Sue Falsone: Segments of The Organizational System
Excerpted from Bridging the Gap from Rehab to Performance.
In a clinical and performance world where there are so many experts to follow, the development of a philosophical training model can be difficult to create and implement, especially for the less-experienced practitioner.
Rather than trying to be exclusive or exclusionary, it is important to recognize that many schools of thought, when broken down to their core principles, focus on the same things. All techniques, exercise types, schools of thought and training principles are valuable when bridging the gap from rehab to performance.
That said, let’s start our exploration by taking a closer look at the shared segments that comprise these systems. This is not a dogmatic classification system. Many interventions or schools of thought might fall into more than one category. Each intervention has many parts to it, and in your thought process, one might fit into an entirely different category than listed. This is fine. As you begin to understand the system, think about where each of the phases, disciplines and concepts fit into your personal practice.
All models fit, all disciplines fit and all “gurus” fit when we work to bridge the gap between rehabilitation and performance. Whatever your specialty, decide where that school of thought lies in this system as you create a process to return athletes to sports performance.
We will look at an overview of each category next. (Bridging the Gap from Rehab to Performance expands upon them in individual chapters.)
Briefly, think about when a client comes to you in pain. Say, for example, the person is a soccer player with a painful groin. First, we need to decide what tissue is the issue. We need to identify the pain generator.
Is the pain coming from a torn muscle or tendon in the adductors or in the abdomen? Is the pain coming from the hip-joint capsule impinged between two bones? Is the pain coming from a degenerated joint surface? Are all structures of the hip normal and the pain is coming from the low back or the central nervous system?
Once this is determined, we need to ensure the joint is moving properly in relation to those around it. Does the hip have full range of motion? Is flexibility normal? Are all aspects of the joint working well so it can fit within the system as part of a whole? Can the lumbar spine stabilize in order for the hip to move? Are there limitations at the ankle that could be affecting the hip? This section will take into account the entire motion segment.
We then need to make sure the right muscles are firing at the right time. We need to ensure there is proper psychomotor control. Is the glute acting as a prime mover for hip extension or are the hamstrings or lumbarparaspinals dominating the movement pattern?
From here, we move into somatosensory control. We consider all aspects of the neurological system, including reflexes, visual, vestibular and all the neuromotor programming aspects affecting how the motion segment moves or why pain is being generated. This is the largest and most complicated category and certainly influences and is influenced by every other aspect.
Next, we have fundamental performance. Not only does the hip itself have foundational strength—which could also fall under the motion-segment category—but we look to see that the entire system has proper fundamental strength to be expressed as power in our next category, fundamental advancement.
It is within fundamental advancement that we begin to move at various loads and speeds, introducing fundamental athletic movements such as acceleration, crossover, drop step and more.
Finally, in advanced performance, we begin to meet the client-specific goals of returning to an activity. Whether the client is a hockey player, lacrosse player or laborer, we introduce the specific movement requirements that must be mastered prior to returning to the activity.
Of course, underlying this whole strategy are the biopsychosocial factors that influence how we each have a different response to pain and to a team’s interventions. The biochemical, nutritional, and genetic factors of each person’s biology will affect the mindset, mood, and attitude of the person. The societal, familial and cultural influences on a person will impact how that person responds to any stimulus. The biopsychosocial influencers are the individual factors we must consider every time; they will never be the same for any two people.
No single part of the continuum is necessarily a prerequisite to another. Many of these areas can and should be addressed simultaneously as an athlete progresses from table to field. However, these all need to be considered prior to an athlete successfully returning to play.
Pain Generator
In Chapter Two, the section on determining the pain generator, we identify the problem tissue. It matters whether we are dealing with a bursa or a tendon. If the client is struggling to manage a bursitis and we attempt tool-assisted soft-tissue work on the inflamed bursa, we might make things worse. However, if we are dealing with a tendinopathy, soft-tissue treatment might significantly help the healing process.
In another case, if the athlete has disc-originating pain, trunk flexion might exacerbate the symptoms. If we are instead looking at a stenosis, trunk flexion might improve the symptoms. Accurately identifying the problem tissue is important for us to appropriately direct our initial treatment efforts.
If you do not have examinations and assessments in your toolbox, befriend a diagnostician and share patients and clients with that person. You do not need to learn how to assess, but you do need to understand assessment and have a referral policy in place.
If no pain generator is present—such as in a patient with phantom-limb pain, chronic pain or non-specific lower-back pain (NSLBP)—we need to use other identifiers, such as restricted range of motion, compromised movement patterns, a lack of stability, neurological influences or biopsychosocial considerations to guide us to the area that needs our first attention. Someone who is in pain without the presence of a pain generator presents a challenging situation. There is no nocioceptive stimulation to alter, therefore our typical pain-eliminating techniques will not work.
In the initial pain discovery, we are defining which “tissue is the issue.” In my case, I might draw from my manual therapy and differential diagnosis background to determine the problem at hand. To determine a working diagnosis for the patient in front of me, this might involve applying the skills learned in physical therapy or athletic training schools or things I mastered when studying for my certification in orthopedic manual therapy.
We might be concerned about pain and want to decrease it by using a method such as kinesiology tape.[i] Perhaps other standard modalities will assist in pain reduction. There are many clinical interventions to choose from; your list of skills will be different, and that will guide your choices.
Motion Segment
We need to reestablish the proper use of the entire motion segment, and not just a localized injury site or source of pain. For example, if we are dealing with an elbow issue, we need to make sure the cervical spine, shoulder complex, elbow, wrist and hand are all working together as a unit (this is the focus of Chapter Four.) We should also ensure that there has not been loss of compensatory range of motion elsewhere in the body. Through proper neuromusculoskeletal evaluation, the diagnostician will be able to determine if and where the body has compensated to protect the injured tissue. The nervous system prioritizes protection of painful tissue, and adjusts movement accordingly.[ii]
I once had an athlete who had dislocated his elbow in a traumatic manner. Despite our good efforts, he ended up with a shoulder issue, including loss of motion and pain, because he was guarded and afraid to move his arm away from his body. As a result, dysfunction developed in the segment next to the injury site, which in this case was the shoulder.
We may not be able to prevent everything, but we know that the motion segments that make up and surround an injured limb or the spinal segments above and below an injury can become compromised due to fear, avoidance and pain.[iii],[iv]
There could also be a restriction along a fascial line feeding tension upstream, downstream or both.[v] You can define a motion segment in many ways. You could simply consider an upper extremity, spine or lower extremity as the motion segment, or you could think of it even broader than that, following fascial lines or kinetic chains. However you define the motion segment for a given patient, you must address and consider it throughout the rehabilitative process, rather than just looking at a joint or tissue in isolation.
Bring the concepts of biotensegrity to mind when thinking of motion segments. Biotensegrity applies the mathematical concept of tensegrity to the human body.[vi] Tensegrity, developed by R. Buckminster Fuller between the 1920s and 1940s, is the concept that a three-dimensional structure is under constant tension with intermittent periods of compression to maintain the structure’s stability.
Biotensegrity states that in the human body, all levels—including molecular, cellular, tissue, organ and organ systems—are operating in the same manner. Humans will maintain their general form despite gravity because of the constant state of tension with intermittent compression that occurs throughout the body. Our bodily systems, down to the molecular level, are built upon this tension. Our movement choices and postures will introduce the necessary compressive forces to allow the body to change and adapt, all while maintaining the general human form.
When we think of the body as a tensegrity system, we realize we never do movement in isolation. In order for movement in one area to occur, a resultant compression or tension must occur elsewhere to allow that to happen. This concept demonstrates a system in which nothing occurs in isolation.
While we consider these concepts and interventions, we are concerned with how the client is or is not using the entire affected limb. We might pull from manual therapy, mobilization with movement, or tool-assisted soft-tissue work to reestablish the motion-segment function. Dry needling or cupping might be a suitable intervention choice. Alternatively, we might perhaps use fascial or visceral manipulation to deal with the affected area.
Corrective exercises learned during the Functional Movement Screen (FMS®), the Selective Functional Movement Assessment (SFMA®) or Functional Range Conditioning® (FRC) training could come in handy. Muscle activation techniques (MAT™) might also be applicable in this stage as we try to get the entire limb and motion segment functioning normally.
The options in this phase are almost limitless, based on your training and area of focus.
Psychomotor Control
In reviewing psychomotor control, which we do in Chapter Five, we are concerned with the right tissue firing at the right time as muscles and other tissues do their jobs. Prime movers must remain prime movers. Synergists must be synergists. Stabilizers must be stabilizers.
When a stabilizer such as lumbar musculature becomes a synergist to hip extension, or a synergist like the hamstrings becomes a prime mover or a prime mover like a glute decreases its activity because another muscle is doing its job, the body gets angry—the body will produce pain. Just as in a factory, the body has individual parts responsible for a job. When people in a factory start doing jobs they were not intended to do, the entire line gets thrown off. One job has too many workers, while another has no one focusing on it. Chaos ensues, and in our example, pain is created in the body.
Neuromuscular control of the body is the fine-tuning we use to ensure proper movement. Of course, the body will figure things out if needed and will compensate its way through a less-than-ideal motor pattern.[vii] That newly created motor pattern certainly has the potential to be efficient; however, biomechanical stresses caused during these compensations can cause damage if left unattended.
Over time, this compensation can lead to pain or asymmetries in flexibility and strength, and will further exacerbate the issue. The compensatory pattern will become the default pattern once the brain myelinates this new workaround.
There are many schools of thought in psychomotor control to pull from, including Dynamic Neuromuscular Stabilization® (DNS), Postural Restoration Institute® (PRI), MAT, dry needling, FMS, SFMA, Shirley Saharmann’s work in Movement System Impairments and Pilates, to name a few. We use whatever aligns best with our specific training and practice.
Biopsychosocial Considerations
The biopsychosocial model was introduced in 1977 by psychiatrist George Engel.[viii] In this model, he suggests that the person’s biology, psychology and social aspects of life have an influence on each other and the human as a whole being. These three things in combination will dictate pain, suffering and response to treatment interventions, and this is what we discuss in Chapter Six.
The psychological stress of an injury can increase stress hormones and inflammatory markers, making a somatic injury difficult to heal. Social activities such as drinking and smoking all impact a person’s overall health and wellbeing. Lack of support from family and friends can increase depression, impacting a person’s biology. It can also lead to unhealthy lifestyle behaviors such as substance abuse, interrupted sleep or poor eating habits, thereby impacting the biological ability to heal.
In fact, biopsychosocial factors could be argued as the number-one element that will impact your patients’ ability to heal and return to play.
We have all had experiences when we had two people who play the same sport walk in the door with the same diagnosis, and later have two very different outcomes. Biopsychosocial factors that are individual to each person are most likely at play when that happens.
When dealing with any athlete, we must recognize that the injury impacts the psychological wellbeing of that person. How a person deals with the trauma will be dictated by social support and techniques used to cope with the stresses of injury. These stresses will impact biology and the person’s ability to heal.
Somatosensory Control
The somatosensory system, covered in Chapter Seven, is a system of nerve receptors and cells that sense and react to alterations in a body’s internal state. We could not have a motor system without a sensory system. Our input gives us our output. Bad input equals bad output.
If we continually type the wrong command into a computer keyboard, we keep getting the wrong output. We have to give the computer the correct commands for it to work properly. The same goes for our bodies. If we send faulty information, our motor responses will be wrong and potentially inefficient. When we are dealing with somatosensory control,[ix] we are addressing vestibular balance, postural sway, reflexes, visual system and proprioceptive awareness.[x]
This phase of moving from rehabilitation to performance centers on reestablishing balance and postural reflexes and creating better sensory input for improved motor output.[xi] Here, concepts of motor learning and motor control are of use, and we might apply techniques from DNS, PRI, yoga or Pilates to assist the client with balance, proprioception and reflexive responses.
Conclusion
We cannot ignore these factors when bridging the gap from rehab to performance . . . and there’s more to consider. Part Two of this article will focus on the performance segments of Organizational System: Fundamental Performance, Fundamental Advancement and Advanced Performance.
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[i] Mark D. Thelen et al, “The Clinical Efficacy of Kinesio Tape for Shoulder Pain,” Journal of Orthopedic and Sports Physical Therapy, 2008.
[ii] Hug F, Hodges PW, Carroll TJ, De Martino E, Magnard J, Tucker K, “Motor Adaptations to Pain during a Bilateral Plantarflexion Task: Does the Cost of Using the Non-Painful Limb Matter?” PLOS ONE, 2016;11(4):e0154524.
[iii] TL Chmielewski, “The Association of Pain and Fear of Movement/Re-injury with Function During Anterior Cruciate Ligament Reconstruction Rehabilitation,” Journal of Orthopedic Sports Physical Therapy, December 2008.
[iv] Leeuw M, Goossens MEJB, Linton SJ, Crombez G, Boersma K, Vlaeyen JWS, “The Fear-Avoidance Model of Musculoskeletal Pain: Current State of Scientific Evidence,” Journal of Behavioral Medicine, 2007;30(1):77-94.doi:10.1007/s10865-006-9085-0.
[v] Stecco L, Fascial Manipulation For Muscuskeletal Pain, 1st edition, Padova, Italy, Piccin Nuova Libraria S. P. A, 2004.
[vi] Swanson RL, “Biotensegrity: a unifying theory of biological architecture with applications to osteopathic practice, education, and research—a review and analysis,” Journal of the American Osteopathic Association, 2013;113(1):34–52.
[vii] Paul W. Hodges and Carolyn A. Richardson, “Insufficient Muscular Stabilization of the Lumbar Spine Associated with Low Back Pain,” SPINE, 1996.
[viii] Papadimitriou G, “The ’Biopsychosocial Model’: 40 years of application in Psychiatry,” Psychiatrki, 2017;28(2):107-110.doi:10.22365/jpsych.2017.282.107.
[ix] Dario Riva et al, “Proprioceptive Training and Injury Prevention in a Professional Men’s Basketball Team: A Six-Year Prospective Study,” Journal of Strength and Conditioning Research, February 2016.
[x] Dario Riva et al, “Proprioceptive Training and Injury Prevention in a Professional Men’s Basketball Team: A Six-Year Prospective Study,” Journal of Strength and Conditioning Research, February 2016.
[xi] Gray Cook, “The Art of Screening, Part 2: Failure, Feedback and Success,” graycook.com.