I’ve recently had the pleasure of watching my newborn son grow and develop. I’ve been amazed by how fast this happens and how quickly skills are acquired. I’ve decided to start a blog series based off of this development and how it applies to my practice and core concepts in rehabilitation today.
This blog in particular seeks to introduce developmental milestones, spend time on the first milestone, breathing, and describe what happens when things go wrong in the normal patient population.
My practice, while constantly morphing, has come to appreciate the developmental approach to rehab. In short, when treating patients with dysfunctional movement patterns (as per the FMS or the SFMA), it becomes clear that we need to hit the proverbial ‘reset’ button and start over. Often, this is a combination of manual therapy and specific movement approaches to correct faulty patterns and alleviate pain (if there is any). As I’ve grown as a practitioner, I’ve come to appreciate how important it is to regress the patient to the developmental stage in which there is no pain, and they are able to achieve appropriate movement patterns.
These developmental stages are based off the movement pattern developed when we are children. The most important thing about these exercises/positions, is that nobody taught us how to move this way. These are ingrained reflexive patterns hard wired into us. We tap into them as we grow as a response to various inputs, desires, challenges. With the right positioning, coaching and progressions, we can use this ‘universal body knowledge’ to help restore natural movement patterns and correct dysfunction.
As I’ve watched my son grow I’ve been lucky enough to objectively (and almost obsessively) watch him and appreciate how he grows and learns to navigate in this world. As tempting as it is, I have abstained from intervention for the sake of observation thus far. It is the purpose of this blog (and the coming ones) – to take the developments of my son and expand these ideas into application in developmental kinesiology while explaining why certain positions, concepts, or techniques may be valuable in hitting the ‘reset’ button for rehab. (This blog is in no way intended to suggest my son’s development is the golden standard, rather I just want to take his achievements and extrapolate them into clinical application).
The stages for my son’s first few months of life are loosely as follows: (hard core experts would argue certain stages and perhaps go into more details, but for our purposes, this works). As a note, this is a loose compilation, normal development is variable and there is no ‘normal’.
-Begins to lift head when on stomach (prone).
– Breathing (diaphragmatic)
– Begins to make cooing/gurgling noises.
– responds to stimuli/particularly sound and light
– Follows object with Eyes.
– Random and unintentional arm and leg movements.
– smiles and laughs
-poor head control in vertical
-eye focus 8-12 inches from face.
-improved head lifting when prone (able to hold for short periods)
– smoother and intentional arm and leg movements.
-some head control into flexion (moving head off surface when on back) (pulling baby off his back)
– begins to lift head and shoulders when prone (on elbows)
– makes louder, more intentional sounds
– begins to grasp objects.
-begins to accept some weight when stood on legs.
-improving head control in vertical
-eyes focus 12-24 inches from face.
– good smooth pursuit and visual tracking
– much improved and intentional reaching and grasping/pulling.
– begins to roll from prone to supine (laying on back)
– mini-pushups in prone
– excellent head control in vertical.
– Able to briefly overcome ATNR.
TLR (tonic labyrinthine reflex): a primitive reflex found in newborn humans. With this reflex, tilting the head back while lying on the back causes the back to stiffen and even arch backwards, the legs to straighten, stiffen, and push together, the toes to point, the arms to bend at the elbows and wrists, and the hands to become fisted or the fingers to curl. The presence of this reflex beyond the newborn stage is also referred to as abnormal extension pattern or extensor tone.
ATNR: is a primitive reflex found in newborn humans, but normally vanishes around six months of age. When the face is turned to one side, the arm and leg on the side to which the face is turned extend and the arm and leg on the opposite side flex.
STNR: a primitive reflex found in newborns which links head movement to arm and leg movement. When the head extends, so do the arms, while the hips and knees flex. When the head flexes, so do the arms and shoulders and the legs extend.
Let’s talk basics. When we are born, we are born in a flexed position. The combination of extensive growth over 40 weeks and a small compartment forces us into a very flexed position. We recognize this as the fetal position. The feet are dorsiflexed, knees flexed, hips flexed, spine flexed, shoulders drawn forward and elevated, hands pulled in and flexed and chin tucked. This is how we were developed and is, not surprisingly, where we revert to when pain, fear, stress, or thoughts threaten us. (yes, thoughts can be threatening).
This flexed position is the dominant muscular system present (the tonic system) until we begin to establish other preferred patterns. Through growth, gravity, and activities we begin to explore outside of this position, but the muscles active in this position become very important when analyzing patients in pain (particularly chronic pain). It is often where patients revert in the presence of a threat. Think of the last time you were scared by a loud noise: your shoulders elevated and became tight, you shrank down and tucked your chin slightly, the neck muscles tensed, your shoulders pulled forward and rounded. Now think about the last patient with shoulder pain you treated, which muscles were tight? Shoulder elevators, internal rotators, pecs, suboccipitals/cervical spine stabilizers, hip diaphragm and superficial abdominals. This isn’t by choice the patient chooses to use these muscles (typically) by rather by reflexive reverting to the flexed, tonic system we were born into. Regardless of area of injury, tightness and pain in these muscles are often present. In the therapeutic setting, getting rid of overpowering tonic muscle tone and retraining the developmental patterns leads to the most successful outcomes.
As we develop, we begin to explore our world outside of the fetal position. The muscles used to counteract the tonic muscles are known as phasic muscles. Generically, if the tonic muscles flex the body the phasic muscles extend the body. It is progressive development of these muscles that allow us to interact with our world, look up, sit up, crawl, roll, and eventually stand. From a rehab standpoint, it is often inhibition, disuse, or underuse of this system that promote injury, perpetuates dysfunctional movement patterns, and can persist following an injury despite healing of the local tissues. It is this pattern we frequently need to promote, while inhibiting the tonic over-riding system in order to promote healing in the physical therapy setting.
So let’s start from the top. Two things happened the second my son emerged into this world.
1. He took a deep breath (from his abdomen).
2. He screamed like hell.
I can appreciate the reaction; if I had just been removed from the warm cozy, rent free home where everything I needed was provided for me and shoved into a cold sterile world with 6 pairs of hands grabbing, examining, probing, testing, and cutting my sole food source, I’d be pretty upset too. But the point is not that birth is unfair, the point is that breathing out (forcefully) and in (abdominally) is automatic. I can vouch that in the 2 seconds it took my son to react to this new world, he was not prepped in the art of diaphragmatic breathing.
This is important to me as a therapist. The most basic, most natural reflex we have as humans is breathing. Abdominally. Stop your reading. Are you breathing through your chest or your belly? Breathing is the key to recovery in so many of my patients. Either through pain, fear, stress, or posture ( or a combination thereof) the vast majority of patients who walk through my door have abandoned the first thing they ever did on this earth. The diaphragm, to me, may be the most important muscle in our body. Through its extensive connections, it’s ability to activate the core, and the internal pressure and centration of our lumbar and thoracic spine it is able to generate, it it often the key to beginning to rehabilitate dysfunctional movement patterns. Not coincidentally, breathing is one of the few ways we have to volitionally alter stress levels, heart rate, blood pH (through a complex series of reactions), reduce protective tone. Patrick Ward has written on the importance of breathing, the diaphragm, and it’s implications in rehab. If you care to read more in depth on this topic, I suggest you start here.
It isn’t uncommon for me to start a session with diaphragmatic breathing. You’d be surprised at how many patients struggle significantly with breathing through their diaphragm. This is something we were born with. While we can teach it, or cue it, the body instinctively knows how to do it. It is my job to put the patient into a position where this pattern can take over. Once the body can recognize it is safe, non threatened, or not in pain, their body will begin to adopt this natural pattern. Once regained, we can build upon that basic pattern through developmental milestones to restore normal function.
Let’s take a look a how my son breathes and then expand that to something we can use:
You’ll note that his chest hardly moves. His abdomen fully expands and his lateral ribs expand. He is not being coached into this. He is clearly not in pain or suffering and, based off his rotund figure, obviously not starving. At roughly one month old, we can assume life’s stressors have had a negligible effect on this little man. Often, we start chest breathing in reaction to something threatening us. This is normal, useful and needed to get away from danger, in the short term. However, in chronic states, this pattern remains and significant alterations in posture, muscle tone, core activation, and joint mobility occur as a result.
Let’s take a look at chest breathing in contrast to the above video:
I like this video because it shows the difference between the two patterns. Subtle, but important on so many levels.
So much of my approach begins from correction of the faulty breathing pattern. Convince the body to adopt it’s natural position and it will begin to understand that not all changes made to it are stressful and require protection (in the form of the tonic muscle dominance and chest breathing).
Positioning is important. When the body is stressed for whatever reason, the body craves stability. This can be provided in millions of ways, but often the easiest it the floor. The floor stabilizes segments unable to stabilize themselves. This provides important feedback to the body that it can shift its priorities from stabilizing in whatever fashion it can manage and put more effort on normal bodily functions (IE breathing) Remember, breathing is one of the few alterable gateways to the nervous system. Normalize breathing, and we can often affect the nervous system in a positive manner. Reduce tonic nervous system tone, and we can restore normal phasic muscle function with less time or effort.
A supine position with the knees bent, or, even better ( if condition allows), feet elevated on a chair, physioball etc. can promote significant stability through the spine.
The picture here demonstrates decent alignment of the neck with the body. However, often, the middle back (thoracic spine) is so stiff, it doesn’t extend to allow the head to contact the ground in this manner. If this is the case for you, please, get a pillow, rolled up towel, or some type of support that will slightly elevate your head so that you can maintain a straight neck in line with the rest of the spine.
Cues I typically use for patients will be to breathe in and out for 3 seconds each, in with the nose, out with the mouth. I want them to focus on the expansion of the entire diaphragm. To begin I will place my hand or the patient’s hand at the point just below the sternum. This is where I want the patient to breathe into when the take their first breath. Slight (not a lot) pressure can help to facilitate this process. Once this is easy and comfortable with the patient, we will progress to filling the entire stomach. When the patient breathes in, I will cue them to breathe and fill the lowest ribs to push out, away from their body as well as having the stomach rise. This is often much more difficult and requires more practice. This can be a struggle and a careful eye needs to be used to make sure the patient isn’t adopting a chest breathing pattern as they work their way through the initial stages.
There are times when this is the only exercise I have the patient perform at home. If the patient is compliant, you can tell immediately if they’ve been doing it. Once ‘rebooted’ diaphragmatic breathing takes over as the primary pattern (the caveat is that the patient also must work on reducing stressors or threats to the system which caused the body to react this way in the first place- if your body is constantly under attack – breathing patterns cannot be expected to alter as rapidly, or at all).
Once the patient can effectively and consciously control their breathing pattern, we will progress through other developmental patterns to restore function.
In future blogs, I will touch on these progressions, how they are achieved by my son, and how we can cue these changes in the clinic to promote better movement patterns.