Rehab professionals speak of treatment interventions as corrective actions. Picture a body segment that is out of position, not moving right, burdened by a problem of stiffness, weakness, or something that is stopping it from working correctly. This then is the stimulus for the actions that will take place, to change the bent to straight, or the straight to bent. With this accomplished the change effort ends and the collaboration between patient and therapist is completed. Too often however the functional gains are not sustained. The initial change is followed by a decrease in corrective actions. Only after the complaint gets to intolerable levels again does the patient/client take action.
What is going on here is the problem solving structure that is being used results in less action as the intensity of the problem decreases. The structural approach and strategic organizing of the plan of care will impact how the interventions are employed. A problem solving structure to get rid of the problem is not a bad choice. However it may be an inadequate structure if the level of function that is desired is not at the current level of the patient.If this is the case, then a different, more robust structure to support many changes over time is needed.
It is helpful to understand the anatomic structure of a body segment, as this is the underlying cause of the function of that segment. It is also helpful to understand how the underlying structure of the plan of care impacts how the change effort will proceed. For the rehab and performance specialist focused on changing function, knowledge of how that body segment will move in different kinetic chains locally is important to understand what outcome is desired. How this movement contributes to the support of critical tasks that are occurring in support of functional movement puts the local movement on the segment into context of the whole body activity. This requires a framework to provide perspective and context of how the body segment contributes to function.
Corrections are done within the context of the body positions required to perform the critical task. The correction is either a mobilization to promote increased motion or stabilizing to promote control. This correction is dependent upon the hierarchically ranked critical tasks. At one point, the knee maybe needing greater mobility, as in the critical task of establishing the base for the sit to stand movement. At another time the knee needs greater stability to accept the body weight shift in asymmetrical stance. It is worth pointing out that it is the influence of the hip that will determine how the knee behaves. To simply focus on interventions that are local to a joint without the context of how that joint is influenced by other joints and its impact in turn is to miss the point. Within a framework that identifies these internal relationships, choices regarding intervention can be more focused.
The change effort also takes place on multiple levels of the hierarchy of function and the underlying body structure. Interventions are different at the highest level of function. This level includes the patient/client having knowledge and being apply knowledge about the functional movements. An example of this is the patient being able to self assess function, and identify changes away from functional limits that increase risk of injury. A patient with knowledge of the connection between sit to stand to sit completion and overall fall risk as it relates to choosing appropriate equipment for safety is well positioned to maintain safe functional movement. As function is supported by critical tasks and the body postures required to accomplish these tasks, interventions become more specific and focused. This hierarchical intervention allows for a granularity of understanding by the clinician, promoting the specific application of an intervention.
This is the difference between technicians and clinicians. Technicians employ interventions or perform data collection from standardized tests. Their focus is on process, on following the directions. A competent technician is invaluable to the clinician, as the clinician can trust the data before and after the intervention is accurate. The role of the clinician is to interpret that data, look for relationships, seek to understand cause and effect and make choices about what is to be done next. Clarification of current reality is critical for the clinician. The testing maybe reproduced confirming the results. Or if something different occurs, the collaborative conversation can begin about what is being seen. Perhaps an intervention is not required after all.
Interventions that are borne of choices that take account of the internal relationships of movement and the hierarchies that exist in human movement are well positioned to support needed motor learning. The intervention makes available to the nervous system the body positions and body motions so that the brain can utilize these when organizing movement. When we mobilize a joint, it is only of benefit if it supports a critical task. When we perform soft tissue mobilization to lengthen a muscle, it is only valuable if the new motion promotes the completion of the critical task, and the antagonist of the muscle is better able to perform in the context of a critical task. With context as part of the decision making process, a successful change effort can occur.