If you work with patients long enough, you come to realize a few in-the-trenches facts. Here are five biggies that require constant consideration when managing any patient with any condition:
- Patients can be master compensators. They can "cheat" and power through movement patterns, pulling from all the wrong places. Movements appear easy and effortless in spite of underlying dysfunctional patterns.
- Just because someone looks good on the outside does not mean they are functioning efficiently on the inside. Think of it in terms of a Ferrari with nothing underneath the hood.
- Patients can only rely on compensations for so long before the movement engine breaks down and the durability factor takes a nosedive.
- The body craves stability (motor control) and will find it anyway possible, whether it's functional or dysfunctional. It's usually dysfunctional!
- People don't like to slow down. They play hard and work hard. Their mind is bigger than their body's ability to keep up. "Go hard or go home" is the paradigm. That paradigm is a breeding ground for dysfunction.
Patients are covert when it comes to dysfunction. Count on it! There are many assessments and evaluation procedures specifically designed to spot dysfunctional patterns and compensations. However, subtle signs of compensation chaos may be overlooked by an untrained eye because the body is so good at cheating movement.
So, what can you do to look for the hidden signs of dysfunction that people are so great at covering up? How can you find the chinks in the armor? Search for neurological signs of compensation the body uses as a fallback mechanism for stability. The best part is the client has no idea they are doing these compensations, so it's a "tell" of instability (poor motor control).
The following five signs, which I call "Red Flags of Dysfunction," are extremely valuable for divulging central core dysfunction. The body must have central (proximal) stability to achieve optimal distal mobility. If this relationship is altered, they will "bleed" energy and move inefficiently with loss of power, speed, endurance and performance. That's bad.
1. Foot Instability
Assess the patient in a single-leg stance position with bare feet. The feet should appear stable. Signs of stability dysfunction include any tendency for the foot to excessively pronate or supinate; toes gripping (clawing) the ground for dear life; extensor tendons on the dorsum of the foot popping out like mad. Loss of stability in the foot fosters loss of mobility in the ankle joint, leading to altered gait patterns and compensation pain syndromes.
2. Breathing Dysfunction
Labored breathing is a surefire sign of dysfunction. Monitoring how a patient breathes during nonstressful movements divulges valuable information about their core. Optimal breathing patterns are achieved via the diaphragm. The diaphragm is one of four primary components of the inner core (diaphragm, pelvic floor, transversus abdominis and multifidi). If the diaphragm is not functioning optimally, you can have inhibition of the pelvic floor and transversus abdominis, leading to faulty recruitment of the core. Look for the following dysfunctional patterns:
- Breathing in deeply and the chest / shoulders (apical breathing) moving up while the abdominal wall hollows, as opposed to the diaphragm pushing out.
- Holding breath when moving through simple patterns.
- Asymmetrical labored breathing. Have the patient rotate to the left in a seated position with arms crossed and tell them to inhale deeply. Then have them repeat on the other side. Ask if they feel more difficulty on one side compared to the other. This may also indicate dysfunctional thoracic rotation.
- Establish an isometric position of a standing straight-arm pushdown using a resistance band and ask the patient to breathe. Can they breathe through the diaphragm while maintaining the position?
3. Jaw Clenching
The jaw muscles are a default mechanism for overcompensation. In other words, the jaw muscles can become facilitated for other inhibited muscles throughout the body. Clenching up the jaw during minimal challenges to the core is a sure sign of instability. The pterygoids often inhibit the scalenes, the latissimus dorsi, the obliques, the quadratus lumborum and the hip abductors.
If these relationships are left unattended tension in the jaw muscles increases tremendously, resulting in the aforementioned symptoms. Jaw muscles must be considered in global relationships with the rest of the movement chains.
Observe for jaw holding or clenching when patients are challenging the core in positions of daily living and corrective exercise. If you see the jaw clenched, have them open and relax the jaw; notice the increase in difficulty performing the movement. Ask them if they feel a difference. The answer will be yes – less stable!
4. Grip (Clenching Fist)
Finger flexors tend to be facilitated in relationship to finger extensors and synergistic muscles of the anterior chain. Often you may see an overcompensation "death grip" on lifting movements when there is inhibition in the psoas. Your brain can't get the stability from the psoas structure, so it fires on grip muscles to pull more with the upper torso as opposed to the core.
Watch for patients complaining of increased elbow tendonitis or shoulder injuries. This indicates altered patterns in grip to upper extremity muscle sequencing. Observe patients making fists when performing isometric movements in rehabilitation.
5. Inadequate Rolling Patterns (Ground Movements)
The ground is the great equalizer for the core. It does not care how big and strong you are because it eliminates most of your global power movers, relying on core stability sequencing for movement. There is no cheating on the floor! Rolling patterns championed by Gray Cook, PT, are a fantastic initial screening process. Have the patient lie supine on the floor with arms and legs extended; then have them roll over to the prone position using only one side of their upper body. The movement should be easy and seamless; no sticking or altered patterns from the lower extremity.
The underlying weakness or core instability of sequencing will be noticed easily. They will feel the difference. If a patient cannot accomplish a simple rolling task on the ground, where gravity is minimal challenge on the core for stability, you can be sure there is no way they will be stable and functional in a standing position. Own the floor!
Be observant and diligent in your assessments. Always be assessing. As Yogi Berra said, "You can learn a lot just by watching." When it comes to optimal core function, regress to progress and own precision of movements. Attention to detail will bring your patient one step closer to having a stable foundation.
It's the details and commitment to excellence that make a difference. Your patients deserve it. So, become obsessive compulsive in your foundational program of inner and outer core assessments. Motor control is the shock-and-awe secret of durability.
- Chek P. Movement That Matters: A Practical Approach to Developing Optimal Functional Movement Skills. Encinitas, CA: C.H.E.K. Institute, 2000.
- Cook G. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010.
- Liebenson C. Rehabilitation of the Spine: A Practitioner's Manual. Philadelphia: Lippincott Williams & Wilkins, 2007.
- Sahrmann S. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis: Mosby, 2002.
- Weinstock D. NeuroKinetic Therapy: An Innovative Approach to Manual Muscle Testing. Berkeley, CA: North Atlantic, 2010.
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