This is one massive topic! However it’s something to consider with pretty much every patient/client you see, as we perhaps have more influence over this than anything else we do, either through movement or manual therapy. It’s also important because a loss of motor control/stability is so common, even if at a low level. The changes in proprioception after any injury are incredible, so it’s worth checking out. If you go in depth it can get a little intense, but there are some simple observations that I use to help guide me to what my patient needs.

The thing that really led me down this path was the contrast between a joints ROM when performing non-functional tests compared to functional tests. For example, I would assess someone’s hip internal rotation in supine: full ROM. The I would ask them to walk, squat or do an excursion test and they didn’t appear to have any range! So why would the body not use the available range? Well, there are probably many reasons, but the ones that spring to mind for me are either:
1. The motion is being limited by another plane/joint
2. There is a lack of stability (motor control) so the body will not allow you to go into an uncontrolled ROM.

If you have completed either the Diploma in Functional Performance or Functional Therapy you will know the process of clearing all the other joints/planes. If the body still won’t let use the ROM you know is available, then I am thinking it’s a stability problem. You can use simple balance-reach tests to compare one side to the other and 99/100 times you will find a lack of stability on the affected side. The situation where you can get caught out is when you are dealing with a good athlete: they may be so adept at compensating that you have to push them harder to find the problem.

This kind of presentation is most obvious with lower back pain, shoulder pain and knee pain, although I am sure it can appear any time. The good thing is, once identified the patients/clients tend to respond really quickly. Pivot matrix, balance reach matrix etc. are awesome in this scenario and the change will be instant, which the patients love. Within a week you can progress to much more challenging exercises, and often the pain scores are starting to come down too.

A similar scenario is when you know there is strength in the range, but the body just isn’t using it. My favourite example of this was a patient who undergone a hip replacement about 3-4 months previously. He’d been through all the usual re-hab and had experienced an uncomplicated recovery, apart from the fact that when he walked and was weight bearing on the affected leg the opposite side of the pelvis dropped dramatically. He had been given lots of hip abductor exercises (clams, resisted clams etc.) and had progressed to the strongest theraband, but there was no corresponding change in his gait! I met him because I was taking over from someone who had gone on holiday. I did an assessment and he showed me his exercises, but that hip drop was still massive! All that strength and yet no motor control.

My strategy was to do some more functional type exercises to try and get the body using the strength I knew it had. We went through some pivot exercises for about 10 minutes using a few different variations and I then asked him to walk across the room without his walking stick. He now walked with a mild hip drop (about 80-90% improved) and couldn’t believe it. It would take a bit of practice to keep this effect, but he can repeat the exercise daily, so that’s no problem. It just goes to show you don’t necessarily have to wait weeks and months to see positive change.

If you look out for these types of presentations it won’t be long before you see them. The results of using functional exercises with them are spectacular. Enjoy!

Neil Poulton