s auto manufacturers began installing computers in cars and now he can’t work on anything but the older models. He can twiddle a wrench or drive a screw, tighten a belt or adjust a spark plug gap with the best of them, but doesn’t have the tools or knowledge to work with control systems. 

Having come out of PT school in 1983, I was trained somewhat mechanistically. We mobilized joints to improve joint play and arthrokinematics. We utilized tissue release techniques to improve fascial mobility and range of motion. We prescribed exercises to stretch or strengthen individual muscles. We used muscle energy techniques, strain/counter-strain and other techniques to move or align vertebrae. 

What we didn’t think of then, and are still in our infancy in terms of clinical application of now, was how to affect the control system. This is not to say that the strategies mentioned above are not helpful or that you shouldn’t use them. But we can do more. Keep in mind that for each joint that is mobilized, for each fascial plane that is released, for each muscle that is strengthened, there needs to be a corresponding change in neuro-motor behavior; the computer needs to be re- programmed to assimilate the new possibilities you have created. 

The habit-driven nervous system is resistant to change. Postural, movement and muscle activation patterns are not set in stone but they do want to bring the skeleton back to homeostasis; to return to what feels like home. Some people can take your intervention and run with it. Their CNS automatically adjusts and there is a permanent change, but these are the lucky few. For most people you need to follow up, to spell it out in the language of the nervous system; experiential movement, proprioceptive sensation and functional intention.
Does strengthening the VMO automatically improve patellar tracking? Does hip flexor stretching automatically reduce lumbar hyper-extension? Can core strengthening truly stabilize the lumbar vertebrae in the presence of path-of-least-resistance movement habits? Does strengthening the triceps improve LeBron James’ jump shot? Peripherally yes, but isn’t there more? Fortunately, we are not limited to working with the hardware. We can coach them to re-program their own software! 

The APTA House of Delegates has adopted a new vision for the physical therapy profession, one that could easily be embraced by all the rehabilitation professions. “Transforming society by optimizing movement in order to improve the human experience”. Transforming society might be a bit ambitious. The optimizing movement part is right up our alley, but we risk frustration if we think we can make someone move better; we don’t have the access codes needed to re-write the program, to change the way people move and act in the world. 

Who does? Our patients! Let’s re-phrase our job description. We assist our patients in recognizing their sub-optimal movement; we encourage people to be aware of what they are doing and how it is affecting their musculoskeletal health and function. We provide conditions in which an individual can experience different movement options, and select from various options, those that work best. We can be facilitators of optimal movement; teachers. We can do things to people to help them, but we can also do things with people by coaching them. 

Embracing this role, there are two primary questions we have to ask. One, what are we going to teach; how do we define optimal movement? Two, how are we going to teach movement skills; what characteristics or tricks of the trade can we use to make our exercise informational? Both questions have commonly/historically been ignored or glossed over with vague generalities in school and con ed. Maybe it’s time for some definitive answers, for specificity; maybe it’s time to make the leap from knowing the mechanics of anatomy to understanding and facilitating the control of integrated movement. Stay tuned for the next installment on defining optimal movement.