Sensorimotor System – What does it mean & What’s the implication for rehab? Bec van De Scheur

IMG_2527After hitting heavy traffic, turning what should have been a swift two hour car trip into an eventful six hour journey to Birmingham, we finally reached the Therapy Expo 2017!

 

Fuelled with coffee, we sat in on a number of interesting presentations. Although there was diversity amongst the guest speakers a common theme seemed to present itself, the role of the sensorimotor system in injury rehabilitation.

 

Steven Hawking said it perfectly when he stated:

 

“Intelligence is the ability to adapt to change”

 

The human body is of no exception. Our desire to move after injury sees that we will go to great lengths to keep our bodies mobile. Often completely subconscious, we find ways to move around pain, stiffness, or imbalances. Thus, compensatory movement patterns or “muscle patterns” are born.

 

Jo Gibson [Twitter: @shouldergeek1], well renowned shoulder rehabilitation specialist, whose lecture we were lucky enough to attend at the Expo, has been quoted to explain it like this in relation to the shoulder:Jo Gibson januar 2016 (2)_edited1

 

“Muscle Patterning refers to inappropriate recruitment, commonly of the torque producing muscles of the glenohumeral joint e.g. Latissimus Dorsi, Pectoralis Major, Anterior /Posterior Deltoid. This unbalanced muscle action is involuntary and ingrained. Patients with muscle patterning essentially have a muscle recruitment sequencing problem that results in abnormal force couples, destabilising the joint.”

It is an important topic, as failure to correctly diagnose a structural instability versus a functional instability is a common factor in patients failing conventional rehabilitation or surgery.

‘Rehabilitation in this situation should be aimed at ‘normalising’ muscle recruitment patterns around the shoulder girdle and this involves appropriate facilitation throughout the kinetic chain. Balance, coordination and core control are all factors that must be addressed to optimise neuromuscular control mechanisms.’(1)

 

Our ability to adapt to change is both the human body’s greatest strength and its biggest weakness.

As a short term strategy compensation is a great tool. It is protective against further injury and it enables us to get on with our daily function. However, when these newfound motor patterns become long term and supersede our normal programming we will at some stage hit a point of failure, which usually manifests as injury or failed rehab.

 

It can be explained like this…..

 

Your weekend football team is down a player and you have no choice but to replace your star striker with the goalkeeper. Chances are he will manage to get the job done for a period of time, but because his training has not been specific to the role of striker and he is not conditioned or well rehearsed to the demands of this position, at some point in the game he will fatigue, his reaction time will diminish and his ability to generate power and keep up with the pace of the game will become apparent, leaving him vulnerable to injury.

 

Similarly, if you delegate a task to a muscle that it is not designed for, it can deal for a time, but ultimately it will not be able to withstand the extra demands that have been placed upon it.

 

For therapists this is very important to recognise as it will guide how we structure our rehabilitation. When patterns become maladaptive and cemented centrally, rehabilitation takes on a different level of complexity. We are no longer treating an isolated system.

 

It is easier to learn than to unlearn a skill. My father always says, “Practice does not make perfect, perfect practice makes perfect”. As performing something in a sub optimal way over and over again only leads you further away from skill mastery.

 

So lets break it down….

 

What does sensorimotor mean?

 

The term sensorimotor system describes, ‘the sensory, motor, and central integration and processing components involved in maintaining functional joint stability’. This encompasses neuromuscular control and proprioception. (2)

 

Sensorimotor Diagram
Neural Basis of sensorimotor learning: modifying internal [Lalazar & Vaadia, 2008] https://www.sciencedirect.com/science/article/pii/S0959438808001578

Lets look at this in relation to a common injury such as an inversion injury of the ankle….

 

It is generally known that the primary risk factor for an ankle sprain remains a history of a previous sprain (5). It is thought that the initial damage to the lateral ankle ligaments alters the function of mechanoreceptors of these ligaments disrupting the ability to sense motion at the joint (4) and can lead to functional instability of the ankle. It is often described as frequent episodes of “giving way” or feelings of instability at the ankle joint.

 

A number of authors support the idea that some patients with functional ankle instability have deficits in neuromuscular preparatory or anticipatory control, which increases the risk of injury to the ankle, as it is less protected in an inadequate ankle joint position. Add to this a sub optimal rehabilitation program and paving the way towards a chronic ankle issue.

 

So what does this mean in terms of exercise prescription?

 

Benoy Mathew [Twitter: @function2fitnes] from Harley Street Physiotherapy during his talk regarding “the problem ankle” discussed the benefits of dynamic exercises such as sport specific plyometrics, which utilises sensorimotor training to promote anticipatory postural adjustments as well as optimise agility, landing technique and reaction time.

 

When it comes to overall running efficiency Mike Antoniades [Twitter: @runningschool], Performance & Rehabilitation Director of The Running School agrees:

 

“To change running technique, theoretical information and tips will not do the trick. The body needs to learn movement through movement – mostly while running but also through other re-patterning exercises”

(1)

 

During his workshop at the Therapy Expo, Mike gave us great examples during a live running assessment of particular movement dysfunctions that result from motor patterning, which often lead to muscle imbalances, poor technique and may be a factor in the recurrence of injury.

 

A common example is poor gluteal activation, which leads to compensatory hamstring dominance. Recognising this as the main offender of a patients running pain is a great start but strength training alone will only get you so far if it is a neuromuscular issue and ‘sensory motor amnesia’ is the primary reason why certain muscles fail to activate during movement.

 

There is a lot to think about during clinical diagnosis to ensure we are not ‘band-aiding’ a sensorimotor issue with strength exercises and manual therapy.

 

It is our responsibility as physiotherapists to ensure that we are continuously looking for opportunities to enhance our clinical skills. By optimising our assessments we are giving each person that seeks our advice the best opportunity to reach their full potential.

 

  1. Antoniades, M (2016), Mikes view on therapy expo 2016. Retrieved December 10, 2017, from http://runningschool.co.uk/blogs/mikes-view-on-therapy-expo-2016/
  2. Foundation of Sports Medicine Education and Research (1997). The role of proprioception and neuromuscular control in the management of knee and shoulder conditions.; August 22–24; Pittsburgh, PA.
  3. Gibson, J (n.d), Advances in rehabilitation of the shoulder. Retrieved December 10 2017, from http://www.physioroom.com/experts/expertupdate/interview_gibson_20041031_1.php
  4. Hertel J. (2002). Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. Journal of Athletic Training. 37(4) 364–75.
  5. Milgrom C, et al. (1991). Risk factors for lateral ankle sprain: a pro- 
spective study among military recruits. Foot Ankle. 12(1), 
26–30.
  6. Lalazar & Vaadia, (2008). Neural Basis of sensorimotor learning: modifying internal models.  https://www.sciencedirect.com/science/article/pii/S0959438808001578

 

Bec van De Scheurcropped-logo-resize-21.png

Commonwealth Day #10 – Refection #5

Well the end is in sight for Glasgow 2014 Commonwealth Games and I’ve had a blast so much so I might go to Rio.

Working in the poly clinic as a physio to the athletes has been a once in a lifetime experience and taught me so much about the world of elite multi-sport events.

I have had the opportunity to work under a great physiotherapy in Lynne Booth and a fantastic team of physio’s from across the UK.

The next goal for me is to get My Physio in sport bronze award and then continue multi-sport event physiotherapy through UK Athletics and BUCS pathways.

Thanks for reading my previous blogs.

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Commonwealth Day #3 – Refelection 3

XX Commonwealth Games
XX Commonwealth Games

Commonwealth Reflection #3;

The Glasgow 2014 commonwealth games are now well and truly underway with Saturday 26th July promising to be a busy schedule of competition across various sports including netball, Judo, and tracking cycling. The athletes are in full swing and the medals are coming thick and fast with this in mind I undertook my third shift at the Games Village Polyclinic.

 

The What?

The poly clinic environment, as I’ve previously mentioned, is a fast paced and exciting environment but requires a cool and collected approach to ensure the athlete gets 1005 the elite care they deserve.  But sometimes the system can be slowed down with bureaucracy  with a classic example of this coming when SEM doctors require ultrasound scans for soft tissue damage. SEM had to refer to radiography for U/S and were unable to perform U/S sans themselves. So SEM referred to radiography but radiography would only do MRI scans due to higher sensitivity rates (1) (2).

 

 

Courtesy of Shoulderdoc.co.uk
Courtesy of Shoulderdoc.co.uk

So What?

The systems clearly works within the polyclinic with this clinic seeing upwards of 400 contacts in a day, but the system can be slowed down. Ideally, the SEM doctor would like to use U/S as part of the assessment process but this may not be time efficient. HCP’s need to carry out a full and thorough assessment of the presenting condition and provide appropriate care, which in this case involved using U/S scans for soft tissue injury. However the radiography preferred MRI scans for diagnostics which cost a lot more money to provide. The resolution came when SEM were finally able to use the diagnostic U/S scans for the athletes. This is by no way a criticism of the current system but goes to show with the best laid systems they need to be flexible to provide a high level of care within a high-octane environment.

 

Now What?

  1. Multi-disciplinary healthcare provision is idealistic and can work with clear and concise communication as well as team work to overcome problems.
  2. Systems and approaches to care provision need to flexible to ensure correct diagnosis and treatment are provided
  3. The athletes are the main priority and excellent care needs to be provided to ensure the best outcome for the athlete

 

Thanks for reading.

 

Tom

 

 

Reference:

1) B Hamilton, R Whiteley, E Almusa, B Roger, C Geertsema1, Johannes L Tol (2013); Excellent reliability for MRI grading and prognostic parameters in acute hamstring injuries; Br J Sports Med.

2) K M Khan, B B Forster, J Robinson, Y Cheong, L Louis, L Maclean, J E Taunton (2003); Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study; Br J Sports Med

 

 

'prehab not rehab'
‘prehab not rehab’

 

Commonwealth Day #2 – Refelection 2

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XX Commonwealth Games

Commonwealth Reflection #2:

Hello and welcome back. Thank you for reading my first reflection on my experiences in the Glasgow 2014 commonwealth games. After completing my first poly clinic shift, I was excited to get back in clinic and enjoy shift number two on Wednesday 23rd July, OPENING CEREMONY NIGHT

A little wiser from previous shift, I was feeling more confident in my new surroundings and raring to go one day before competition began.

The What?

So Wednesday turned out to be a quieter shift in the polyclinic due to preparation for the opening ceremony. Naturally, most the attendees were either competing the following day or an acute injury needing attention in preparation for the games.  The team scheduled to cover the evening shift was the same team I worked with the previous day, so I was glad to have some familiar faces in the clinic.

 

So What?

A number of athletes came to the polyclinic seeking intervention for strapping and taping, this is something that is usually undertaken by the national team medical staff but as some nations have differing budgets, not all nations have a full medical team at the games and so they optimised the services at the polyclinic.

Over the course my shift I assessed and treated athletes from sports including Judo, weightlifting, hockey and long jump. these four examples demonstrated a good variety of stage of injury and the appropriate treatment undertaken, difference in teams and the medical support available to prevent such injuries, and expectations from treatment.

– A Judo athlete attended clinic requesting strapping and taping for bilateral posterolateral corner of the knees. No pain upon assessment and so I taped the knees. I think there are many properties to tape and differences between tape and strapping but one underlying factor is the psychological impact it has. I believe that it gives competitors confidence to push their bodies to the highest level despite the absence of injury. In the injured athlete it can be high effective to stabilise a joint (i.e subluxed shoulder).

 

Patellar Femoral Compartment Stress
Patellar Femoral Compartment Stress

– I saw another weightlifter with acute patella tendon tendinopathy and high irritability, why is this a common occurrence? I could only assume it was due to an increased volume of training in preparation for the games. In an ideal world I would love to sit down with the athlete and analyse the training volumes to cross-correlate it to the onset of injury but in a fast paced environment like a polyclinic as well as communication limitations, this is unrealistic. If I were set within a national medical team I would use those skills to monitor injuries within training regimes and highlight these impacts on injury rates thus enabling a team to improve training and performance. These guys would benefit from some eccentric tendinopathy rehabilitation.

– I saw an acute adductor strain (Grade I – MRI confirmed) from one of the larger commonwealth teams and experienced first interaction with national teams doctor requesting treatment. As part of the immediate management, the athlete was put on cryotherapy in the shape of ‘game ready’. This device works by pumping ice cold water into a cuff that is attached to the athlete. The machine setting mean temperature, length of time and compression can be regulated by the clinician. Its a marvellous piece of kit to have especially as it addresses two of the five P.R.I.C.E principles for the immediate management of soft tissue injuries.

Now What?

  1. Its important as a clinician that all patient are thoroughly assessed especially if we have not assessed or don’t know anything about the athlete
  2. Don’t just do what the athlete thinks will help. Clinically reason the problem and take suitable action in the form of treatment
  3. Taking treatment requests from medical teams is acceptable but again question the reasons behind the intervention.

 

Thanks for reading, hope you enjoy the blog, watch this blog for more Commonwealth games posts

 

Tom

Enjoying Games Life
Enjoying Games Life