The concept of “movement optimization” and the assignment of this role to rehabilitation professionals were previously introduced. It was suggested that if we embrace the role of movement teacher or coach we are obliged to answer two questions: what do we want to teach, and how do we want to teach it? How do we define optimal movement? What are the characteristics of our recommended exercises that make them informational, facilitate patient recognition of sub-optimal movement, and provide an organic selection of more optimal movement and postural choices?
What is the definition of optimal? Best, most favorable or most desirable. Notice that these are subjective/qualitative terms. We are not asked to transform society (as per 2013 APTA vision) by improving goniometric measurements or manual muscle testing scores, but by improving quality of movement. While quantitative movement characteristics (how many, how much, how far and how long) are an aspect of well-organized movement, and are easier to observe and measure, they do not by themselves constitute optimal movement.
We could define optimal movement or most desirable movement with terms like smooth, fluid, satisfying, comfortable, efficient, easy, gratifying or painless, but these are sensations unique to the experiencer and are hard or impossible for observers to assess. Is there a middle ground between unobservable subjective experience and objective but incomplete measurable criteria? Yes, if we have an understanding of how integrated bodies are coordinated, and if we can move beyond a simplistic anatomical framework for understanding human movement.
As a starter, we can propose four basic principles of optimal movement. We can observe violations of these principles and medically articulate why sub-optimal movement creates or perpetuates musculoskeletal misery. We should then have ways of getting our patients to recognize the error of their ways,. And, we should provide options that our patients can agree work better in terms of their presenting musculoskeletal complaint. Keeping open the possibility of further refinement or additions, what are these four proposed principles?
- Fascio-Skeletal Weight-Bearing
- Minimization of Unnecessary Effort
- Appropriate Distribution of Movement
- Proportional Use of Synergists
We will deal with the first two principles in this blog and tackle the rest in the next installment. Bones aren’t square blocks and don’t have flat surfaces, so stacking them without some ligamentous and muscular support is impossible; the concept of tensigrity as proposed by B. Fuller has merit here. Fascio-skeletal weight-bearing (or alignment) means arranging bones to create an inner sensation of solidity or easy support. Alternatives to fascio-skeletal weight-bearing are ligamentous or muscular weight-bearing.
Examples of ligamentous weight-bearing are: foot pronation, knee hyper-extension or valgus, hanging on hip Y-ligaments, slamming onto trochanteric bursa while one-leg flop standing, and sagging against spinal ligaments in slouch sitting. Possible consequences of habitual and long-standing ligamentous weight-bearing are ligamentous and capsular over-stretching, postural muscle weakness and joint hypermobility.
Examples of muscular weight-bearing are: standing with weight forward on toes (calf hypertonus and hammer toes), standing or sitting with lumbar hyper-extension (extensor hypertonus and facet compression) and forward head posture (cervical hypertonus and lower cervical shearing). Possible consequences are muscular over-use and myofascial syndromes and, through the mechanism of reciprocal inhibition, chronic antagonist muscle imbalances.
Minimization of effort means not working harder than is necessary for the task at hand, whether this is relaxing in your recliner or engaging in some heart-pounding, sweat-popping, vein-bulging, athletic endeavor. It means coordination of antagonists; smooth, efficient and appropriate reciprocal inhibition so you aren’t working against yourself… not driving with your brakes on. This can be difficult to see, but can be assessed manually, and positively influenced relatively easily.
Minimization of effort also encompasses the vast subject of physical manifestation of emotional stress (holding breath, clenching jaw, pulling shoulders up/in, furrowing brow, etc.), and cultural idiosyncrasies (sucking gut in, ladies sitting with knees/feet together, gentlemen puffing out chest and pulling shoulders back, etc.). These can be easier to see but harder to work with; they are often ingrained into a persons’ identity. The next two principles, distribution of movement and proportional synergists, will be addresses in the next article and will provide an introduction to movement integration styles or choices.