- Email: [email protected]
Osteopathic neuromuscular re-abilitation
International Journal of Osteopathic Medicine 13 (2010) 3–10
Contents lists available at ScienceDirect
International Journal of Osteopathic Medicine journal homepage: www.elsevier.com/ijos
Masterclass
Osteopathic neuromuscular re-abilitation Eyal Lederman* Centre for Professional Development in Osteopathy & Manual Therapy, 15 Harberton Road, London N19 3JS, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 May 2009 Accepted 30 June 2009
This article explores osteopathic neuromuscular re-abilitation (ONR) and exemplifies the use of the approach through a case study. The aim of ONR is to help individuals recover and optimise their control of movement after musculoskeletal injury, pain conditions or central nervous system damage. Ó 2009 Elsevier Ltd. All rights reserved.
Keywords: Osteopathy Motor rehabilitation Movement control
1. Background Osteopathic neuromuscular re-abilitation (ONR) was developed by Lederman1 at the British School of Osteopathy in the early 1990s. It originated from a doctoral research project in collaboration with the physiotherapy school at King’s College, London.2 The study examined the effects of manual therapy on motor control. The development of ONR was in response to emerging knowledge that musculoskeletal injury, pain experiences and central nervous system injury are all associated with diverse neuromuscular and movement control changes. It was also evident that these central processes are well buffered against passive external influences.3 Osteopathy was, and still is, dominated by passive manual approaches and low level active engagement of the patient outside the treatment session. These approaches have little or no lasting effect on movement control and neuromuscular recovery.4 ONR was developed from this clinical need to provide a therapeutic solution to an area that has received little attention within osteopathy. 2. A functional approach One of the key principles in ONR is the use of functional movement to help recover motor losses. Functional movement is defined in ONR as the unique movement repertoire of an individual.4 Some of this repertoire is the movement behaviour associated with daily needs and demands such as
* Tel.: þ44 0207 263 8551. E-mail address: [email protected] 1746-0689/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijosm.2009.06.004
feeding, grooming, going places, etc (general skills). Some of this repertoire is partly shared by others and some may be unique to particular individuals; they include physical hobbies, sports and occupational activities (special skills). For some people, their functional repertoire will include playing tennis, for another standing on their head (Yoga) or playing the piano and so on. Once a person learns a movement or a new skill it becomes a part of their movement repertoire and therefore, their behaviour. Movement which is outside the normal repertoire of an individual is termed in ONR as ‘‘extra-functional’’ (Fig. 1).4 Functional rehabilitation is defined here as the process of helping a person to recover their movement capacity by using their own movement repertoire (whenever possible).4 Hence, for a person who has motor losses at the knee and is unable to walk or run, the rehabilitation will use gradual exposure which may begin with walking, then running, jumping and stair-climbing, etc. If this person plays tennis, this activity will eventually be added to the rehabilitation programme. However rehabilitation is likely to be less effective if the remedial movement patterns or tasks are outside the individual’s movement experience (extra-functional). For example, it would be less helpful for a tennis player with a leg injury to be given rehabilitative exercise such as football, or leg presses in the gym or leg exercise lying on the floor. For this particular patient, rehabilitation that incorporates tennis tasks is more likely to be useful. For a person who is suffering from lower back pain and enjoys Yoga, a functional rehabilitation would consist of the shared functional activities (general skill) but may also include some of the upright postures from Yoga (special skills). A less suitable rehabilitation approach would be to prescribe tennis, an extra-functional task, to this particular individual. This may seem obvious; however,
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E. Lederman / International Journal of Osteopathic Medicine 13 (2010) 3–10
Functional repertoire
General skills
special skills
Extra-functional
Fig. 1. Functional movement represents the movement repertoire of the individual. It includes all the general activities and special skills. Extra-functional movement is all activities outside the individual’s movement experiences. (With permission Lederman E 2009 (to be published) Neuromuscular rehabilitation in manual and physical therapy. Elsevier, Edinburgh).
movement rehabilitation often prescribes extra-functional tasks such as core stability training on the floor, bracing the trunk or strength training with equipment. The question is how effective these activities are in recovering functional movement. The introduction of extra-functional activities during rehabilitation raises some problems. Extra-functional activities or exercise require learning a new task at a time when the patient is experiencing pain or loss of movement ability. This might not be the best time to enter a new exercise regimen. Learning requires set-aside time, intense mental focus and physical effort. Often it means the patient has to depend on others for instructions and guidance during the training. A functional approach which aims to use the patient’s own movement resources does not require additional learning; the cognitive demands are less taxing and do not require protracted training. Also the set-aside time for practice is more manageable for the patient. Furthermore, the rehabilitation programme seldom relies on any specialised exercise equipment. The remedial movement challenges are an integral part of the person’s daily activities and, therefore, can be practised anywhere and at any time. A functional approach is easy to apply and it empowers the patient to self-care. There are exceptions to the functional approach in rehabilitation. There are circumstances where the patient will require specific, extra-functional exercises for particular motor losses. This would be useful in situations where the individual is physically unable to perform functional activities. This could be in patients who had surgery or are suffering from CNS damage that limits their functional repertoire.
However, this approach does not always lead to the intended results. Individuals who are in pain or have motor losses may develop movement patterns that circumvent their losses. A patient may present with walking difficulties due to losses in the control of balance and coordination. Using the similarity principle, one would imagine that by encouraging the patient to increase their walking, ‘‘walking would train balance and coordination during walking’’. However, what may happen is that the patient will get better at using their compensatory pattern; walking slowly, using wider gait, shorter steps, rather than truly improving their control of balance and coordination during walking. Balance and coordination are part of several control building blocks that make up skilled movement.5 These building blocks are called sensory-motor abilities. A therapeutic approach that targets the various motor abilities is termed ‘‘Re-Abilitation’’.4 At this level of rehabilitation the aim is to recover control losses associated with particular abilities. Hence, in the walking scenario described above, the rehabilitation would aim to challenge balance and coordination in dynamic and upright postures (Fig. 2). The different motor abilities are described in Table 1. Skill rehabilitation and re-abilitation are both clinically important and are often used in combination. However there may be a shift of focus towards one of these particular approaches depending on the individual’s condition and their phase of recovery.
4. The code for neuromuscular adaptation Neuromuscular rehabilitation is a straightforward process – anyone can do it. Indeed, we all do it all the time. Every day we take actions that result in movement and behaviour changes; we can self-modify our motor control. Furthermore, the neuromuscular system has the capacity for self-recovery and to reorganise in response to injury. It means that within our behaviour there are certain elements that facilitate the recovery of movement control. There are five elements that can help optimise neuromuscular adaptation (Fig. 3)1,4:
cognition, being active, feedback, repetition, and similarity.
Skills Rehabilitation
3. Rehabilitation levels: skill and ability level rehabilitation
Re-Abilitation
Composite abilities Motor complexity
Movement rehabilitation and motor normalisation following injury occurs naturally for most individuals. Following injury most humans will take physical actions that will support their spontaneous and unaided recovery. This can happen without any special knowledge or understanding of the underlying physiological principles underpinning their recovery. In this form of rehabilitation the individual is attempting to, partially or fully, execute the movement that has been lost. Attempting to walk becomes the rehabilitation for the person who has lost the ability to walk. Similarly, if an individual with an arm injury is unable to reach their repeated attempts in that pattern would often be their rehabilitation. The focus in this form of movement recovery is on the overall skill of performing the particular movement. This will be loosely referred to as skill rehabilitation.4
Balance, coordination, Transition time, motor relaxation
Synergetic abilities CoCo-contraction & reciprocal activation
Parametric abilities Force, velocity, length, endurance Fig. 2. The motor complexity model including some of the motor abilities underlying movement control. (With permission Lederman E 2009 (to be published) Neuromuscular rehabilitation in manual and physical therapy. Elsevier, Edinburgh).
E. Lederman / International Journal of Osteopathic Medicine 13 (2010) 3–10
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Table 1 Motor abilities and their description. Motor ability Parametric abilities
Synergistic abilities
Composite abilities
Description Force Force relaxation Maximal force Force grading (Dynamic or static)
The ability to provide adequate force for optimal execution of movement.
Length (also range or angle) Max length Max shortening Length grading
The ability to effectively regulate the range of movement
Velocity Max Grade acceleration/deceleration Neuromuscular endurance
The ability to regulate the rate of movement or velocity of contraction / elongation in muscles
Co-contraction Dynamic & static Reciprocal activation
The ability to control the active stability of joints
Coordination Balance and postural stability Transition time
The harmonious and synchronous control of two or more joints or body masses The ability to maintain upright movement or stance efficiently and with minimal physical stress. The duration needed to reorganise movement between two dissimilar tasks and to carry out the subsequent task skillfully The ability to reduce neuromuscular activity to an optimal level necessary for maintaining a motor task or to become inactive
Motor relaxation
The ability to maintain a physical activity until it can no longer be continued
The ability to control local paired movement at a joint
In order to learn a new task, modify our behaviour or help our system recover we need to be aware of what we are doing (cognition); and we have to actively perform the action that we aim to recover (being active). In order to correct our movement we rely on internal information from our senses or depend on guidance from someone else (feedback) and we have to practise the task many times (repetition). One of the adaptive code elements that determines the physical manifestation of the rehabilitation programme is the similarity principle. In essence, the practice during rehabilitation has to closely resemble the movement we aim to recover. It seems that for learning or recovering particular movement patterns the practice should be both similar and within the context of the task. This suggests that if a patient cannot balance during walking, rehabilitation should focus on balance during walking.6–8 Equally, if force losses impede stair-climbing, than leg strength should be challenged during that or very similar activity.9 If the patient, due to lack of coordination, cannot raise their arm to eat, then rehabilitation should focus on coordination within similar movement patterns. Under these circumstances the individual parts of the whole movement are being practised simultaneously, i.e. the relationships between them are being rehearsed.5 Practising movement which is similar and within context is more likely to transfer to
related daily activities. Transfer is the ability to take a motor experience from one situation and apply it to another.10–12 Practising a dissimilar movement pattern or movement that is out of context may reduce the likelihood of transfer (Fig. 4). Imagine a patient who has standing difficulties due to a balance problem. The treatment will be dissimilar if strength exercises, such as standing knee squats, are used to challenge standing balance.4 The strength challenge is the dissimilar element as it fails to challenge balance. However, it is still performed within the context of standing. The rehabilitation will be out of context if the training for balance is practised sitting on a Swiss ball. In this situation the balance is similar but movement is performed in sitting and out of the context of standing. The rehabilitation can be both dissimilar and out of context; for example, straight leg raising (dissimilar) practised on the floor (out of context). The recovery of motor control can be facilitated by introducing the five adaptive code elements into the clinical management. It will promote a functional recovery that is more likely to benefit the patient in their daily activities. The results are more likely to be maintained in the long-term and could help to reduce the overall duration of the treatment programme.
5. Developing a neuromuscular rehabilitation programme Much of ONR is the combination of the three concepts discussed so far4:
One motor/behaviour adaptive state
Cognition Being active Feedback Repetition Similarity
Another motor/behaviour adaptive state
Fig. 3. Experiences that contain the five code elements are more like to promote adaptive changes within the neuromuscular system resulting in movement and behavioural changes. (With permission Lederman E 2009 (to be published) Neuromuscular rehabilitation in manual and physical therapy. Elsevier, Edinburgh).
1. The focus on functional movement, 2. The principle of skill/ability level rehabilitation, 3. The code for motor adaptation. Through a simple three steps procedure the therapist decides which level of rehabilitation will be used and applies the motor adaptation elements to the treatment programme. Many of the remedial challenges are selected from the patient’s own movement repertoire. These principles can be applied to any condition in which the neuromuscular system is implicated:
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Highly transferable
Least transferable Dissimilar out of context
Similar out of context
Dissimilar within context
Similar within context
Lumbro-pelvic tilts practiced on the floor Core tensing or bracing Extension exercise on the floor
Laying on the floor moving both legs in a walking-like pattern
Core tensing or bracing in walking (this may seem surprising. As long as the person is walking they are practicing walking. The dissimilar movement is redundant as far as motor learning)
Walk
Rehabilitating: Trunk control during walking
Fig. 4. Similarity and context principle in rehabilitation. The effectiveness of practice can be assessed by examining how similar it is and whether it is in the context of the goals of training. Rehabilitation is likely to be more effective if is similar and within the context of the movement goals of the treatment. (With permission Lederman E 2009 (to be published) Neuromuscular rehabilitation in manual and physical therapy. Elsevier, Edinburgh).
5.1. Conditions with an intact motor system Neuromuscular changes associated with musculoskeletal injuries, sports injuries, post-surgery, back pain and other musculoskeletal pain conditions Conditions where certain behaviours impede recovery or may lead to injury or pain Non-traumatic pain conditions such as trapezius myalgia, chronic neck pain and painful jaw
5.2. Conditions where there is damage to the central nervous system (CNS) Stroke, head trauma and post-CNS surgery and all the degenerative conditions
Movement challenges out of context
Movement challenges within context and similar
Condition timeline Fig. 5. Challenging motor abilities within and out of context. Out-of-context challenges do not resemble functional motor control. They therefore have limited scope in recovering full functional movement. This group of challenges is mostly used for patients who are unable to perform functional movement, often during the initial part of the treatment. Once the patient demonstrates an improvement in control, the motor abilities should be challenged within context.
Fig. 6. Challenging co-contraction ability of the ankle and foot. The patient ‘‘stiffens’’ their foot against cyclical movement imposed by the practitioner. This procedure can be performed in different planes of movement (AP and rotational planes), velocity, force angles.
E. Lederman / International Journal of Osteopathic Medicine 13 (2010) 3–10
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balance. During examination movement control losses were observed in many of the motor abilities described above (Table 1). The rehabilitation programme composed of two groups of motor challenges: 1. Movement challenges that are out of context but similar to leg and foot movement patterns during stance and locomotion. 2. Movement challenges that are within context and similar to weight-bearing activities.
Fig. 7. Challenging co-contraction of the whole leg and foot. The patient stiffens the whole leg and tries to maintain their position against the imposed movement. Variations: change plane of movement, force velocity and duration.
The main differences in managing these conditions is in the magnitude of losses, the duration of recovery and the extent of potential recovery. 6. Neuromuscular re-abilitation by an example The use of ONR can be exemplified by a case study of a patient who had lost motor control to the lower leg following a fracture to the ankle joint. The patient was seen immediately after six weeks of lower leg immobilisation. The patient was able to put some body weight on the affected side immediately after the plaster cast was removed. However, there was complete loss of normal control of the lower leg and during standing the affected side was used as a stump to help
Out-of-context challenges do not resemble motor control of the lower limb during stance and locomotion. They therefore have limited scope in recovering full functional movement. This group of challenges is mostly used for patients who are unable to perform functional movement, often during the initial part of the treatment. Once the patient demonstrates an improvement in control, the motor abilities should be challenged within context, i.e. within all upright activities (Fig. 5).4 The out of context challenges were carried out either in sitting or on the treatment table. They included challenges to the foot and ankle within their paired movements (flexion-extension and inversion-eversion cycles). Co-contraction control can be challenged by instructing the patient to stiffen their foot and resist the movement imposed by the practitioner (Figs. 6 and 7). This ‘‘stiffening’’ procedure can be performed in different angles of the foot/ ankle, varying forces, velocity of perturbations and duration of applied perturbation (endurance). These four variables represent the parametric abilities described in Table 1. Reciprocal activation was challenged by instructing the patient to perform exercise with the lower limb, in patterns that resemble normal functional movement (Figs. 8 and 9). Here too, the four movement parameters are integrated within the synergistic level: the movement can be performed in different ranges/angles, with varying degree of resistance provided by the practitioner (force), in varying velocities and increasing duration (endurance). Many of
Fig. 8. Challenging reciprocal activation of the ankle and foot in the AP plane (A&B). The patient is instructed to move their foot between two positions marked by the practitioner’s hands. Velocity can be challenged by instructing the patient to move as fast as possible between the two hands. Control of length or movement plane (inversion-eversion) can be challenged by changing the position of the hands (B).
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E. Lederman / International Journal of Osteopathic Medicine 13 (2010) 3–10
Fig. 9. Challenging reciprocal activation, integrating the whole leg in the movement. The patient oscillates their foot between the two positions marked by the practitioner’s hand (A and B). Variations: change velocity, length/plane of movement and force.
Fig. 10. Challenging force control using gentle squats (A), progressively shifting the body weight onto the affected side (B).
Fig. 11. Rolling up and down over the feet, rising alternately on the heels and toes will challenge reciprocal activation and force control.
E. Lederman / International Journal of Osteopathic Medicine 13 (2010) 3–10
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Fig. 12. Challenging co-contraction control within context of standing. The patient gently kicks the practitioner’s foot while weight-bearing on the affected side. The duration of weight-bearing on the affected side can be increased by the practitioner moving their foot further away or instructing the patient to increase the number of taps.
these procedures will also challenge the coordination of the lower limb. Within the upright activities, specific abilities can be further challenged. For example: Force control – Force control can be challenged by small amplitude rhythmic squats (Fig. 10a), and progressively shifting the body weight onto the affected side (Fig. 10b). Another is to roll over the feet rising alternately on the heels and toes (Fig. 11). This challenge can be increased by shifting progressively the body weight to the affected side. A simple functional force challenge is to climb one stair at a time, eventually progressing to climbing two stairs at a time. Length control – the control of dorsiflexion range can be challenged by using the rhythmic squatting movement while gradually shifting the body weight, forward, over the feet. Control of plantar flexion can be challenged by instructing the patient to walk on the tip-toes. A simple length control challenge is to instruct the patient
to take wider steps. This will tend to increase the challenge to plantar and dorsiflexion. As the patient improves, walking up and down a sloped surface is one of the most effective challenges to length control. Velocity control – repeat any of the above challenges, progressively increasing the speed of movement. Control of coordination, postural stability and the two synergistic patterns can be challenged by dynamic or static upright tasks. Supported standing (holding on to something) and weight-bearing on the affected side will tend to increase the co-contraction challenge. This can be further encouraged by instructing the patient to use their unaffected side to gently kick the practitioner’s foot (Fig. 12). This will challenge the control of the affected, weightbearing side. The duration spent on the affected side can be extended by increasing the number of taps during each kick or placing the target foot further away from the patient. A similar challenge could be to instruct the patient to weight-bear on the
Fig. 13. Challenging postural stability. Patient stands on the affected side and draws imaginary numbers from 0 to 10 with the unaffected side. Variation: increase the speed of drawing or draw larger amplitude numbers (no need for a wobble board!).
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E. Lederman / International Journal of Osteopathic Medicine 13 (2010) 3–10
Fig. 14. Challenging reciprocal activation. The patient performs forward and backward steps with the non-affected leg while maintaining the affected foot in the same position.
affected side and draw imaginary numbers from 0 to 10 with the non-affected side (Fig. 13). These challenges can be performed later, unsupported, to further challenge postural stability. Dynamic upright activities will tend to challenge reciprocal activation patterns. Walking is the ideal challenge to improve control of walking (similarity principle). One of the basic therapeutic aims is to expand the four movement parameters during walking: gradually increase the weight-bearing on the affected side during walking (force control), increase the stride length (length control), gradually increase the speed of walking (velocity control) and increase the distance (force and endurance). However the patient initially found walking difficult. Therefore dynamic tasks that are performed in patterns that resemble walking were added. For example, repetitive stepping forwards and backwards with the unaffected leg while maintaining the affected foot in the same position (Fig. 14). This task tends to challenge reciprocal control of the leg in the anterior–posterior (AP) plane. Similarly, stepping sideways will challenge reciprocal control in the lateral plane. Eventually, the patient can switch to weight-bearing on the nonaffected side and performing stepping movements with the affected limb (practising landing with the affected side). Eventually, the squats can develop into gentle hopping on both feet keeping the forefoot in contact with the floor. During this procedure the patient can gradually shift their body weight towards the affected limb. Later, the hopping can be performed with the feet fully clearing the floor. In time this can be developed into single leg hopping and skipping with the affected side. Further challenges can be introduced by performing gentle forward lunges on to the affected foot or lunges initiated from the affected side. At this point in the recovery the patient is expected to be able to return to her special skills, which in this case was jogging. This activity was introduced gradually, progressively expending the four movement parameters; increasing the running distance (force þ endurance), stride length (length) and speed of jogging (velocity). The alternative rehabilitation for this patient could be to use extra-functional challenges such as introducing a wobble board, resistance bands or exercise machines at the gym, activities of which she has no experience or particular interest. Is one approach more effective and which is she more likely to maintain?
7. Summary Neuromuscular rehabilitation aims to help the individual recover their movement control Functional movement is the movement repertoire of an individual Functional rehabilitation uses the patient’s own movement repertoire to help them recover their movement losses ONR has three basic recurring concepts 1. It aims to be functional 2. It uses the skill/ability level rehabilitation concept 3. It uses the learning/adaptation code to optimise motor control changes For full text and video demonstration of Neuromuscular ReAbilitation see Lederman.4
References 1. Lederman E. The science and practice of manual therapy. Edinburgh: Elsevier; 2005. 2. Lederman E. The effect of manual therapy techniques on the neuromuscular system. Doctoral thesis, King’s college, London; 1998. 3. Newham DJ, Lederman E. Effect of manual therapy techniques on the stretch reflex in normal human quadriceps. Disabil Rehabil 1997;19:326–31. 4. Lederman E. Neuromuscular rehabilitation in manual and physical therapy. Edinburgh: Elsevier; 2009. 5. Schmidt RA, Lee TD. Motor control and learning. 4th ed. UK: Human Kinetics; 2005. 6. Asseman F, Caron O, Cremieux J. Is there a transfer of postural ability from specific to unspecific postures in elite gymnasts? Neurosci Lett 2004;358:83–6. 7. Heitkamp HC, Horstmann T, Mayer F, Weller J, Dickhuth HH. Gain in strength and muscular balance after balance training. Int J Sports Med 2001;22:285–90. 8. Faber MJ, Bosscher RJ, Chin A Paw MJ, van Wieringen PC. Effects of exercise programs on falls and mobility in frail and pre-frail older adults: a multicenter randomized controlled trial. Arch Phys Med Rehab Jul 2006;87:885–96. 9. Sale DG. Neural adaptation to resistance training. Med Sci Sports Exerc 1988;20:5. 10. Cratty BJ. Movement behaviour and motor learning. 2nd ed. London: Henry Kimpton; 1967. 11. Dragana MC, Golubovic´ J, Bratic´ M. Motor learning in sports. Phys Educ Sport 2004;2:45–59. 12. Osgood CE. The similarity paradox in human learning: a resolution. Psychol Rev 1949;56:132–43.
Contents lists available at ScienceDirect
International Journal of Osteopathic Medicine journal homepage: www.elsevier.com/ijos
Masterclass
Osteopathic neuromuscular re-abilitation Eyal Lederman* Centre for Professional Development in Osteopathy & Manual Therapy, 15 Harberton Road, London N19 3JS, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 May 2009 Accepted 30 June 2009
This article explores osteopathic neuromuscular re-abilitation (ONR) and exemplifies the use of the approach through a case study. The aim of ONR is to help individuals recover and optimise their control of movement after musculoskeletal injury, pain conditions or central nervous system damage. Ó 2009 Elsevier Ltd. All rights reserved.
Keywords: Osteopathy Motor rehabilitation Movement control
1. Background Osteopathic neuromuscular re-abilitation (ONR) was developed by Lederman1 at the British School of Osteopathy in the early 1990s. It originated from a doctoral research project in collaboration with the physiotherapy school at King’s College, London.2 The study examined the effects of manual therapy on motor control. The development of ONR was in response to emerging knowledge that musculoskeletal injury, pain experiences and central nervous system injury are all associated with diverse neuromuscular and movement control changes. It was also evident that these central processes are well buffered against passive external influences.3 Osteopathy was, and still is, dominated by passive manual approaches and low level active engagement of the patient outside the treatment session. These approaches have little or no lasting effect on movement control and neuromuscular recovery.4 ONR was developed from this clinical need to provide a therapeutic solution to an area that has received little attention within osteopathy. 2. A functional approach One of the key principles in ONR is the use of functional movement to help recover motor losses. Functional movement is defined in ONR as the unique movement repertoire of an individual.4 Some of this repertoire is the movement behaviour associated with daily needs and demands such as
* Tel.: þ44 0207 263 8551. E-mail address: [email protected] 1746-0689/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijosm.2009.06.004
feeding, grooming, going places, etc (general skills). Some of this repertoire is partly shared by others and some may be unique to particular individuals; they include physical hobbies, sports and occupational activities (special skills). For some people, their functional repertoire will include playing tennis, for another standing on their head (Yoga) or playing the piano and so on. Once a person learns a movement or a new skill it becomes a part of their movement repertoire and therefore, their behaviour. Movement which is outside the normal repertoire of an individual is termed in ONR as ‘‘extra-functional’’ (Fig. 1).4 Functional rehabilitation is defined here as the process of helping a person to recover their movement capacity by using their own movement repertoire (whenever possible).4 Hence, for a person who has motor losses at the knee and is unable to walk or run, the rehabilitation will use gradual exposure which may begin with walking, then running, jumping and stair-climbing, etc. If this person plays tennis, this activity will eventually be added to the rehabilitation programme. However rehabilitation is likely to be less effective if the remedial movement patterns or tasks are outside the individual’s movement experience (extra-functional). For example, it would be less helpful for a tennis player with a leg injury to be given rehabilitative exercise such as football, or leg presses in the gym or leg exercise lying on the floor. For this particular patient, rehabilitation that incorporates tennis tasks is more likely to be useful. For a person who is suffering from lower back pain and enjoys Yoga, a functional rehabilitation would consist of the shared functional activities (general skill) but may also include some of the upright postures from Yoga (special skills). A less suitable rehabilitation approach would be to prescribe tennis, an extra-functional task, to this particular individual. This may seem obvious; however,
4
E. Lederman / International Journal of Osteopathic Medicine 13 (2010) 3–10
Functional repertoire
General skills
special skills
Extra-functional
Fig. 1. Functional movement represents the movement repertoire of the individual. It includes all the general activities and special skills. Extra-functional movement is all activities outside the individual’s movement experiences. (With permission Lederman E 2009 (to be published) Neuromuscular rehabilitation in manual and physical therapy. Elsevier, Edinburgh).
movement rehabilitation often prescribes extra-functional tasks such as core stability training on the floor, bracing the trunk or strength training with equipment. The question is how effective these activities are in recovering functional movement. The introduction of extra-functional activities during rehabilitation raises some problems. Extra-functional activities or exercise require learning a new task at a time when the patient is experiencing pain or loss of movement ability. This might not be the best time to enter a new exercise regimen. Learning requires set-aside time, intense mental focus and physical effort. Often it means the patient has to depend on others for instructions and guidance during the training. A functional approach which aims to use the patient’s own movement resources does not require additional learning; the cognitive demands are less taxing and do not require protracted training. Also the set-aside time for practice is more manageable for the patient. Furthermore, the rehabilitation programme seldom relies on any specialised exercise equipment. The remedial movement challenges are an integral part of the person’s daily activities and, therefore, can be practised anywhere and at any time. A functional approach is easy to apply and it empowers the patient to self-care. There are exceptions to the functional approach in rehabilitation. There are circumstances where the patient will require specific, extra-functional exercises for particular motor losses. This would be useful in situations where the individual is physically unable to perform functional activities. This could be in patients who had surgery or are suffering from CNS damage that limits their functional repertoire.
However, this approach does not always lead to the intended results. Individuals who are in pain or have motor losses may develop movement patterns that circumvent their losses. A patient may present with walking difficulties due to losses in the control of balance and coordination. Using the similarity principle, one would imagine that by encouraging the patient to increase their walking, ‘‘walking would train balance and coordination during walking’’. However, what may happen is that the patient will get better at using their compensatory pattern; walking slowly, using wider gait, shorter steps, rather than truly improving their control of balance and coordination during walking. Balance and coordination are part of several control building blocks that make up skilled movement.5 These building blocks are called sensory-motor abilities. A therapeutic approach that targets the various motor abilities is termed ‘‘Re-Abilitation’’.4 At this level of rehabilitation the aim is to recover control losses associated with particular abilities. Hence, in the walking scenario described above, the rehabilitation would aim to challenge balance and coordination in dynamic and upright postures (Fig. 2). The different motor abilities are described in Table 1. Skill rehabilitation and re-abilitation are both clinically important and are often used in combination. However there may be a shift of focus towards one of these particular approaches depending on the individual’s condition and their phase of recovery.
4. The code for neuromuscular adaptation Neuromuscular rehabilitation is a straightforward process – anyone can do it. Indeed, we all do it all the time. Every day we take actions that result in movement and behaviour changes; we can self-modify our motor control. Furthermore, the neuromuscular system has the capacity for self-recovery and to reorganise in response to injury. It means that within our behaviour there are certain elements that facilitate the recovery of movement control. There are five elements that can help optimise neuromuscular adaptation (Fig. 3)1,4:
cognition, being active, feedback, repetition, and similarity.
Skills Rehabilitation
3. Rehabilitation levels: skill and ability level rehabilitation
Re-Abilitation
Composite abilities Motor complexity
Movement rehabilitation and motor normalisation following injury occurs naturally for most individuals. Following injury most humans will take physical actions that will support their spontaneous and unaided recovery. This can happen without any special knowledge or understanding of the underlying physiological principles underpinning their recovery. In this form of rehabilitation the individual is attempting to, partially or fully, execute the movement that has been lost. Attempting to walk becomes the rehabilitation for the person who has lost the ability to walk. Similarly, if an individual with an arm injury is unable to reach their repeated attempts in that pattern would often be their rehabilitation. The focus in this form of movement recovery is on the overall skill of performing the particular movement. This will be loosely referred to as skill rehabilitation.4
Balance, coordination, Transition time, motor relaxation
Synergetic abilities CoCo-contraction & reciprocal activation
Parametric abilities Force, velocity, length, endurance Fig. 2. The motor complexity model including some of the motor abilities underlying movement control. (With permission Lederman E 2009 (to be published) Neuromuscular rehabilitation in manual and physical therapy. Elsevier, Edinburgh).
E. Lederman / International Journal of Osteopathic Medicine 13 (2010) 3–10
5
Table 1 Motor abilities and their description. Motor ability Parametric abilities
Synergistic abilities
Composite abilities
Description Force Force relaxation Maximal force Force grading (Dynamic or static)
The ability to provide adequate force for optimal execution of movement.
Length (also range or angle) Max length Max shortening Length grading
The ability to effectively regulate the range of movement
Velocity Max Grade acceleration/deceleration Neuromuscular endurance
The ability to regulate the rate of movement or velocity of contraction / elongation in muscles
Co-contraction Dynamic & static Reciprocal activation
The ability to control the active stability of joints
Coordination Balance and postural stability Transition time
The harmonious and synchronous control of two or more joints or body masses The ability to maintain upright movement or stance efficiently and with minimal physical stress. The duration needed to reorganise movement between two dissimilar tasks and to carry out the subsequent task skillfully The ability to reduce neuromuscular activity to an optimal level necessary for maintaining a motor task or to become inactive
Motor relaxation
The ability to maintain a physical activity until it can no longer be continued
The ability to control local paired movement at a joint
In order to learn a new task, modify our behaviour or help our system recover we need to be aware of what we are doing (cognition); and we have to actively perform the action that we aim to recover (being active). In order to correct our movement we rely on internal information from our senses or depend on guidance from someone else (feedback) and we have to practise the task many times (repetition). One of the adaptive code elements that determines the physical manifestation of the rehabilitation programme is the similarity principle. In essence, the practice during rehabilitation has to closely resemble the movement we aim to recover. It seems that for learning or recovering particular movement patterns the practice should be both similar and within the context of the task. This suggests that if a patient cannot balance during walking, rehabilitation should focus on balance during walking.6–8 Equally, if force losses impede stair-climbing, than leg strength should be challenged during that or very similar activity.9 If the patient, due to lack of coordination, cannot raise their arm to eat, then rehabilitation should focus on coordination within similar movement patterns. Under these circumstances the individual parts of the whole movement are being practised simultaneously, i.e. the relationships between them are being rehearsed.5 Practising movement which is similar and within context is more likely to transfer to
related daily activities. Transfer is the ability to take a motor experience from one situation and apply it to another.10–12 Practising a dissimilar movement pattern or movement that is out of context may reduce the likelihood of transfer (Fig. 4). Imagine a patient who has standing difficulties due to a balance problem. The treatment will be dissimilar if strength exercises, such as standing knee squats, are used to challenge standing balance.4 The strength challenge is the dissimilar element as it fails to challenge balance. However, it is still performed within the context of standing. The rehabilitation will be out of context if the training for balance is practised sitting on a Swiss ball. In this situation the balance is similar but movement is performed in sitting and out of the context of standing. The rehabilitation can be both dissimilar and out of context; for example, straight leg raising (dissimilar) practised on the floor (out of context). The recovery of motor control can be facilitated by introducing the five adaptive code elements into the clinical management. It will promote a functional recovery that is more likely to benefit the patient in their daily activities. The results are more likely to be maintained in the long-term and could help to reduce the overall duration of the treatment programme.
5. Developing a neuromuscular rehabilitation programme Much of ONR is the combination of the three concepts discussed so far4:
One motor/behaviour adaptive state
Cognition Being active Feedback Repetition Similarity
Another motor/behaviour adaptive state
Fig. 3. Experiences that contain the five code elements are more like to promote adaptive changes within the neuromuscular system resulting in movement and behavioural changes. (With permission Lederman E 2009 (to be published) Neuromuscular rehabilitation in manual and physical therapy. Elsevier, Edinburgh).
1. The focus on functional movement, 2. The principle of skill/ability level rehabilitation, 3. The code for motor adaptation. Through a simple three steps procedure the therapist decides which level of rehabilitation will be used and applies the motor adaptation elements to the treatment programme. Many of the remedial challenges are selected from the patient’s own movement repertoire. These principles can be applied to any condition in which the neuromuscular system is implicated:
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Highly transferable
Least transferable Dissimilar out of context
Similar out of context
Dissimilar within context
Similar within context
Lumbro-pelvic tilts practiced on the floor Core tensing or bracing Extension exercise on the floor
Laying on the floor moving both legs in a walking-like pattern
Core tensing or bracing in walking (this may seem surprising. As long as the person is walking they are practicing walking. The dissimilar movement is redundant as far as motor learning)
Walk
Rehabilitating: Trunk control during walking
Fig. 4. Similarity and context principle in rehabilitation. The effectiveness of practice can be assessed by examining how similar it is and whether it is in the context of the goals of training. Rehabilitation is likely to be more effective if is similar and within the context of the movement goals of the treatment. (With permission Lederman E 2009 (to be published) Neuromuscular rehabilitation in manual and physical therapy. Elsevier, Edinburgh).
5.1. Conditions with an intact motor system Neuromuscular changes associated with musculoskeletal injuries, sports injuries, post-surgery, back pain and other musculoskeletal pain conditions Conditions where certain behaviours impede recovery or may lead to injury or pain Non-traumatic pain conditions such as trapezius myalgia, chronic neck pain and painful jaw
5.2. Conditions where there is damage to the central nervous system (CNS) Stroke, head trauma and post-CNS surgery and all the degenerative conditions
Movement challenges out of context
Movement challenges within context and similar
Condition timeline Fig. 5. Challenging motor abilities within and out of context. Out-of-context challenges do not resemble functional motor control. They therefore have limited scope in recovering full functional movement. This group of challenges is mostly used for patients who are unable to perform functional movement, often during the initial part of the treatment. Once the patient demonstrates an improvement in control, the motor abilities should be challenged within context.
Fig. 6. Challenging co-contraction ability of the ankle and foot. The patient ‘‘stiffens’’ their foot against cyclical movement imposed by the practitioner. This procedure can be performed in different planes of movement (AP and rotational planes), velocity, force angles.
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balance. During examination movement control losses were observed in many of the motor abilities described above (Table 1). The rehabilitation programme composed of two groups of motor challenges: 1. Movement challenges that are out of context but similar to leg and foot movement patterns during stance and locomotion. 2. Movement challenges that are within context and similar to weight-bearing activities.
Fig. 7. Challenging co-contraction of the whole leg and foot. The patient stiffens the whole leg and tries to maintain their position against the imposed movement. Variations: change plane of movement, force velocity and duration.
The main differences in managing these conditions is in the magnitude of losses, the duration of recovery and the extent of potential recovery. 6. Neuromuscular re-abilitation by an example The use of ONR can be exemplified by a case study of a patient who had lost motor control to the lower leg following a fracture to the ankle joint. The patient was seen immediately after six weeks of lower leg immobilisation. The patient was able to put some body weight on the affected side immediately after the plaster cast was removed. However, there was complete loss of normal control of the lower leg and during standing the affected side was used as a stump to help
Out-of-context challenges do not resemble motor control of the lower limb during stance and locomotion. They therefore have limited scope in recovering full functional movement. This group of challenges is mostly used for patients who are unable to perform functional movement, often during the initial part of the treatment. Once the patient demonstrates an improvement in control, the motor abilities should be challenged within context, i.e. within all upright activities (Fig. 5).4 The out of context challenges were carried out either in sitting or on the treatment table. They included challenges to the foot and ankle within their paired movements (flexion-extension and inversion-eversion cycles). Co-contraction control can be challenged by instructing the patient to stiffen their foot and resist the movement imposed by the practitioner (Figs. 6 and 7). This ‘‘stiffening’’ procedure can be performed in different angles of the foot/ ankle, varying forces, velocity of perturbations and duration of applied perturbation (endurance). These four variables represent the parametric abilities described in Table 1. Reciprocal activation was challenged by instructing the patient to perform exercise with the lower limb, in patterns that resemble normal functional movement (Figs. 8 and 9). Here too, the four movement parameters are integrated within the synergistic level: the movement can be performed in different ranges/angles, with varying degree of resistance provided by the practitioner (force), in varying velocities and increasing duration (endurance). Many of
Fig. 8. Challenging reciprocal activation of the ankle and foot in the AP plane (A&B). The patient is instructed to move their foot between two positions marked by the practitioner’s hands. Velocity can be challenged by instructing the patient to move as fast as possible between the two hands. Control of length or movement plane (inversion-eversion) can be challenged by changing the position of the hands (B).
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Fig. 9. Challenging reciprocal activation, integrating the whole leg in the movement. The patient oscillates their foot between the two positions marked by the practitioner’s hand (A and B). Variations: change velocity, length/plane of movement and force.
Fig. 10. Challenging force control using gentle squats (A), progressively shifting the body weight onto the affected side (B).
Fig. 11. Rolling up and down over the feet, rising alternately on the heels and toes will challenge reciprocal activation and force control.
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Fig. 12. Challenging co-contraction control within context of standing. The patient gently kicks the practitioner’s foot while weight-bearing on the affected side. The duration of weight-bearing on the affected side can be increased by the practitioner moving their foot further away or instructing the patient to increase the number of taps.
these procedures will also challenge the coordination of the lower limb. Within the upright activities, specific abilities can be further challenged. For example: Force control – Force control can be challenged by small amplitude rhythmic squats (Fig. 10a), and progressively shifting the body weight onto the affected side (Fig. 10b). Another is to roll over the feet rising alternately on the heels and toes (Fig. 11). This challenge can be increased by shifting progressively the body weight to the affected side. A simple functional force challenge is to climb one stair at a time, eventually progressing to climbing two stairs at a time. Length control – the control of dorsiflexion range can be challenged by using the rhythmic squatting movement while gradually shifting the body weight, forward, over the feet. Control of plantar flexion can be challenged by instructing the patient to walk on the tip-toes. A simple length control challenge is to instruct the patient
to take wider steps. This will tend to increase the challenge to plantar and dorsiflexion. As the patient improves, walking up and down a sloped surface is one of the most effective challenges to length control. Velocity control – repeat any of the above challenges, progressively increasing the speed of movement. Control of coordination, postural stability and the two synergistic patterns can be challenged by dynamic or static upright tasks. Supported standing (holding on to something) and weight-bearing on the affected side will tend to increase the co-contraction challenge. This can be further encouraged by instructing the patient to use their unaffected side to gently kick the practitioner’s foot (Fig. 12). This will challenge the control of the affected, weightbearing side. The duration spent on the affected side can be extended by increasing the number of taps during each kick or placing the target foot further away from the patient. A similar challenge could be to instruct the patient to weight-bear on the
Fig. 13. Challenging postural stability. Patient stands on the affected side and draws imaginary numbers from 0 to 10 with the unaffected side. Variation: increase the speed of drawing or draw larger amplitude numbers (no need for a wobble board!).
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Fig. 14. Challenging reciprocal activation. The patient performs forward and backward steps with the non-affected leg while maintaining the affected foot in the same position.
affected side and draw imaginary numbers from 0 to 10 with the non-affected side (Fig. 13). These challenges can be performed later, unsupported, to further challenge postural stability. Dynamic upright activities will tend to challenge reciprocal activation patterns. Walking is the ideal challenge to improve control of walking (similarity principle). One of the basic therapeutic aims is to expand the four movement parameters during walking: gradually increase the weight-bearing on the affected side during walking (force control), increase the stride length (length control), gradually increase the speed of walking (velocity control) and increase the distance (force and endurance). However the patient initially found walking difficult. Therefore dynamic tasks that are performed in patterns that resemble walking were added. For example, repetitive stepping forwards and backwards with the unaffected leg while maintaining the affected foot in the same position (Fig. 14). This task tends to challenge reciprocal control of the leg in the anterior–posterior (AP) plane. Similarly, stepping sideways will challenge reciprocal control in the lateral plane. Eventually, the patient can switch to weight-bearing on the nonaffected side and performing stepping movements with the affected limb (practising landing with the affected side). Eventually, the squats can develop into gentle hopping on both feet keeping the forefoot in contact with the floor. During this procedure the patient can gradually shift their body weight towards the affected limb. Later, the hopping can be performed with the feet fully clearing the floor. In time this can be developed into single leg hopping and skipping with the affected side. Further challenges can be introduced by performing gentle forward lunges on to the affected foot or lunges initiated from the affected side. At this point in the recovery the patient is expected to be able to return to her special skills, which in this case was jogging. This activity was introduced gradually, progressively expending the four movement parameters; increasing the running distance (force þ endurance), stride length (length) and speed of jogging (velocity). The alternative rehabilitation for this patient could be to use extra-functional challenges such as introducing a wobble board, resistance bands or exercise machines at the gym, activities of which she has no experience or particular interest. Is one approach more effective and which is she more likely to maintain?
7. Summary Neuromuscular rehabilitation aims to help the individual recover their movement control Functional movement is the movement repertoire of an individual Functional rehabilitation uses the patient’s own movement repertoire to help them recover their movement losses ONR has three basic recurring concepts 1. It aims to be functional 2. It uses the skill/ability level rehabilitation concept 3. It uses the learning/adaptation code to optimise motor control changes For full text and video demonstration of Neuromuscular ReAbilitation see Lederman.4
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