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Thinking Outside the Body: External Control Cues for Lower Limb Rehab

Motor Control – defined as “conscious (intentional) or unconscious brain activation to coordinate the trunk and/or limbs to perform a motor skill or action” – is a popular topic in movement performance and rehabilitative research.

Research over the last 10 years seems to indicate that “external cues” (in which the individual’s attention is drawn an object or mental image outside the body part in question) are superior to “internal cues” (their attention is drawn to the body part in question).

You can start applying these simple principles with your patients immediately, and get creative with the concept. Below are some common exercises followed by an internal cue and, in green, an external cue.

Double-leg squat:
INTERNAL: Bend your knees while keeping your knees over your feet.

EXTERNAL: While bending your knees, reach toward the cones with your hands and point your knees toward the cones.

ANOTHER EXTERNAL: Pretend that you are going to sit on a chair while keeping a ball between your knees.

Double-leg drop jump:
INTERNAL: Jump down from a 30 cm box. Land with your feet at shoulder width, and bend your knees while keeping knees over toes.

EXTERNAL: Jump down from a 30 cm box, land on the markers on the floor, and put your toes and knees toward the cones.

Vertical jump:
INTERNAL: Jump as high as you can while concentrating on the tips of your fingers, reaching as high as possible during the jumps.

EXTERNAL: Jump as high as you can, push off against the ground as forcefully as possible, and pretend like you have to hold a ball between your knees.

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Countermovement jump:
INTERNAL: Jump as high as you can and reach your fingers as high as you can.

EXTERNAL: Jump as high as you can and touch the hanging ball.

Sidestep cutting maneuver:
INTERNAL: Run 4 to 5 steps straight ahead. While changing direction and making the cut, move your trunk forward, bend your knee, and keep your knee over your toe.

EXTERNAL: Run 4 to 5 steps straight ahead. While changing direction and making the cut, try to make a fluent motion and point your face and toes toward the direction you are going.

Other external cue options for the lower extremity examples above could be 1) descriptive language (push off from the ground forcefully), 2) tactile cues (push into the resistance band from your knees as you squat), and 3) visual cues (aim your knee at the cone).

In addition, systems such as the Motion Guidance system can offer a visual cue in the form of a laser pointer, enabling the patient to visualize their movement in real time.

Reference: Benjaminse et al: Optimization of the Anterior Cruciate Ligament Injury Prevention Paradigm: Novel Feedback Techniques to Enhance Motor Learning and Reduce Injury Risk. journal of orthopaedic & sports physical therapy. No. 170, Mar. 2015, Vol. 45, No. 3

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