The "F" word - Part II

[Barrett Dorko]

“So, how is ideomotor activity functional?”

I’ve heard this question a few times and it has always made me pause. The questioner is sincere and clearly understands the worth of ideomotion as corrective, probably leading to profound pain relief and immediately useful as a preventative home program. Of course, in today’s definition of therapy that isn’t enough – something functional must emerge from it.

I suppose you could say that less pain will naturally translate to greater function but we all know that these things aren’t necessarily related. Function is said to be related to strength and range of motion, neither of which are related to pain in any direct way.

If I write a poem am I stronger in some measurable way? If I paint a picture is there any measurable increase in my range? Don’t both of these tasks come from the same territory of the brain from which ideomotion arises?

Therapists should understand more about the nature of creativity and what its pursuit implies about brain activity. The consequent alteration in Melzack’s neuromatrix will then be considered primary and function will no longer dominate our plan of care - pain relief will.

From post #17 of this thread

In Part I of this blog post a great deal of discussion was generated. I thought I’d try to get some more going, especially from those who want to clearly define a functional approach and its use.

Here’s your chance.

[tom Reeves]

I'm still here.

A functional exercise/treatment would be one that implements proprioceptive cues to stimulate action that is similar to activities that occur in life. In general: rapid velocity over slow, integrated movements over isolated movements, feet on the ground rather than feet in the air (for lower extremity), and body weight plus over isokinetics or therabands.

The rationale is that if a muscle doesn't know when it is supposed to contract, it doesn't matter how strong it is. The proprioceptive cues provided by functional exercise trains the system to function more efficiently.

Sitting on a ball and teaching someone to contract their abdominals may very well be more challenging to stability than lying on a plinth but it is difficult for me call it functional. It does however meet some of the criteria. i.e. some instability is introduced that the core must control. On the plinth, the table provides the stability.

In my practice, functional exercise always looks like something the patient does in real life and has been identified as something that is not being done efficiently. This may be locomotion which can be broken down into parts that still "feel" like locomotion, it may be sit to stand or stand to sit transfers that do not incorporate adequate weight shift to get the center of gravity to within the base of support, or it might be multidirectional lunges for higher level physical function.

examples of non-functional ways that some PTs address the above are: Locomotion:asking the patient to slow down and concentrate on how they walk (locomotion is a series of swings and controlled falls using stretch reflexes in a plyometric way to intiate the next step).

Sit to stand transfers: often PTs will have their patients do quad sets or straight leg raises or even squats with knees well in front of the toes and the trunk vertically oriented. These can strengthen but do nothing to reinforce the forward weight shift required to get the butt off of the seat.

Higher level function (read basketball or tennis): Many PTs encourage the athletes to do single joint/single plane exercises to isolate the quads, then the hamstrings, then the gluteals, then the adductors, then the triceps surae, etc . . . Function requires that they fire in particular sequences and together to adequately control forces in all planes and generally at high speed. Since we know from exercise physiology class that muscles get good at what they practice, to practice slow,isolated exercise in otder to control fast integrated movement is foolish.

[John W]

Tom,

If you take a look at the right side of the neuromatrix diagram, you'll seen the middle "Action Program" section depicting what should "normally" occur in response to a pain output from the neuromatrix.

The point of inducing ideomotion from the patient is to restore this "normal" or perhaps "more adaptive" action program in order to bring resolution to the pain output. Otherwise, all bets are of in terms of restoring "function" because pain will continue to "smudge" both sensory and motor maps in the brain.

Thus, the required movements need not be framed in terms of "function". In fact, I don't see any of the "rules" that you described- feet on floor, something the patient does in real life, etc.- to be a requisite to moving in this way. These qualities may accompany ideomotion, but they don't define it in any way as far as I know.

You may be referring more to re-gaining performance once pain is no longer the primary complaint. In that case, I agree with just about everything you said.

[tom Reeves]

John, I am definitely not talking about functional exercise with a primary goal to reduce/manage pain. I am strictly talking about improving performance/enhancing function, as you said, once pain is not the primary limiting factor.

In my practice however, if I am going to do exercise of any sort, I am going to try and make it functional, so long as it is not provocative, simply because I will will be working on more than one thing at a time. If my patients have a finite amount of time to devote to my assignments, I will try to kill as many birds with as few stones as possible.

[zimney3pt]

I like to go back to the dictionary definition, because our use of words often times gets distorted to our personnal definition and not one that should be mutually agreed upon. Lets look at Ideomotion compared to various definitions of Fucntional. From Dictionary.com

–adjective
1. of or pertaining to a function or functions: functional difficulties in the administration.

Not a fan when they use the root of a word to define the word, so lets look at the root word function, especially the verb form as exercise/movement is action.

–noun
1. the kind of action or activity proper to a person, thing, or institution; the purpose for which something is designed or exists; role.

–verb (used without object) 8. to perform a specified action or activity; work; operate: The computer isn't functioning now. He rarely functions before noon.

9. to have or exercise a function; serve: In earlier English the present tense often functioned as a future. This orange crate can function as a chair.

Ideomotion is a specific action that serves a purpose for which the body was designed. To unload mechanical deformation of the tissues. CHECK

2. capable of operating or functioning: When will the ventilating system be functional again?

A primary intent of ideomotoric motion is to allow our system to be capable of operating without having to focus on pain. CHECK

3.
having or serving a utilitarian purpose; capable of serving the purpose for which it was designed: functional architecture; a chair that is functional as well as decorative.

Ideomotion is primarily designed to reduce an origin of pain (mechanical deformation). CHECK

5. Medicine/Medical . without a known organic cause or structural change: a functional disorder. Compare organic ( def. 5 ) .

Isn't this a primary context that nociception is neither sufficient or necessary for pain. And this is why idoemotion can be effective in pain disorders. CHECK

When comparing the definition of functional to ideomotion, I would have to say it CHECKS out.

I would agree Tom,

A functional exercise/treatment would be one that implements proprioceptive cues to stimulate action that is similar to activities that occur in life.

But we would have to agree any movement, has to activate the proprioceptive system. Yes specificity of training is best - play more basketball to get better at basketball (playing soccer might help some, but not as much as playing basketball, most likely).

But aren't all motions possible in any activity, that is the unpredictability of life, so probably impossible to train for every possible motion. So any motion has the potential to be needed, thus any motion could potentially be a worthwhile training exercise.

For an exercise to be functional to me is more a question of not which exercise or type of exercise, but what is the reason or purpose behind the exercise. Has the therapist used some form of clinical reasoning to create a motion that serves a distinct purpose. If so, then the exercise is functional. If it is done without thought and completed because every total knee patient gets these exercises, because someone at some time created a protocol that I blindly follow, then potential it is not very functional. If it is functional it is blind luck, not through any thought of the therapist.

[John W]

Barret,
Can you get a slide out of Kory's post somehow?

You could title it: "Why Ideomotion is Fundamentally Functional".

No need to thank me for the title.

Another keeper, Kory.

[garydiny]

Kory,

I think that is a great breakdown of these items.

Keep it up!!!!!

Gary

[Barrett Dorko]

A slide cannot do this wonderful writing and thinking justice, but I'll try.

I think Kory knows who I'll credit when I speak of this; he was in Rhinelander.

[zimney3pt]

Tom, was hoping you could expand on your statement.

In my practice, functional exercise always looks like something the patient does in real life and has been identified as something that is not being done efficiently.

Wasn't sure how we measure efficiently. Does that mean it is done without pain, faster, with less energy expenditure or some other measurement? What is the measurement we compare efficiency with from one person to the next?

Also I was wondering how one would classify "visual imagery". Is it a functional exercise? It has been shown to improve performance (does that mean it helps with efficiency) in those that use it. Yet they are not using there proprioceptive or motor system at all, just the brain. They are visualizing in their brain neuromatrix the real life activity, but aren't physically doing it. I would think it has a purpose and pertains to a specific activity, so functional definition would fit. So would it be a functional exercise, even if the body itself is seen not moving or doing anything that resembles the activity at all?

[Barrett Dorko]

While Tom composes an answer, there's also this:

The word natural has taken a real beating during the past twenty years – so much so that now it means nothing.

Still, there are movements that fall into this realm, and ideomotion is certainly among them. It is, in fact, a normal response to pain with a mechanical origin. This would place it on the right side of Melzack's model just as John suggests. It's a normal (read natural) action program.

I recall Paris lecturing about how “non-physiologic” side bending of the cervical region was, yet I see it all the time when the patient is moving ideomotorically; something Paris would never encourage.

What is more appropriate than the instinct to preserve the nervous system? Why wouldn’t it be considered “fundamentally functional”? (Thanks John)

My old friend Mel Siff always advocated playing the sport in order to get better at it, not doing motions that resembled it. In effect he said, "Play the game, compete within the rules, let yourself move freely within them, don't make up some artificial motion that "looks like" something within the skill, pursue the skill itself."

If this is all "functional," well, fine. Do we need to be told that?

[tom Reeves]

Originally Posted by zimney3pt

Tom, was hoping you could expand on your statement.



Wasn't sure how we measure efficiently. Does that mean it is done without pain, faster, with less energy expenditure or some other measurement? What is the measurement we compare efficiency with from one person to the next?

Also I was wondering how one would classify "visual imagery". Is it a functional exercise? It has been shown to improve performance (does that mean it helps with efficiency) in those that use it. Yet they are not using there proprioceptive or motor system at all, just the brain. They are visualizing in their brain neuromatrix the real life activity, but aren't physically doing it. I would think it has a purpose and pertains to a specific activity, so functional definition would fit. So would it be a functional exercise, even if the body itself is seen not moving or doing anything that resembles the activity at all?

The way I was using the word "effiency" it was meant as economy of movement with limited extraneous or wasted effort. It could be measured by looking at heart rate or PsO2, measured against velocity or distance with walking, but I generally don't. I generally don't do that unless they are very debilitated or ill.

It is easier for me to explain with athletes. A runner who is more "efficient" bounces less, glides more, decelerates less and generally gets as much speed out of their efforts as their fitness level and heredity allows. A pitcher who throws efficiently, generates maximum desired velocity without creating unmanageable loads on their elbow or shoulder.
I suppose how you measure it would vary based upon the task being observed.

As far as visualization goes, my understanding is that visualization does activate motor centers and associated EMG readings have been shown to increase when experienced visualizers visualize. Elite gymnasts do it all of the time as do divers, golfers and the like. I don't know if I could characterize it as functional exercise but it certainly does have a purpose. If it enhances performance, then it makes the visualizer more efficient. Again, the definition of which, depends upon the task.

[tom Reeves]

Originally Posted by Barrett Dorko

While Tom composes an answer, there's also this:

The word natural has taken a real beating during the past twenty years – so much so that now it means nothing.

Still, there are movements that fall into this realm, and ideomotion is certainly among them. It is, in fact, a normal response to pain with a mechanical origin. This would place it on the right side of Melzack's model just as John suggests. It's a normal (read natural) action program.

I recall Paris lecturing about how “non-physiologic” side bending of the cervical region was, yet I see it all the time when the patient is moving ideomotorically; something Paris would never encourage.

What is more appropriate than the instinct to preserve the nervous system? Why wouldn’t it be considered “fundamentally functional”? (Thanks John)

My old friend Mel Siff always advocated playing the sport in order to get better at it, not doing motions that resembled it. In effect he said, "Play the game, compete within the rules, let yourself move freely within them, don't make up some artificial motion that "looks like" something within the skill, pursue the skill itself."



If this is all "functional," well, fine. Do we need to be told that?

In response to the bolded part of your quote and the addition below: No we don't need to be told. Unless of course our instructors have convinced us in PT school that doing straight leg raises will make us a better runner. The best way to become a better golfer is to golf more but practice makes permanent, not perfect. (someone wiser than me said that first, I just don't know who it was) There may be parts of your golf swing that cause inconsistent contact with the ball and doing drills to flatten your swing plane, or maintaining slight flexion of the right knee, or finishing with your navel pointing at the target might make the overall performance better. I see plenty of people who play golf every day and are really not very good at it at all.


That is the essence of identifying "inefficiencies" within motions. Finding a nut within the whole that causes the whole movement to be inefficient or unproductive, then try and train the nut to fit the whole better.

[John W]

Tom,
Based on everything you've said thus far, I don't hear any disagreement with Barrett's argument that many of our colleagues' use of "functional" movement with respect to treating the primary complaint of pain is not only not functional within the context of pain, but it's silly and meaningless.

I think the problem is that the biomechanical/structural approach to treatment tends to lead therapists towards this mis-conception of what "functional" is. They are often in simply the wrong context when they are treating the patient with pain.

As Cory Blickenstaff has so succinctly stated elsewhere at this site, we are contextual architects. This requires, in part, a deep understanding of the context in which we "build" the therapeutic relationship with the patient. Which means, we need to understand what pain is and how it works, or we will fail to build a worthy and sustainable structure from which to proceed with treatment.

I submit to you that the profound lack of basic pain science knowledge prevents the vast majority of therapists from building an effective therapeutic relationship with their patients.

[zimney3pt]

Thanks Tom. I agree in part with efficiency as you state, because we have probably all seen it, it is just hard to define. But when you can't define it, how do you tell someone that is the best way.

Take golf for example as you brought up. Jim Furyk has one of the strangest hinges at the top of his swing that in no way, would most of us think of it as efficient. But he did win the Fed Ex cup this year, so was effective.

My point that I struggle with is that we just need to be careful to say some type of movement is more effecient when it may not be more effective for them. Some people like Jim Furyk can take what might by some be considered an inefficient swing and be very effective.

So when it comes to functional is it better to be efficient or effective?

[Barrett Dorko]

As I left today another PT sat before an elderly woman newly re-referred to therapy after a fall last week.

"Do you know what her x-ray said?' he asked. "Negative," I said, seeking brevity and movement toward my car.

But I stopped for a moment and looked at the therapist - completely flummoxed by this patient's continued complaint and NO idea how this could possibly be.

I know this guy, and John described him perfectly.

[TexasOrtho]

Tom did you download Siff's and Plisk's article I posted in the Sounds of Silence forum? They are both excellent reads on this issue.

[Jason Silvernail]

Originally Posted by tom Reeves

The rationale is that if a muscle doesn't know when it is supposed to contract, it doesn't matter how strong it is. The proprioceptive cues provided by functional exercise trains the system to function more efficiently.

How does a muscle know this? How does a muscle know...anything?

Originally Posted by tom Reeves

Examples of non-functional ways that some PTs address the above are: Locomotion:asking the patient to slow down and concentrate on how they walk (locomotion is a series of swings and controlled falls using stretch reflexes in a plyometric way to intiate the next step).

This is certainly not the only mechanism for locomotion and gait stability. It's a complex subject about more than just stretch reflexes. Cortical processing and motor control - which have been demonstrated to improve with part vs whole training and variation in speeds - is certainly a large part of that as well. Seems pretty "functional" to me.

Originally Posted by tom Reeves

Sit to stand transfers: often PTs will have their patients do quad sets or straight leg raises or even squats with knees well in front of the toes and the trunk vertically oriented. These can strengthen but do nothing to reinforce the forward weight shift required to get the butt off of the seat.

Higher level function (read basketball or tennis): Many PTs encourage the athletes to do single joint/single plane exercises to isolate the quads, then the hamstrings, then the gluteals, then the adductors, then the triceps surae, etc . . . Function requires that they fire in particular sequences and together to adequately control forces in all planes and generally at high speed. Since we know from exercise physiology class that muscles get good at what they practice, to practice slow,isolated exercise in otder to control fast integrated movement is foolish.

Is it not possible that strength training for a weak muscle group can be a useful part of a rehabilitation program prior to other "functional" activities? We discussed these concepts in detail in the strength training progression models thread in the Performance Lab.

Your "nonfunctional" examples seem less than clearly that to me.

[Ken Jakalski]

A runner who is more "efficient" bounces less, glides more, decelerates less and generally gets as much speed out of their efforts as their fitness level and heredity allows.

A point of note: Descriptions of what we often see in faster runners--- economy of movement, no extraneous or wasted effort--are effects and not the cause of the stance phase mechanics that determine speed. At top speed, faster runners apply appreciably greater mass-specific ground forces, and do so during shorter periods of foot-ground contact.

[tom Reeves]

Originally Posted by John W

Tom,
Based on everything you've said thus far, I don't hear any disagreement with Barrett's argument that many of our colleagues' use of "functional" movement with respect to treating the primary complaint of pain is not only not functional within the context of pain, but it's silly and meaningless.

I think the problem is that the biomechanical/structural approach to treatment tends to lead therapists towards this mis-conception of what "functional" is. They are often in simply the wrong context when they are treating the patient with pain.

As Cory Blickenstaff has so succinctly stated elsewhere at this site, we are contextual architects. This requires, in part, a deep understanding of the context in which we "build" the therapeutic relationship with the patient. Which means, we need to understand what pain is and how it works, or we will fail to build a worthy and sustainable structure from which to proceed with treatment.

I submit to you that the profound lack of basic pain science knowledge prevents the vast majority of therapists from building an effective therapeutic relationship with their patients.

I agree with you totally John. That is why I have been drawn to this site. My debates with the SS folks at RE have piqued my interest in figuring out why I fail with some of my patients. The ones I fail with are the ones where the pain that they feel is not proportional with the biomechanical indicators that I assigned as the "source" of their pain. The biomechanical approach really works with the majority of my patients but with those blasted outliers that I have, in the past, reconciled my failure often by faulting the patient for not doing what I told them to do. Sometimes I think I was right, but not all of the time. Probably not even most of the time. Thus I am here trying to ingest and digest and be able to implement the thought processes that you all are so comfortable with.

I do believe that I build a good therapeutic relationship with the majority, but that minority still causes an itch that I can't yet scratch.

[tom Reeves]

Originally Posted by zimney3pt

Thanks Tom. I agree in part with efficiency as you state, because we have probably all seen it, it is just hard to define. But when you can't define it, how do you tell someone that is the best way.

Take golf for example as you brought up. Jim Furyk has one of the strangest hinges at the top of his swing that in no way, would most of us think of it as efficient. But he did win the Fed Ex cup this year, so was effective.

My point that I struggle with is that we just need to be careful to say some type of movement is more effecient when it may not be more effective for them. Some people like Jim Furyk can take what might by some be considered an inefficient swing and be very effective.

So when it comes to functional is it better to be efficient or effective?

I would say effective. Furyk does however do one thing exactly the same as all other professional golfers. He strikes the ball with the club exactly (most of the time) where he wants to strike it. The point here, I think, is that there may be an easier way to do it than the way he does it. His swing is very repeatable and that is why he is proficient at it. He has had some injuries but I don't think that they were related to his golf swing so it is both efficient and effective, jus different.

[tom Reeves]

Originally Posted by TexasOrtho

Tom did you download Siff's and Plisk's article I posted in the Sounds of Silence forum? They are both excellent reads on this issue.

I just realized that I have access to them. I will read them tomorrow.

[tom Reeves]

Jason,

How does a muscle know this? How does a muscle know...anything?

It is a metaphor to describe what happens "automatically" without conscious thought, that is all. Plyometric loading increases the power generated and I am referring to the feedback loops that do not necessarily reach the brain to accomplish. So I am not really saying that the muscles "think" anything.

This is certainly not the only mechanism for locomotion and gait stability. It's a complex subject about more than just stretch reflexes. Cortical processing and motor control - which have been demonstrated to improve with part vs whole training and variation in speeds - is certainly a large part of that as well. Seems pretty "functional" to me.

No but the closer someone walks to their "normal" walking velocity, the more eficient they are. Classmates of mine in PT school did a study where they had several of us walk with hoses in our mouths to measure O2 use on expired air. They had us walk on a level treadmill at various speeds ranging form 1 mph to 3.5 mph. They graphed efficiency. A month later, they asked us to select our own speed and walk for 30 minutes. Without fail, we all picked the speed where our graph peaked with regard to efficiency a month earlier. So, most of the time, not always, our TKA and THA patients walk more slowly than they did before they had significant knee or hip pain and rather than inundating them with multiple cues like "push off more vigorously" or "take longer steps" or "roll off your toes" or "strike your heel first", simply asking them to walk faster has the effect of the patient doing all of those things.

Is it not possible that strength training for a weak muscle group can be a useful part of a rehabilitation program prior to other "functional" activities? We discussed these concepts in detail in the strength training progression models thread in the Performance Lab.

I haven't read he performance lab thread you refer to. I will. and yes it can be a valuable part of the program to isolate a weak muscle. However, if my patient will agree to spend only a finite portion of their day to address a certain problem, I choose to have them work on something other than isolated strengthening. I try to teach them "when" to contract a muscle first, then work on strength later.

[zimney3pt]

so it is both efficient and effective, jus different

I think you answered it right there!!! We are all different, we need to find out how we are efficient and effective. Ideomotion can be just that - a person finding out how they are efficient and effective. Any movement can help a person find out how to be efficient and effective if pain does limit it.

That is where basic biomechanical model will fail, it can not always predict efficient and effective, because we have to take into consideration the neural system and the brain. Every brain is different and constantly changing. It is built off an individuals life time of beliefs, experiences, logic, knowledge, culture, work/social environment, expectations AND the sensory input from the body. But biomechanics (sensory input from the body) is a small part of this very complex equation.

I think it is not a coincidence that John W choose these words:

I submit to you that the profound lack of basic pain science knowledge prevents the vast majority of therapists from building an effective therapeutic relationship with their patients.

my bold included.

Furyk may be inefficient getting to the ball, but he is effective to get the club face square more often with proper speed then the rest of us. Being effective wins out over efficient. Many therapist are efficient with treatment (doing the right biomechanics), but miss the effectiveness.

[norton]

This has been around a long time. Late 70's early 80's.
http://www.sybervisiongolf.com/

[Ken Jakalski]

If I recall, they also had a "sybervision baseball" tape. I think it was Rod Carew who was the model/template for that video.

[tom Reeves]

Rod,
I read through the articles that you posted. I think that they were very good summarizations of a perspective very close to my own about what functional exercise is and what its limitations are. Every exercise is functional to someone. Atlas has to do isolated isometric bilateral shoulder flexion/abduction for long periods of time.
If I ever said that isolated exercise is never good, then I take it back. I simply choose to spend my patients' time first by integrating rather than isolating.

Analogy: You are the choir director at a church. Your choir is awesome. You are invited to sing at every church in the county at Christmas time every year, you travel to Austria to sing in the castles etc . . . A new family moves to your church and they LOOOOOVE to sing. Problem is, they sound like fingers on a chalkboard. the problem is, you have to let them sing because it is church. So, you have options. The one I would choose would be to bury them in the choir and spread them out as much as possible. Do this until they learn to sing better, then you can gradually put them into smaller groups and ultimately, they can even sing duets and solos. But not right away.

The last exercises that I do when rehabilitating a rotator cuff repair are isolated ER/IR/supraspinatus exercises. I do them but I do them last because the singers need to first learn to sing with the choir.

I enjoyed each of the articles. I think that most of what was discussed in them is consistent with how I practice. I probably have some bits and pieces where I disagree, but by-and-large consistent.

One interesting point was in the Siff article. He wrote about how the stepping reflex is often the first response to a perturbation of the COG and that it happens before the COG approaches actual loss of balance. That may well be true but when someone is cutting on one foot, the base of support is much smaller and the athlete does not necessarily have the option to take a step or otherwise change their base of support. Just a thought.

The Enoka article seemed to basically say that our neural system is plastic and it responds to training. It was a good lit review.

Thanks for posting them.

I have no problem isolating a muscle or group but i find it to be useful later in the process rather than first, in most cases.