What We Do:
My name is Gordon Browne and I am a physical therapist with a talent for movement, a knack for teaching it and a practical foundation in the nitty-gritty of orthopedic clinical practice. With professional interest in musculoskeletal pain and sports medicine, I have explored various manual therapy, therapeutic exercise and soft tissue release methods during my 25 year career. As interesting and beneficial as they have been, I felt that my array of exercises and manual techniques lacked overall cohesion, purpose or unifying theme; they were a list of possible ingredients without a recipe. After taking a zillion courses, I realized that I was still missing key knowledge concerning my orthopedic practice; a comprehensive framework for understanding and describing real-life human movement, what goes wrong with it and how to best facilitate improvement of it.
In searching for this knowledge, the philosophical split between "neuro" and "ortho" PT's became glaringly obvious. While the neuro PT's are thinking about and working in terms of whole-body functional movement, neuromuscular facilitation and sensory awareness techniques related to their neuro population, we ortho PT's went in another direction and focused on localized arthrokinematic movements and the use of exacting positions and angles to facilitate individualized muscle contractions or stretches. I wanted big-picture movement but worked in precision ortho; what's a boy to do? Since physical therapy schools and continuing education courses were not adequately applying functional movement and neuromuscular facilitation techniques to ortho populations, I began a personal exploration of and clinical experimentation with a variety of non-traditional exercise approaches; including the Feldenkrais Method�, Yoga, Pilates and Tai Chi.
I have now come out on the other side, unscathed, with a host of movement gems ready for immediate application to your orthopedic patients! These gems are mined from the integrated movement systems listed above, but modified and simplified to make them more clinician- and patient-friendly. In our Therapeutic Movement training materials we will show you how to teach each movement, how to simplify or complexify each movement and how to recognize indications and contra-indications of each movement. We will break down each movement gem into its constituent parts so that you can appreciate how, through the application of constraints, we can still ensure individual muscle strength, fascial flexibility or joint stability while coordinating those individual parts with local and distal synergistic parts in a larger functional movement. Therapeutic Movement makes comprehensive functional movement and neuromuscular facilitation techniques available to the ortho clinician for the first time, presented in ortho-understandable language and in an ortho-familiar format!
What's Wrong with Therapeutic Exercise?
What is the distinction between Therapeutic Movement and Therapeutic Exercise? Why ditch the tried and true and take a leap into the unknown? Therapeutic Exercise is simple and logical, it localizes the action and cuts down on variables, and it lends itself well to the objective measurement of reps and amount of resistance. Therapeutic Exercise is a fine example of an isolation philosophy of exercise. Terminal knee extensions, bicep curls or triceps presses with the humorous supported, ankle eversion or glenohumeral external rotation against elastic tubing and the weight machines in the gym are some examples. Isolation exercises tend to be linear, run in some variation of a cardinal plane and are designed for one thing only; to isolate and localize a muscle, joint, ligament, fascial band or nervous tissue for subsequent stretching or strengthening. These are exercises based on cadaver anatomy, invisibly influenced by the xyz axis and ideas of origin and insertion, cooked up in the forebrain of people more engineer than athlete and firmly focused on the local functioning of one specific part.
As simple and logical as this system is, we have made some faulty assumptions in our traditional use of Therapeutic Exercise. We have assumed that doing an isolated exercise for a particular muscle would automatically result in that muscle timing and coordinating its action with local and distal synergists in the context of everyday functional activity. We have taken as an article of faith that quantitative strengthening of a local muscle would necessarily improve the qualitative coordination of the whole; a stronger peroneus longus would stabilize the ankle in cutting; the infraspinatus would glide the head of the humorous downward when reaching overhead; the multifidi would stabilize L5 when lifting; the vastus medialis would track the patella when climbing stairs.
We have assumed that stretching exercises for the hamstrings would reduce lumbar flexion stresses in bending; that stretching the psoas would reduce anterior pelvic tilt in standing; that stretching the pecs would make you sit up straighter. We assumed the whole was merely a summation of its parts; that we could positively and permanently change the habit-driven motor behavior of an incredibly complex human being with a few simple exercises. But now we are starting to realize the bitter truth; people are not tinker toys, we are not mechanics and Therapeutic Exercise is inadequate when it comes to teaching coordinated, whole body movement skills. Therapeutic Exercise is too focused on precision isolation of individual muscle fibers and not enough on whole body coordination; we forgot that bodies move as integrated units and that we need to teach muscles how to work in specific relationships with others.
Therapeutic Exercise is too focused on doing and not enough on feeling; we have forgotten that the motor quality relies on accurate and actionable sensory information and have neglected to teach proprioceptive self-awareness skills. We have been trying to think of ortho rehab strictly in terms of science and mechanics, and have neglected to think in terms of behavior modification and patient software upgrades. Trying to teach lumbar stabilization skills, shoulder girdle myofascial re-organization, improved postural support, patellar alignment or the myriad of other sensory-motor skills we are trying to facilitate in our orthopedic patients needs another exercise paradigm; one that is less isolated and more integrated, one that is less mechanical and more organic, one that is less about doing reps and more about sensing differences. Fortunately for our patients, we are moving in that direction!
The Core Stability Model�Case Closed?
We are now in the age of Pilates and the concept of core stability. This core stabilization philosophy represents a quantum leap from the isolation/Therapeutic Exercise model in that it now acknowledges and seeks to facilitate an integrated relationship between movements of the limbs and organization of the pelvis and torso. It more closely simulates real-life whole body movement, it is more functionally relevant than Therapeutic Exercise or the typical gym machines, and it has solid research to back up its use in treating low back pain. This exercise model emphasizes abdominal and deep spinal muscle strength; the intent is to set/isometrically contract these "core muscles" to prevent intervertebral and intra-articular shearing or other hypermobility stresses.
Supine or side lie leg lifts, hands and knees leg and opposite arm lifts and plank poses are some common examples of this type of exercise. The original research on low back pain reported on the benefit of an intra-articular stabilizing system (dubbed the core and starring multifidi and transverse abdominus) that kicked in first or contracted in anticipation of gross movements driven by the larger and more superficial muscles. Later research showed a corollary stabilizing system in the cervical spine, starring the longus colli and rectus capitus.
This holy grail of musculoskeletal health has been avidly pursued into other joints, and various exercises have sprung up designed to access and strengthen these core muscles; though mostly still in the old familiar "isolate, strengthen and hope for automatic application" format of therapeutic exercise. The stabilization philosophy has since evolved to include not just intra-articular stabilization, but also the stabilization and control of the pelvis or chest (when moving the legs or arms) with the belly/intercostal or back muscles. This is where a good idea got derailed.
The Good Stuff
The idea of core stabilization has great merit on three particulars. First, the concept of joint instability or hypermobility as a likely culprit in many spinal/peripheral joint or disc conditions has finally supplanted the old idea that everything that hurts needs to be stretched; old school class of '83. The existence and centrality to low back pain of the transverse abdominus and multifidi, as shown by Hodges, Richardson, et al., demonstrated the importance of joint stability systems not only in the spine, but throughout the whole body. Longus colli in the neck, infraspinatus and teres minor in the shoulder, vastus medialis and popliteus in the knee; all are arthrokinematic or stabilizing muscles. The question then becomes not one of whether these various stabilizing muscles are important to musculoskeletal health and to our orthopedic population, but how to go about facilitating their use and coordination in a way that optimizes their effectiveness in everyday activity and results in a decrease in pain and dysfunction.
Second, the concept of an interconnected or integrated body has taken hold in our institutional consciousness. We now know that when lying supine and lifting a leg that the pelvis and low back will be moved, with possible shearing stresses or even pain provocation, unless the pelvis and low back is stabilized. There is a relationship between the movement of the limbs and the movement or stability of the pelvis and torso. The acknowledgement of this relationship should raise a few questions for the curious clinician. Which ways of arranging these relationships, which patterns of coordination, are most beneficial or most ideal for the health of the musculoskeletal system? What common motor mistakes do people make in coordinating their limbs and torso that lead to musculoskeletal dysfunction? How can we modify our exercises to more closely simulate and more profoundly affect these relationships? The question is not whether to prescribe isolated or integrated exercise, but what style or philosophy of integrated exercise you want to teach.
Third, the concept of motor control exercise is a key one. Previously, we have categorized exercise primarily in terms of stretching, strengthening or conditioning; these kinds of exercises have quantitative goals measured in distances, weights, repetitions, range of motion or calorie consumption. While it is true that many of these types of exercises are prescribed for motor control purposes, they are not all true motor control exercises. What distinguishes motor control exercises from our more traditional exercise models? With motor control exercise, coordination of movement, not isolation of movement, is now a goal. With motor control exercise, movement quality, not just quantity, is a goal. Instead of blindly assuming automatic application of an exercise to real life activity, we must now factor in functional relevance and include patient proprioceptive self-awareness and motor self-regulation as valid goals. The implications of such a paradigm shift are profound both in terms of how we view our role in the health care profession and in how we treat our patients.
On the Other Hand
Does this coronate the core stabilization philosophy as king; is the case closed? Have we reached the very pinnacle of clinical exercise evolution? I think not. While intra-articular stability and core muscle activation is a very important advancement, the current interpretation of this core stabilization exercise approach has a few drawbacks in comparison to an integrated movement model. These drawbacks include some disputable beliefs; that the belly muscles should control the pelvis and that the torso should be stabilized when moving the head, neck and arms. These drawbacks include some glaring omissions; not adequately addressing the hypomobile evil twin to the hypermobile victim and not adequately emphasizing patient self-awareness, self-regulation and individual variations.
Disputable belief number one; the belly is the powerhouse or engine for the whole body. We know that the pelvis can be moved or controlled by either the hip or waist muscles; hip flexors or back extensors can drive anterior tilt, hip extensors or abdominals can drive posterior tilt. We know that the legs can move relative to a belly-stabilized pelvis (classic stabilization strategy) or the pelvis can move relative to stabilized legs (closed kinetic chain and the reality of everyday life). We could train our patients to use their legs to move their pelvis and low back, but we have been seduced by the logic and familiarity of Pilates orthodoxy. Central to Pilates philosophy, and seen clearly embodied in popular core stabilization exercises, is the notion that the back and especially the abdominal muscles are responsible for re-positioning or stabilizing the pelvis and for controlling lumbar flexion/extension balance. This is not how movement should be organized or what we should be teaching our patients!
In an integrated movement model of exercise, the long thigh muscles and the big hip muscles are the powerhouse. In these systems, the smaller core stabilizers are relegated to the more size-appropriate role of intervertebral stability while the legs are responsible for the position, movement and stability of the pelvis and the superficial belly and back muscles control the relationships between the pelvis and chest. The belly muscles control spinal flexion in response to hip muscle controlled posterior pelvic tilt; the back muscles control spinal extension in response to hip muscle controlled anterior pelvic tilt; the obliques control spinal rotation in response to hip muscle controlled pelvic rotation. These big hip and thigh muscles, through their control of the pelvis, exert a primary influence on spinal postural balance, movement and stability.
These same big hip and thigh muscles, through the kinematic chain and their control of the distal end of the femur, exert a primary influence on knee, foot and ankle position and stability; the hip abductors can reduce knee valgus and patellar mal-alignment and can coordinate with the peroneus longus to reduce foot pronation; hip flexor shortening can contribute to knee hyperextension and hip extensor driven posterior pelvic tilt can reduce it; the hip external rotators coordinate with the hamstrings and popliteus to protect the MCL and ACL in pivoting/cutting movements. In the upper body these integrated movement systems inform and encourage the pelvis, directed from the hip muscles and coordinating through the thoracic spine and rib cage, to initiate and provide range of motion assistance with movements of the head or arms. The hips are the engine or powerhouse; the belly is part of the transmission system!
As medical professionals, we all remember memorizing the origins and insertions of each muscle; there was always a bone that moved relative to a bone that was stationary. Thigh flexes or extends relative to stationary pelvis; neck rotates left and right relative to a stationary thorax; humorous rotates in and out relative to a stationary scapula. While Therapeutic Exercise and the isolation philosophy is an obvious derivative of this "Barbie Doll" way of thinking about movement, Pilates and the core stability philosophy are also influenced by the same origin and insertion thinking.
When you assume that the legs (insertions) move relative to the pelvis (origin), rather than the other way around (as happens in real life movement), you will train the waist muscles to control the pelvis and might overlook the hip muscles as prime players in the low back game. When you cling to disputable belief number two, that the neck and arms (insertions) should move relative to an immobile torso (origin), you will design exercises that embody this belief (neck stretches flex/ext and rotation/side bending). Perversely, this encourages distal hypermobility and proximal stability, rather than more properly proportional distal movement initiated from and integrated with proximal mobility, and might unwittingly fan the flames of further joint instability.
What we really want in motor control exercise is simultaneous local stabilization of a hypermobile area with proximal mobilization of hypomobile areas. In integrated movement systems, the head and arms are assisted by or integrated with dynamic movements of the pelvis, spine and rib cage; they move as an extension of the torso, rather than relative to an immobilized or stabilized torso. This encourages a more even distribution of movement and effort, leading to a reduction in spinal or glenohumeral hypermobility stresses and neck and shoulder girdle muscle overuse while encouraging movement in stiffer or less participatory areas.
As a further result of this origin and insertion thinking, the core stability model has not been looking for and addressing the corresponding hypomobile areas in the right areas. When we think the neck should move separately from the torso, we look for the corresponding hypomobile area in some other part of the neck, rather than in the thoracic spine and rib cage. When we think of the legs moving relative to a stabilized pelvis in lumbar instability, instead of viewing the legs as controlling the pelvis, we look for corresponding hypomobilities in the upper lumbar or lower thoracic spine, while overlooking movement inadequacies in the hip joints. This is glaring omission number one; not identifying the correct hypomobile twin and not simultaneously addressing local stability and distal mobility at the same time and in the same exercise!
The Ghost in the Machine
Besides erroneously assigning pelvic stability and powerhouse status to the belly and failing to accurately address hypermobility/hypomobility relationships, core stability philosophy omits patient proprioceptive self-awareness training. Recall that even with our ortho patients, we are still working with sensory-motor systems. For the machines of their bodies to work, they need the means to act (muscle contraction), the means to sense (proprioceptive acuity) and the means to decide (motor planning). Historically with Therapeutic Exercise and now carrying on into Core Stabilization, we have emphasized the former and ignored the latter. It's time for that to change.
Proprioceptive self-awareness skills include position sense, direction and velocity of movement, muscle effort and relationships to distal and proximal parts. Moshe Feldenkrais used to say "when you know what you're doing, you can do what you want." The Browne Addendum states "when you don't know what you are doing, you're doomed to repeat what you have always done". Where is spinal neutral and how do I know how to get there? Which shoulder is elevated and what does that have to do with my pelvic and torso imbalances? What does it feel like to rotate around my hips instead of around my lower back when walking? Where are my feet pointed? Which specific muscles do they mean when they say to lift with your legs? By and large, people don't "know where they are", and we need to equip ourselves with the skills necessary to teach our orthopedic population how to better listen to their bodies.
Moshe Feldenkrais was brilliant in his ability to paint verbal pictures of how he wanted his students to move and where/how he wanted them to direct their attention; he was a master at facilitating proprioceptive self-awareness with precise use of descriptive and inquisitive language. He was also very effective in his ability to help people decide which way of moving felt the best/easiest/most efficient; to decide on the merits of different ways to doing the same movement. In his Awareness Through Movement� exercises, he integrated the means to act with the means to feel with the means to decide.
We could use some of the language skills/techniques from this system. We need to be better able to describe, to contrast, to inform the comparator, to question, to empower patient decision-making, to encourage exploration outside the habitual, to link the principles and patterns learned in the exercise to daily activity. With some modifications specific to clinical practice, this is an instance of where we can profitably borrow from successful integrated movement system techniques in order to make our exercise prescription more informational and more effective.
New Horizons�Integrated Movement Systems
The Integrated Movement Systems of Yoga, Tai Chi and Feldenkrais have elements that could be of great use to the ortho clinician. One, they are cognitive exercises that incorporate the three elements of movement (move, sense, decide); you have to think about what you are doing, you have to be able to feel what you are doing, and you have to decide when the movements you are trying to make "feels right."
Two, they apply specific constraints that require certain relationships between different bones or between different muscles; this principle is called pattern specificity. If you want to strengthen the gluteus maximus, an exercise that calls for hip extension with back extension (camel pose in Yoga) is very different than one that calls for hip extension with back flexion (cat stance in Tai Chi or pelvic clock in Feldenkrais). In real world function, a movement that calls for glenohumeral external rotation with elbow pronation is very different from one that features glenohumeral external rotation with elbow supination (can you spot the clinical relevance of the first relationship to shoulder girdle pain?) These are examples of global relationships vs. differentiated relationships, and these global/differentiated distinctions are crucial to teaching integrated/relational exercise.
Three, they associate movements of the head, eyes, hands and feet with larger coordinated movements through the rest of the body; they simulate functional context. In this philosophy, it is not enough to get more hip flexor length; it needs to be in the context of standing and walking and result in a decrease in lumbar extension stresses. It is not enough to get more thoracic mobility into rotation; it needs to be in the context of looking or reaching along the horizon and result in a decrease in cervical hypermobility or glenohumeral impingement stresses. It is not enough to strengthen the vastus medialis; it needs to be coordinated with the hip abductors and external rotators to control the position of the knee relative to the foot and hip in the context of pushing your foot into the ground and result in a decrease of patellar mal-alignment and compression stresses.
The movement gems I have culled from the various integrated movement systems and called Therapeutic Movement have all three of these characteristics; they emphasize proprioceptive self-awareness, they are pattern specific and they are linked to specific functional contexts. If these systems are so great, why not just take a training program or send someone to a class taught by a practitioner of one of these systems?
Hook, Line and Sinker?
With a training program you get lots of detail but may lack the overview necessary to put the claims made by the various practitioners of these methods in perspective; no need to go hook, line and sinker with any one particular philosophy. Too often, the subjectively based integrated movement systems (Yoga, Tai Chi and the Feldenkrais Method) are presented to the health care practitioner on a "take it or leave it" basis: all the movements in the system are good and should be done by everyone; they are good for you because they feel good; we do it this way because it has always been done this way; mind and body are linked so the movements have other applications to visceral, emotional or metaphysical health and well-being. As a result, I think many of my ortho colleagues have shied away from these systems because they are perceived as un-scientific, unproven or just too airy-fairy.
In reality, not all movements within each of the systems should be done by everyone; and you shouldn't cut your patients loose to a public class unless they know their contraindications. As health care professionals and budding movement experts, we need to be able to recognize the specific characteristics of each Yoga pose, each Tai Chi step and each Feldenkrais lesson variation that justifies either home exercise inclusion or contraindication for each individual that comes in to see us. We need to be able to assess patient movement and postural bias, see these biases as a body-wide pattern of semi-predictable muscle imbalances and prescribe modifications of these movements that are selected for patient specificity and clinical appropriateness. Where a true believer might prescribe movements from their systems based on anecdotes and conventional wisdom, we can help you to recognize what to use, and what not to use, for each person and why!
We also need to come up with a better rationale for using these integrated movement systems than "it feels good to do it" or "it is ancient wisdom." There has already been a fair amount of research done on these systems, especially Yoga and Tai Chi, but there needs to be a lot more. Cognitive movements (and Feldenkrais piggy-backs on Yoga and Tai Chi research in this regard) have been studied and found to be of great benefit not only for balance and gait improvement (hence their popularity among home health and geriatric populations) but for specific knee, low back, neck and shoulder dysfunction as well. We need to better articulate what specific Yoga poses, Tai Chi stances or steps, or Feldenkrais lessons are used in each study and explain what the characteristics of the movement are that result in the observed outcome. It is not enough to say that Yoga is good for low back pain; what kind of low back pain was treated, what poses were used, why would that pose benefit that a person with that specific type of movement dysfunction and resultant low back pain.
Finally, all three of these systems tend to be presented concurrently with life philosophy or metaphysical teachings. Don't let this scare you off! Movement is movement and proprioceptive self-awareness doesn't depend on spiritual enlightenment, energetic balance, political correctness or the alignment of Venus and Mars. While I wouldn't discourage you from your own personal growth, I believe that as health professionals we should limit our role to one of healer and movement teacher; we should educate, encourage, demonstrate, motivate, admonish, comfort and explain, but we shouldn't proselytize. In our Therapeutic Movement courses and trainings, we stick to the concrete and the practical; what to teach and how to teach it. We use gems mined from the Integrated Movement Systems to treat musculoskeletal pain, but milled and distilled to fit our patient population and scope of practice.
Movement Model of Musculoskeletal Pain
The third glaring omission in the Core Stability model is not accounting for individual variability within the same diagnoses. We are all creatures of habit, and this includes motor habits. The way we sit, stand, walk, bend, reach or slurp soup was self-programmed into us long ago and put on autopilot. Habitual postures or movements are beneficial in that we don't have to re-invent the wheel every minute of the day; it frees up our brains to do who knows what all else. Unfortunately, habitual movement eventually becomes repetitive movement, and that gets us into trouble.
Treatment of musculoskeletal pain follows different models. The Medical Model identifies the tissue and the pathology (arthritis, tendonitis, bursitis, bulging disc, bone fracture, dislocation, muscle spasm, pinched nerve) and treats the tissue (anti-inflammatories, surgery, fusion, cast immobilization, manipulative re-location, ultrasound, electrical stimulation, massage, traction). The Alignment or Arthrokinematic Model identifies the malalignment or joint arthrokinematic fault (innominate rotation, sacral torsion, patellar tracking, vertebral subluxation, positional faults, poor accessory joint play) and treats with manual manipulation and localized/cortically engineered exercises (like muscle energy techniques) to mobilize or stabilize a localized joint.
A Movement Model acknowledges the tissue pathology and the value of treating the tissue, but also asks how that tissue became unhealthy. While traumatic injuries and disease processes may make up a significant portion of our ortho problems, and have their own motor control issues, their numbers are dwarfed by the numbers of repetitive stress injuries we see. Figure everything that is not obvious trauma is self-inflicted. Plantar fascitis, Achilles and peroneus longus tendonitis, shin splints, patellar complex problems, trochanteric bursitis, piriformis syndrome, shoulder girdle pain, glenohumeral impingement, thoracic outlet, tennis/golfers elbow and the vast majority of low back and neck pain are all consequences of operator error.
Repetitive stress injuries occur because we do repetitive movement all day and every day. We make motor habits and persist in them even when the joints we are moving too much or the muscle we are working too hard or the disc we are shearing too often starts to protest. We persist in motor habits because we don't know they exist, we don't know that they are contributing to our misery and we don't know that there are better alternatives to the way we are doing things. To treat repetitive stress injuries, we need to teach our patients how to recognize and control repetitive stress; they need to be able to perceive their old habits and to create new and better ones.
In a Medical Model, degenerative changes in the lower lumbar or lower cervical joints and discs are often described as "normal aging", even though the effect is not systemic throughout the rest of the spine. In a Movement Model, degenerative changes in these areas are a logical consequence of moving too much or maintaining an invariant position for too long at those segments; the fact that a lot of people over a certain age are wearing out at the same places illustrates an epidemic of common movement dysfunctions, not an inherent genetic weakness in L4-S1 or C4-C7. If age is the cause, we are all doomed. If faulty or repetitive movement is the cause, then qualitatively improved or more varietal movement is the answer. Teach these folks how to stabilize locally and move more at the hips and thoracic spine, then show them how the integrated movement pattern they are practicing relates to real life functional activity.
The Alignment or Arthrokinematic Model assumes an ideal that should be universally applied. Example one; if the alignment is off, if the bony landmarks are asymmetrical, there is a deviation of the body from a normal/ideal state and this needs to be corrected manually or with mathematically precise muscle contractions. In a Movement Model, we neither expect nor consider left/right skeletal symmetry normal; though we do seek to facilitate it. But rather than artificially pushing those wayward bones back into place, we will encourage our student to move, perceive and control those bones. If someone is habitually bent to the right with a low right shoulder girdle, we would teach them how to bend more easily to the left and then split the difference instead of pushing them back to our conception of center and telling them to hold it there. We will have our student move bones forward and back, left and right, up and down, in and out; we will do reciprocating movements to near end-range in each direction to facilitate better antagonist coordination and to help the nervous system to more accurately calibrate where the middle is.
Example two; there is a norm or ideal for the amount of lumbar lordosis a person with low back pain should maintain. A neutral spine is the same for every one of the nearly seven billion people in the world. In reality, we were not made with a cookie cutter and we all created our own movement habits; we designed our own repetitive stresses. Some people with low back pain experience it because they flex their low back too much; they are unstable into flexion. For these folks, a lumbar arch might be just what the Dr. ordered. But some people have back pain because they extend their back too much; they are unstable into extension. For these folks, they might do better with as small an arch as possible. Other people might be multi-directionally unstable and will need to arch a bit away from their habitual round in sitting or bending, but will need to flex away from their habitual lordosis in standing; sometimes there are different situational needs.
Both the Medical and the Alignment Models pre-suppose a "best way" of doing any particular movement or posture. The Movement Model provides a paradigm shift in that non-traumatic musculoskeletal pain is not just a result of a deviation from ideal, but as a result of habitual overuse of certain well established movement patterns. By recognizing that people move and posture themselves differently, and that the resultant repetitive stresses will be different for different people, we are freed from the tyranny of the ideal and encouraged to creatively and pragmatically personalize our exercise prescription to each individual.
Since a Movement Model acknowledges individual variation and assumes repetitive or habitual stress injury with any non-traumatic musculoskeletal pain complaint, we essentially teach them what they don't know how to do. If they move too much in one place, we teach them how to move somewhere else; if they are too tense, we teach them to relax; if they are systemically hypermobile, we teach them to ground and stabilize; if they zig too much, we teach them to zag;. We are not one size fits all. The stuff we teach is harder and more complex than the standard ortho rehab fare; it is harder because we teach them what they don't know and it is more complex because we look beyond the parts to include relationships to the whole. We help our students to recognize their own unique habitual movement and postural habits and how those habits contribute to their pain or dysfunction. We then help them to find new ways of moving that are perceptibly or demonstrably better than what they were doing before; leading them into proprioceptive enlightenment as modern-day Pied Pipers of musculoskeletal hygiene.
Wave of the Future
We should consider ourselves movement teachers, whose job is to create learning environments that facilitates change in our patients' harmful or inefficient motor behavior. When prescribing motor control exercise (either Core Stability and Integrated Movement Models), or when using our manual skills for that matter, we should be more like shepherds guiding our wayward flock to greener pastures and easier trails, and less like watchmakers loosening a spring over here or tightening a screw over there to tweak the machine into running more accurately.
Our patients are students, not just dropping their bodies off at the mechanic to spiffy up the parts, but active participants in a motor learning progression akin to learning to dance, or to play golf or the violin. Coordination and quality of movement, functional relevance, proprioceptive self-awareness facilitation techniques, creative use of constraints, manual and verbal cuing, recognition and reinforcement of whole-body patterns of coordinated movement; this is the changing language of clinical exercise prescription. Integrated motor control exercise is the wave of the future; ride it for fun and profit or watch your patients flock to those who can.
Understanding movement is not strictly an intellectual endeavor; it requires an experiential or personal component as well. A painter needs to see, a chef needs to taste and a movement teacher needs to both do movement and feel the effects of movement. A complete understanding of human movement and how to influence it cannot be had just through book learning and knowledge of anatomy, biomechanics or arthrokinematics. The map, as important as it is, is not the territory! Learning how to better see movement quality in our patients, how to relate movement dysfunction or poor musculoskeletal organization to our patients' pain and how to teach them to be more self-aware and more in control of their musculoskeletal health requires both the subjective experience of movement and the objective knowledge of why, with whom and how to use it. Our courses, books, audio cd's, manuals and videos are designed to both give you that subjective experience of movement and to help you to understand the rationale and the scientific "specs" of each movement; the method behind the madness.