Part 2 – Opportunities in Clinical Practice from an Ecological Perspective
This is part 2 of a blog series unpacking how an ecological dynamics perspective influences clinical practice. The series is aimed to be an invitation for any practitioner who helps and guides individuals with pain and injuries to reflect on their own assumptions about how humans perceive, cognize, and act. These assumptions, implicit or explicit, heavily influence the experiences we facilitate for our patients. Readers are encouraged to (re)visit part 1, which began to describe components of an ecological dynamics (EcoD) framework for understanding perceptual-motor behaviors. In part 2, additional layers of contemporary motor learning theories will be introduced with practical examples of its manifestation in management of musculoskeletal pain and injuries.
Complexity
Prior to diving deeper into the practical ideas for applying an ecological dynamics (EcoD) approach in the clinical contexts, it is worth stating again that pain and injuries are complex and emergent experiences. Cholewicki et al. (2019) illustrates this interactive and multifactorial nature of pain. In this image, they map out the components that contribute to an experience of low back pain.
Along with the non-modifiable factors such as socioeconomic status and genetics, each person’s experience around pain is influenced by a set of beliefs and expectations they hold based on their unique collection of previous experiences and cultural influences. As practitioners, we face the challenging task of skillfully navigating such constraints.
Drawing parallels from the concept of coach-athlete system perspective presented by Orth, van der Kamp, and Button (2019), it may be helpful for practitioners to understand that our interactions with patients are complex, emergent and co-adaptive phenomena of their own. We need to be attuned and sensitive to the subtleties within the patient’s behaviors to guide our own, just as great sport coaches do in their interactions with their athletes during practices and games.
In other words, we must prioritize meeting each person where they are in every clinical encounter. Management plans are continuously adapted based on the emerging information within our interaction with them. The person experiencing pain along with the peculiar set of circumstances surrounding them are just as important considerations as their biomedical diagnoses, if not more. This process of zooming out requires us to ask questions such as:
- How is this pain or injury affecting them, particularly at the level of movement actions and behaviors?
- What key individual constraints are potentially modifiable over time?
- How can I provide support for them as an active agent within their organism-environment system?
- What experiences can we facilitate during the sessions so that they are willing and able to interact with their environment outside of the clinic in more meaningful ways?
Because the rest of this blog series will be focused on the movement experience we facilitate, it was necessary to take a step back and signpost some of the complexities surrounding practitioner-patient systems in order to properly represent how an EcoD perspective shapes clinical practice. Perhaps, more specifically, systems thinking warns us against losing sight of the whole for the sake of optimizing one small part of the system (e.g., exercise selection). The abilities to see the bigger picture and to stay adaptable in the face of informed uncertainty and complexity are necessary skills for us to continue refining throughout the course of our careers.
Ok, now that we have added extra nuance to the conversation, let’s start exploring the bits you are here for—practical application of an ecological dynamics framework in clinical care. The 3 main themes that will be introduced over the next two blog entries are 1) accepting variability and encouraging exploration, 2) keeping perception and action coupled, and 3) coaching to guide problem solving.
Seeing the good in variability – manipulating constraints surrounding an activity
One of defining characteristics of an EcoD friendly approach is acceptance of movement variability and encouraging it through purposeful manipulation of constraints. Variability of movement through an EcoD lens is not noise in a system that should be eliminated. Instead, it is a necessity for humans to function as part of the organism-environment system (Davids et al. 2003).
As highlighted in Part 1 of this blog series, performance (daily life and/or sport) environments involve dynamically changing landscapes shaped by interacting constraints. Each context requires individuals to coordinate system degrees of freedom (i.e., perceptual-cognitive-motor system components) in order to achieve an intended task outcome. From an ecological perspective, it is vital that practitioners present patients with alive movement problems (Myszka, Yearby, & Davids 2023a; Yearby et al., 2024) so that they can repeat the process of finding a solution that fits each particular context, rather than simply reproducing the same movement coordination in rote repetition (Bernstein, 1967).
In practice, variability and problem-solving demands can be scaled to match the patient’s needs and current tolerance (physical and psychological), similarly to other exercise variables such as load, positions, ranges of motion, volume, and tempo. Activities involving high degrees of variability and complex problem-solving demands can be complemented with slightly more repetitive exercises within a program as to not overwhelm the patient.
Below are some examples of how constraints of a simple lifting activity can be manipulated to start shifting away from rote repetition and towards encouraging problem-solving:
- lifting various implements (various boxes, barbell, dumbbell, kettlebell, medicine ball etc.)
- lifting from various heights (ankle, shin, knee, midthigh, belt etc.)
- lifting to various heights (lifting onto a table, over a box, between two hurdles etc.)
- lifting with different footing (wide, narrow, split stance, feet on uneven heights etc.) or grip (mixed, pronated, supinated, wide, narrow)
- lifting under various time constraints (as many times as you can in X seconds etc.)
- lifting using a different phase tempos (1,3,5s eccentric rather than the same tempo each rep etc.)
- lifting around people or with people (consider movement problems in our daily life or athletic contexts such as carrying groceries up a set of stairs while passing a neighbor, exercising in a public gym, group/CrossFit workouts with several other participants in close proximity, moving a large piece of furniture with a friend, lifting the catcher during rugby lineouts etc.)
- Lifting under various levels of fatigue (practitioner may choose to organize the order in which exercises are performed in a session to facilitate problem-solving under various levels of fatigue)
- Lifting with different lighting, flooring, room temperature etc.
- Feedback to encourage more hinging movements, squatting movements, back flexion etc. (more on cueing and coaching in another blog post)
It quickly becomes evident that there are infinite ways to change the nuanced parameters for a movement problem without changing the global nature of the movement problem. As an entry point, a practitioner may find it easiest to consider manipulating something about the starting condition for an exercise or activity. Manipulation of constraints in this way can make the activities slightly more “alive” as the performer is more frequently required to reorganize their system degrees of freedom to achieve the task under a given set of constraints.
Variability ≠ Complete Randomness – How it fits in to the bigger picture
Of course, it is still crucial to gain extensive knowledge about the condition (specific and non-specific to the person) in order to manage risks in this approach. Identifying pain tolerance and tissue capacity thresholds based on joint positions/ranges of motion, load intensity, load type, speed, and volume can reduce the likelihood of inducing significant pain exacerbation or a tissue damage.
However, by abandoning the idea that there is one correct and ideal movement pattern to be drilled and perfected, the focus can shift towards nudging the person away from highly sensitizing and potentially ineffective movement strategies, as well as any compensation strategies developed to off-load certain structures following an injury. Well designed constraints act to “put fences around” those avoid-for-now affordances while encouraging variability and reorganization of perceptual-cognitive-motor degrees of freedom (Myszka, S., Yearby, T., & Davids, K. 2023a) within set boundaries.
https://youtu.be/E7BGZL5YoPU?si=wVAgw4rbuUKMA0K0
- An example of lifting activity for people managing low back, hip, knee pain etc. with high degrees of variability.
https://www.instagram.com/reel/C-p4ZglPtfU/?igsh=NjZxcHUxbG91NXdp
- An example of how purposeful manipulation of constraints and variability can be incorporated into exploration of ‘hinging’ movements—providing an alternative way to teaching the “perfect” hinge as it is done traditionally.
https://youtube.com/shorts/Y1wT4A76S9k?si=LRuQfKRaN90-gY6b
- additional task constraint to “touch x number of different targets” adds more variability in a slightly more “alive” activity.
https://www.instagram.com/reel/C9h0P2BJ-qX/?igsh=ZGV1aXlhbnY2cWRx
- An example of repetition without repetition approach incorporated into a medicine ball activity.
What the EcoD framework advocates for is not manipulation of constraints at random. Some constraints need to be kept constant and more purposefully manipulated in order to define the movement problem at hand. In the video examples above, task constraints such as the height of the box/target and the amount of weight used can be set based on the pain or tissue capacity thresholds identified. These constraints act as safety boundaries and allow the person to perceive and accept affordances that were previously unavailable (or less attractive) to them because of pain or fear and anticipation of pain. They offer the person different ways to interact with their environment. They constrain to afford (Renshaw et al. 2019).
Because there is no clear definition for when constraints become “handcuffs” that enforce a movement solution instead of “guardrails” that guide the search for a solution, how strictly to define (i.e., constrain) a movement problem will be up to each practitioner based on the needs of the patient. As stated earlier, sudden introduction of such a vastly different approach to movement can quickly overwhelm patients. Similarly, in cases where certain tissue capacity measures have been identified as major rate limiters for progress, a more tightly constrained and repetitive approach may have an advantage in terms of implementability and efficiency.
Reducing variability and simplifying activities may be a necessary choice along the non-linear journey of rehabilitation, as illustrated above. However, one of the key differences in an EcoD perspective is the recognition that practicing movements in rote repetition may not be optimal (Myszka et al., 2023a). By choosing to eliminate variability for the sake of addressing isolated parts “efficiently”, it takes away opportunities for the person to learn to problem-solve. The end-goal environment for most individuals is much more open, messy, and ‘alive’ compared to the clinic environment. They require flexible coordination of degrees of freedom within the movement system to accomplish complex tasks.
EcoD perspective shows us how we can better guide this adaptation process without taking a reductionist approach. We may be able to address pain, tissue capacity and even nudge a person towards more effective movement strategies without isolating them completely from the information-rich environments. Introducing variability to the organism-environment system in a scaled and softly assembled manner is a potential starting point to free up the person’s perceptual-motor-cognitive degrees of freedom and help them become as adaptable as possible as a result of the rehab journey.
Warm up as an opportunity to prime problem-solving
Activities that incorporate problem-solving and intentional exploration may fit most easily as part of the warm up. Low intensity activities utilized primarily to raise body temperature and prepare joints and tissues for the bulk of the session affords us opportunities to facilitate exploration of movement options. Instead of drills based on an ideal technical model, the use of novel, task-based activities can prime individuals for movement problem-solving by freeing their frozen degrees of freedom (Bernstein, 1967). It can be a perfect time for people whose movement options have been limited by a pain and/or injury to practice “thoughtless, fearless movements” (Gifford, 2014). Here are some examples:
- Ball roll
https://youtube.com/shorts/D640tm8v32g?si=NDuSi65DB1HtVKDd
- Dowel touch
https://youtube.com/shorts/iKV6mnMwPNU?si=u4SY1wPyEtxFxyPq
- Three zones
https://youtube.com/shorts/i-PFlrHMO3w?si=n51yofG-Kb04qbP8
- Floor getups
https://youtube.com/shorts/kg76srcjr_8?si=Vljmxh0cgXTKwwcm
Activities such as these allow us to embody the message that there is no one correct way to move. Instead, there is degeneracy (Edelman & Gally, 2001) in the human movement system. Meaning different muscles and joints have overlapping functions, and they are able to coordinate (self-organize) in a way that maintains similar overall output despite varying conditions (constraints). Myszka et al. (2023a) state that exploration and enhancement of this perceptual-motor degeneracy may be a potential path for facilitating dexterity (Bernstein, 1967). An ability to solve any emerging movement problem (Myszka et al. 2023b) may not be a realistic, or appropriate, goal for many of our patients, but perhaps with a bit of creativity and courage to change our practice, we can help them become more adaptable and fit to solve whatever movement problems they will encounter on their own.
We’ve only scratched the surface…On to part 3
In part 3, we will explore perhaps the most important principles within the ecological dynamics framework, perception-action coupling. My goal is to provide examples of how these concepts can be incorporated from early stages of rehabilitation (or re-adaptation) and not just exclusively for the elite level athletes in the very latter stages of return to sport journeys.
References:
Bernstein, N. A. (1967). The coordination and regulation of movements. Pergamon Press.
Cholewicki, J., Breen, A., Popovich, J. M., Jr, Reeves, N. P., Sahrmann, S. A., van Dillen, L. R., Vleeming, A., & Hodges, P. W. (2019). Can Biomechanics Research Lead to More Effective Treatment of Low Back Pain? A Point-Counterpoint Debate. The Journal of Orthopaedic and Sports Physical Therapy, 49(6), 425–436. https://doi.org/10.2519/jospt.2019.8825
Davids, K., Glazier, P., Araujo, D., & Bartlett, R. (2003). Movement Systems as Dynamical Systems. Sports Medicine, 33(4), 245–260. https://doi.org/10.2165/00007256-200333040-00001
Edelman, G. M., & Gally, J. A. (2001). Degeneracy and complexity in biological systems. Proceedings of the National Academy of Sciences, 98(24), 13763–13768. doi: https://doi.org/10.1073/pnas.231499798
Gifford, L. (2014). Aches and Pains / Nerve Root Sections 15-20 / 1-5. CNS Press
Myszka, S., Yearby, T., & Davids, K. (2023a). Being water: how key ideas from the practice of Bruce Lee align with contemporary theorizing in movement skill acquisition. Sport, Education and Society, 29(4), 451–467. https://doi.org/10.1080/13573322.2022.2160701
Myszka, S., Yearby, T., & Davids, K. (2023b). (Re)conceptualizing movement behavior in sport as a problem-solving activity. Frontiers in Sports and Active Living, 5. doi:https://doi.org/10.3389/fspor.2023.1130131
Orth, D., van der Kamp, J., & Button, C. (2019). Learning to be adaptive as a distributed process across the coach–athlete system: situating the coach in the constraints-led approach. Physical Education and Sport Pedagogy, 24(2), 146–161. https://doi.org/10.1080/17408989.2018.1557132
Renshaw, I., Davids, K., Newcombe, D., & Roberts, W. (2019). The constraints-led approach: Principles for sports coaching and practice design(1st ed.). Routledge. doi:https://doi.org/10.4324/9781315102351
Yearby, T., Myszka, S., Grahn, A., Sievewright, S., Singer, A., & Davids, K. (2024). Applying an ecological dynamics framework to mixed martial arts training. Sports Coaching Review, 1–28. doi:http://dx.doi.org/10.1080/21640629.2024.2325822
Yuji is a licensed chiropractor and a certified strength and conditioning specialist based in Portland, Oregon. His views on how a musculoskeletal clinician can be most helpful to someone dealing with pain and injuries have been informed by the updated evidence around pain and the ecological dynamics framework for approaching human movement. He currently helps people overcome pain and performance related obstacles through his coaching platform.
