There are thousands of ways to reach up into a cabinet to grab a cup. Each action is made up of a complex interaction of intention, attention, multisystem rules and behaviors, context, execution, feedback and response across multiple joints throughout the body that ultimately yields an outcome. Human movement allows for countless numbers of ways to do things that are wonderfully adaptable to accomplish things that we want to get accomplished. At the same time, there are ways in which human movement can start to develop rules that are not as helpful as others and progress to a point of being unworkable.
When a person shows up for rehabilitation for a specific movement problem of reaching into a cabinet to grab a cup, particularly a problem involving pain. Something strange happens. Movement rehabilitation professionals suddenly get distracted with things they were taught rather than paying attention to person in front of them. It’s literally like someone superimposed an abstract black and white cartoon over a living colorful and vibrant picture. Rather than addressing movement problem directly, we start breaking it down into mechanical parts and dehumanizing the movement. Their problem is suddenly dumbed down to a collection of so called “dysfunctions” in one very specific area, or randomly in some other area without a clear understanding on how to define how they are related. These “dysfunctions” require specific protocols to “fix”.
So, once again, we put on our protocol-clown suits, where a massively inadequate evaluation strips away all of the reality (and humanity) of the problem and instead offers it’s take of the problem via reductionistic model called ‘differential diagnosis’. This model forces the clinician to commit to one single diagnosis (probably the mythical “subacromial impingement syndrome” in this example) by which we are supposed to do our protocol dance from. The dance has all always found a way to sneak in a “stabilization exercise”, if not for the “Core”, we had to find one for the shoulder. But to “stabilize” and lock down the shoulder what you are functionally moves away from your body to an object has absolutely no functional of protective benefit! Why would you want to lock the glenohumeral and scapula to the trunk with “down and back” cues when you are reach upward and forward toward a cup?!? The amount of unnecessary and potentially aggravating forces yielded on the tissues make no biomechanical sense when you just pause for a moment to look at it, but we do what we’re “trained” to follow this protocol regardless! After a lengthy dance in protocol land, the person meets some arbitrary “objective measure” of strength, ROM, or whatever isolated measure. At this point, they are now considered better, perhaps “Fixed”, and perhaps the client even reports they are better. Everyone is happy, a bell is rung on the wall, celebrate! Off they go until 6 months later the problem comes back, worsens, or turns into a new movement problem with symptoms around the same area. On goes the protocol hat, perhaps with a new diagnosis! Only the problem is this time it doesn’t improve.
Soon they may end up in the surgeon’s office (if they weren’t already coming from there before) and this time, perhaps based on the almighty differential diagnosis, incidental structural changes, or sadly perhaps even for financial reasons, now a surgery is performed. Back to rehab, back to possibly feeling better, only for the problem to come back or change again. Now the surgeon doesn’t have anything to offer other than to refer them to “pain medicine” for injection or pharmacology. All the while, the rehab team (likely by now the client is on their 3rd or 4th rehab clinician) is poking, popping, zapping, and doing all they to offer. The client is sent to multiple more disciplines, all looking through the same protocol-based lens. It must be in their head, send them to the counselor, they’ll fix them. Still not improving, let’s see the alternative and eastern medicines providers, who still follow protocols, just like everyone else. All the while, the client increasingly becomes isolated from work, life, and social engagement with worsening or unchanging symptoms and swimming in thoughts and emotions of hopelessness, anger, and fear.
Sadly, this is the point at which many of these individuals present to us at our clinical practice, still unable to do that simple movement (which has now grown to countless number of movement and symptom problems) of reaching up in the cabinet for their cup…
What happened here? How did we lose contact with the original problem? Why are we not paying attention to the simple actions people are doing on a daily basis and starting there before we create new artificial stories for which to distract ourselves? Let’s take the simple action of reaching the cup in the cupboard:
What’s happening during the action of the fingertips reaching toward the small inanimate object is dependent on a history and the context of that moment. Historically, what has happened to that person’s upper quadrant in the past? How have genetics, use, disease or injury, influenced the anatomical structural and behavioral ways it functions now? Tissues change and adapt to our use over time, it’s different now in countless structural ways then when they were a small child. There are millions of actions that had been learned from, adapted to millions of different contexts, and socially and culturally groomed for appropriateness. What physical, psychological, emotional, or social traumas have involved that area of the body? This history creates multiple flexible rules by which that person can use that dominant arm to interact in their environment. What if those rules become inflexible? What if they are only inflexible in specific situations? What if the rules expand and change other areas, or to other situations, even in the absence of having learned those rules from direct exposure? Instead of just rushing to a physical exam without context, wouldn’t you want to get to know a little about their story to see what may relate with what you are seeing in the clinic that contributes to the way they move? What if by following the protocols you always use, started to reinforce motor behavioral rules that have become more and more rigid and less and less adaptable to the anatomical and tissue loading capacity of that shoulder? What if the education someone provides is making them fearful of doing something wrong which further reinforces the motor behavioral rules contributing to tissue overload? If you told me the stove was hot, I’d reach for it in a far different movement manner than if you told me it was cold. Why aren’t we paying attention to real human movements???
We’re tired of asking these questions and we’re going to provide a real workable way forward. We have developed a framework that works with real humans. Our process-based framework was design to comprehensively evaluate, dynamically monitor prognostic variables, and create functional and contextually relevant interventions. All the while giving you the ability to make fast and efficient clinical decisions that scale up and scale down to the real-world complexity of movement and pain problems! We call this approach the Human Rehabilitation Framework (HRF) and it is the world’s first biopsychosocially-oriented process-based approach to rehabilitation.
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