The often overlooked issues of functional rehabilitation

In this summary I will discuss why your skills such as addressing articular function and myofascial issues are critical when rehabilitating musculoskeletal problems, and why the often prescribed exercise alone approach is so poor. We will outline the basic principles here, and cover the details and references in the resources listed below.

A general overview

Biomechanical dysfunction can cause abnormal stresses in structures such as joints, muscles and ligaments, and is commonly involved in musculoskeletal pain syndromes. To understand how such dysfunctions are best addressed it is necessary to understand how this function is controlled. Here we will:

• give an overview of neuromuscular control,
• give a very common specific example, and
• examples of where this issue is handled properly.

An overview of neuromuscular control

How function is controlled

Biomechanical function is typically controlled by the coordinated activity of many muscles. The timing, contraction and relaxation of each of these muscles is determined by the Central Nervous System (CNS). The CNS receives general instructions, then works out how to best do these using pre-programmed patterns plus feedback from proprioceptors and other sensors.

How dysfunction occurs

Dysfunction typically occurs when there is an issue with one or more functional elements. The CNS will receive feedback about this then alter the neuromuscular control to compensate. For example if one had a sprained ankle the CNS would alter function to limp and avoid stressing the injured ankle. This is obvious, but the CNS needs to continually adapt for a variety of potential issues including muscular and articular.

Dysfunction cannot be consciously corrected with exercise

The key issue is that the conscious brain can only give general guidance. The timing, contraction and relaxation of the various muscles is determined by the CNS.  If there is an issue with for example a muscle or joint that is being compensated for the CNS will continue to compensate, and follow the general guidance allowing for any issues.

The bottom line

As long as the issue being compensated for remains the CNS will continue to compensate, and any exercises will be performed in the same dysfunctional manner. If the dysfunction is causing abnormal stresses then performing exercises in this manner will continue to cause pain, damage and injury. If the issue being compensated for is removed the CNS no longer has to compensate and function is able to return to normal.

An example

The shoulder joint has a large ball sitting in a shallow socket, so it requires a coordinated effort from a large number of muscles including the rotator cuff to maintain proper contact between the joint surfaces. If this function becomes abnormal it can result in pain syndromes which receive diagnoses such as “impingement syndrome”.

The neurological control of the various muscles is known as a Muscle Activation Pattern (MAP). Scientist are able to monitor this using sensors that monitor electrical activity.

(Myofascial) trigger points cause muscle activation patterns to become abnormal

Researchers at RMIT University in Melbourne (where I studied) compared the muscle activation patterns of normal shoulders vs shoulders with muscles affected by (myofascial) trigger points. Trigger points inhibit the function of muscles.

The normal shoulders had consistently normal muscle activation patterns.

Those with muscles affected by trigger points had abnormal muscle activation patterns, meaning muscle control had become uncoordinated.

Treating trigger points caused muscle activation patterns to return to normal

When the researchers treated the trigger points using dry needling the activation patterns returned to normal. They noted that dry needling only temporarily restores function so these changes did not last. We discuss how to properly eliminate trigger points in a previous email.

Exercises cannot return muscle activation patterns to normal

There have been other trials where researchers have attempted to correct abnormal muscle activation patterns using exercises. In every case they failed to do so. As long as an issue requiring compensation remains the CNS will continue to compensate.

Examples of where this issue is handled properly

The information above illustrates that issues potentially affecting function need to be dealt at the start of any rehabilitation process. In the example of the shoulders given above, when the trigger points were dealt with function returned to normal without any other intervention. If other issues such as de-conditioning exist exercises can be prescribed once the CNS is able to give normal control.

Example one: in clinical trials

There have been several studies of shoulder pain where exercises alone have been compared with exercises plus physical therapies such joint manipulation (freeing up restricted joints) and soft tissue therapy (massage and trigger point therapy)⁠. In each case the results were much better when using the therapies. The soft tissue therapies help address the trigger points as discussed above, while the joint manipulations help address joint issues. These are another common causes of CNS compensation.

Resources

Functional rehabilitation
Do exercises help shoulder pain
Latent (Pain Free) Trigger Points Alter Neurological Control of Shoulder Movement Causing Damage, Impingement and Injury