Gaining new insights in motor control with Frans Bosch was a professional “life-changing” experience. Going away from analytic stability training to dynamic functional training. There remain challenges to integrate this perspective in current shoulder rehabilitation but boosts the creativity in exercise therapy. To share this boost, we throw a few of the important ideas below.
- Top down – bottom up: Dynamic systems model.
There is no hierarchy from brain to limb in motor control but every part of the body system interacts with itself and with his neighbours. Compare it with birds flying in a formation, every individual bird will respond to the continuously changing actions of the birds flying around him. The bird corrects himself to not have a conflict and the result is a fluently organized formation we see at the sky.
Not all movement reaches the brain, a lot of our decisions remain unconscious. The brain does not have enough capacity to direct all movement actions. Every joint has multiple degrees of freedom, resulting in infinite combination possibilities in limb motion. The decision on movement has to be made that quick that the brain would be too late to respond. The system steers itself, is resiliant and able to take decisions under time pressure and in routine actions.
2. Pain decreases variability and freezes degrees of freedom
When in pain we tend to freeze degrees of freedom in the attempt to protect the painfull part. This affects motor control and results in decreased variability of motion patterns. Decreased variability is not a successful solution on the long term. Exercise therapy needs to gradually build up from low to high amount of degrees of freedom. Therapists need to select exercises that challenge the body to broaden the spectrum of movement possibilities again. The exercises should be at the right difficulty level so that the body should get out of comfort zone. Often the mistake we make is that exercises don’t challenge motor control and allow the body to stay in it’s low variable pattern to complete the task of the exercise.
3. Don’t give the answer – ask the body the right question
Telling patients how to move and what to change in their movement pattern is top-down control of movement. To transfer this knowledge of performance into daily life is impossible. The brain is occupied with other stimuli from the task or the environment. Exercises with internal focus will increase knowledge of performance but are not usefull. As a therapist, we elicit the pattern that we want by setting the right task. This task should be determined in a way that the body chooses the pattern you want. For example if you want the patient to rotate his upper back when reaching backwards, ask him/her to reach back with hands touching eachother. That way, the only option to reach this goal is to rotate the upper back, shoulder motion alone would never suffice. This type of training increases knowledge of result instead of performance. The result of the task is obvious to the patient. Repeating this task under constantly changing conditions to challenge motor control results in storage of new patterns.
- remember to stop telling your patient HOW to do an exercise but tell them WHAT to do, to achieve your therapy goal.
- make exercises challenging and get the body out of comfort zone so new possibilities are discovered
- aim to replicate functional tasks with elements from the functional environment, this lowers the step for the body to transfer motor control strategies to the real world
And there is a lot more for you to discover in this course!