3 Tips to Optimise your Movement Coaching in Rehab

In our line of work as physios we deal with teaching people how to move differently every day, whether it be to improve a pain experience or to improve functional performance. However, have you ever stopped and wondered how much of that great looking movement you were able to get your patient to achieve in the clinic actually carries over once they step out the door? Well it may surprise you, but unless you have nailed these 3 tips it’s unlikely much of your movement coaching is going to carry over

I see it time and time again – clinicians telling someone to maintain their arch or squeeze their glutes as they are in the stance phase of gait; clinicians over-cueing with thousands of technical words while a patient is mid-set trying to decipher what on earth to do. Therefore, my intention with this blog is to set out a framework to help you design the environment and modify your language to make teaching common rehab movements easy and effective.

Let’s dive into it!

Tip 1 – Don’t forget Newell’s theory and Dynamic Systems Theory

These baseline theories of motor learning underpin the art and science of creating an effective cue.

Newell’s theory – a person will organise their movement patterns based on the complex interactions of task constraints (open vs closed), individual constraints (structure / function, cognition / perceptions), and environmental constraints (1).

Dynamic systems theory – this builds on Newell’s theory and describes movement and motor learning as an emergent concept. Based off all the constraints above, the person has a multitude of solutions to a movement problem and will automatically choose the one that will most likely achieve the goal task in the specific context (2-3).

Tip 1 Clinical implications

A thorough assessment of the limitations and affordances of the individual can help you modify the task and/or environment to achieve the desired movement. You then design your cue based on the constraints of the environment you have set up. As this will be a self-selected pattern, relying more heavily on the feedback > feed forward pathways of our cerebellum, the likelihood of actual long-term motor learning occurring will be much higher.

For example, if we want a hip dominant squat due to anterior knee pain we set up a posterior environmental target.

For example, if we want to build quads in rehab we use a leg extension rather than a squat.

Here’s another example below for the trunk.

Tip 2 – Know your types of cues and their most likely outcomes

The cue is the fundamental piece of communication between the clinician and the learner that facilitates the desired movement. The cue, like all forms of communication, is a dynamic process.

1. Cognition and problem solving from the clinician drawing on all their knowledge and experience to formulate the desired movement intervention.
2. Output (both verbal and non-verbal language) from the clinician cueing desired movement.
3. Interpretation / perception is the cognitive and subconscious processes performed by the learner to try to make sense of the communicated cue.
4. Movement is the resultant output from the learner based off the above interaction.
5. Analysis from the clinician of the effect of their cueing strategy.
6. Debrief between the clinician and learner on the effect of the cueing strategy (4).

See an example of the cueing process below.

Cues are about attentional awareness. While completing a task, 1-2 areas of attentional awareness appears to be the maximum that someone can process at once (5).

Internal cues

Internal cues are designed to get the person performing the task to focus on the movements or feelings of their own body in space. These types of cues have only one benefit for motor learning and rehabilitation – they increase individual muscle EMG on isolation movements. This can lead to greater hypertrophy (especially in the upper body). The long-term learning effect from internal cues is poor and poorly correlates to performing efficient motor tasks (e.g. “squeeze your glutes” in a hip bridge) (4,6,7).

External cues

External cues are a way to bring the person performing the task’s attentional focus to their environmental context and how their body will interact with it. These cues usually have a goal or objective (real or imagined), a distance/direction component (near or far), and an intensity of action (low to high). These types of cues when done with the appropriate environmental set up are superior for all other outcomes including retention of simple and complex motor learning, and maximal performance (strength, power, and neural drive) (4,6,8).

Here is an example below.

Analogies and stories

These are supercharged external cues and have been shown to be the most beneficial for maximizing performance, e.g. “Imagine you’re coming out of the starting blocks like a jet plane launching from an aircraft carrier” (6).

Here’s another example below.

Tip 2 Clinical Implications

In early stage rehab where you want to focus on increasing muscle excitation / possibly hypertrophy, internal cues can be useful. However long-term motor learning from these cues is poor. All other biomotor performance and motor learning goals should bias external cues and analogies.

Tip 3 – Know the stages of learning and apply them to your patient

Cognitive

• Requires a lot of attentional focus.
• Movement will be purposeful but inconsistent. This introduces a large error signal to the system which promotes large positive changes in movement performance. This results in rapid learning of the baseline skill competence.
• Requires more explicit external coaching rules of how to organise movement around tasks / environment constraints.
• Requires a debrief for feedback. Here the use of shaping and chaining are handy. Break down the task into smaller components and don’t be too worried about a little form slip which can be cleaned up with more practice.

Associative

• Requires less attentional focus.
• Learner shows increasing self-organisation of movement, with smaller error signals in response to external task / environment constraints.
• External cues should be heavily biased, however some internal cues can benefit and not interfere with learning as much as the previous phase.
• Learning will be more gradual and refining in nature.

Autonomous

• Requires very little attentional focus.
• Cues should be highly individualized, designed to introduce the exact required error signal to create the subtle learning effect.
• The use of analogies here are best for performance and learning.
• There will be a lot more input from the learner in cue development.
• If you choose to use internal cues they can enhance learning in simple closed tasks (e.g. a squat), but will interfere with maximal performance in open tasks (e.g. soccer kicking) (9).

The coaching of these 3 groups is best described by the long and short arcs of movement coaching.

Long arc:

• Describe, Demonstrate, Cue, Do, Debrief.
• This allows the learner to understand the reasoning for the task and get a visual template for the task to be completed, which engages large parts of our cortex involved with learning.
• The cue distils things down to 1 or 2 key details to be focused on. The learner then completes the task and debriefs with the clinician around performance.

Short arc:

• Cue, Do, Debrief.
• Best used between sets to refine cues to shape the desired performance (4).

Tip 3 Clinical Implications

Know the stage of learning your patient is currently in with the goal movement. This will allow you to appropriately vary the level of detail in the verbal communication and environmental set up / task constraints of your cues. Getting this process right can also help shorten the time in consultation taken up by inefficient teaching of movement.

Conclusion

So there it is! A simple 3 tip framework to enhance your movement coaching in the clinic

To summarise:

1. Assess the individual brutally well and manipulate the task and environment to get the highest probability of achieving the desired movement.
2. Know your cues function. Is the goal muscle excitation (internal cues best), or basically anything else (external cues / analogies best).
3. Communicate with the patient at their level. It’s unlikely you’ll need more than a couple of targeted words and a good demo. TALK LESS. Less experienced learner = less words is better.