How to Use Reactive Neuromuscular Training to Enhance Joint Stability & Movement

Written by: Nick Jack

Category: 2014

on 26 March 2022

A very common problem during a rehabilitation program for injury is when you get to that point that you do not have pain but you know your body is only one small step away from losing stability and control putting you at risk of going backwards. Trying to force your way through with strength methods is risky, but sticking with easy isolated mobility and floor based stability exercises achieves very little too. It is at this point I regularly use a training technique called REACTIVE NEUROMUSCULAR TRAINING (RNT for short). This is where a small amount of resistance is applied to a faulty movement that “feed the mistake” and therefor forces the body to make a correction. This can be a very frustrating phase to work through but extremely rewarding if you spend the time to work through it. In this article I will explain how I use several versions of this technique to rehabilitate injuries and even improve sporting performance!

This is a method that is credited to Gray Cook and Michael Voight, however I learned similar techniques to theirs from a different therapist 15 years ago by the name of Ulrik Larsen. And one could argue this really came from techniques developed in the 1960's by leading researchers and physicians who pioneered PNF. Anyway, regardless of who came up with it these techniques they are incredibly effective in restoring joint stability and motor control in a short amount of time.

A good example of RNT in action is seen in the picture above of myself completing a lunge with a resistance band pulling my knee inwards.

The band around my knee is attempting to pull my knee into a valgus position (knock knee) and ruin my knee stability. Instead of trying to help me it is "feeding the very problem" of poor hip control with even more loss of control. My brain can sense what is going on and attempt to correct it with the opposing strategy which is what it should have been doing in the first place.

I know it sounds confusing but it is a very clever way of making the body "feel" something out of balance and instantly recruit the right muscles to provide the correction. In the example with this lunge exercise the band resistance is attempting to force my body to find a way to correctly align my knee so I can lower myself into the lunge. The glutes are responsible for a big part of this and if they do not activate I will most likely fall inwards towards where the band is pulling and be unable to complete the movement. However, it is not just the glutes at play here, as the muscles of the feet and even the core are highly involved. It requires the BRAIN to respond and give the reflex command that is needed to multiple muscles in a blink of an eye.

The Challenge Is to the Brain, Not the Body

It is important to understand that this method is not trying to improve muscular strength as such but trying improve the correct stabilizing and righting reaction needed for efficient movement.

A true stability problem is a subconscious problem. Meaning the brain is allowing the poor stability to occur before the conscious brain is aware of it.

This is why isolated muscle strengthening have such a poor success rate in changing stability problems with walking and single leg movements. The challenge therefor is to the brain and not the muscles for the brain has a series of movement patterns it has memorized and would prefer to keep using them. It will continue using them if it perceives it still can.

This is where the RNT works tremendously fast for it shows the brain there is a problem with its current strategy and needs a new one. IMMEDIATELY!

Now before you jump straight into these exercises you need to have some degree of good motor control with movements using two arms or two legs. For example, you should be able to execute good form with a deadlift or a squat before you attempt to use RNT with a single leg deadlift or squat. The stability demands are amplified considerably with RNT and while this is a good thing your brain will have no chance if it does not have a good foundation to build upon.

Okay, now that you understand a bit more about RNT let's take a look at several examples starting with some really simple ones.

Improving Posture & Core Function with RNT

Posture is defined as: "The position from which movement begins and ends."

Ideal Posture - That state of muscular and skeletal balance, which protects the supporting structures of the body against injury or progressive deformity, whether you are moving or not. It is during a state of ideal posture that the muscles will function most efficiently.

With all corrective exercise programs you are trying your best to help the person move with ideal posture and this is where RNT works perfectly.

These first two exercises are relatively simple in terms of skill to complete but surprisingly difficult for many to get right. The emphasis is on good posture and body control to allow good movement. Strength is not of great importance, however a good feeling of where your body needs to be positioned is more critical.

Your brain likes to see, feel, and hear things and it wants to be positioned in the best possible way in order to move efficiently. These type of exercises are fantastic for achieving exactly that. However, you must understand that a lot of mistakes are made during this process of the brain trying to figure out what is going on and how to make the appropriate correction at the right time. You must remain patient and avoid giving up too quickly because you make too many mistakes.

Another video shown below is a recent one I added to You Tube about exercises to help someone with weak glutes and a weak core causing lower back pain. Both of these exercises use RNT to help the core engage by using reactive, reflex, adjustments. The kneeling deadlift with the band feeds the poor hip movement often associated with SIJ and extension back pain and the only way to move is to resist the pull of the band which helps engage the glutes.

All of these exercises work great if you close your eyes as this forces the proprioceptive system to become more involved and instantly apply the right adjustment. Unfortunately, doing this also makes the movements very difficult to complete. Just remember the mistakes are a good things for it helps the brain to see what it needs to change.

Inline Stability Lunge

The INLINE LUNGE STABILITY DRILL shown below is another classic example of this in action and this is an exercise I use a lot for older adults to prevent falls. It is also a great exercise for those with rigidity in their torso such as those with lower back pain. Often the stiffness in the hips is a big part of their back pain and this movement forces the hips to let go and encourages the trunk to continue moving excessively. The correction is to learn how to keep the torso and core engaged to prevent falling over while the hips move.

Easier said than done.

The last simple drill that explains RNT easily for you is the CRAB WALK.

Crab Walks

This is a progression of the lying glute exercise called the clam and due to the standing position it gets the quadriceps and hamstrings involved into the movement while still heavily targeting the gluteus medius and gluteus maximus. This exercise works best if you use small micro resistance bands around the legs to force the glutes to work harder to provide external rotation of the hip.

The band attempts to make you walk with your knees together which demonstrates weak glutes and tight hips. As your body can sense this is happening it naturally fights against it with external rotation of the hip and as a consequence helps to engage the glutes.

You can read more about this in the article - How useful is the clamshell exercise for the glutes?

Now we are ready to look at some much more complex drills involving the shoulder and this is where RNT can make a massive difference to overcoming compensation causing pain.

Improving Shoulder Stability Using RNT

Out of all the injuries to work with, shoulder and neck pain would be the most difficult. There is just so many factors at play, it can lead you a wild goose chase as to what is the problem and you could be using exercises and treatments that aggravate the problem instead of correcting it.

Most of you would have heard of the rotator cuff muscles being:

Supraspinatus - external rotator
Infraspinatus - external rotator
Teres minor - external rotator
Subscapularis - internal rotator

These four muscles work together to externally rotate and internally rotate the shoulder but they are very important in keeping the humeral head stable and cantered within the joint. If we lose that stability, we get some extra mobility of the humeral head within the joint, and that begins to pinch some of the structures around it. The weakness of the stabilizers forces greater activation of the prime mover muscles exacerbating dysfunction and compensation of the shoulder.

Interesting to note that 3 of these muscles are external rotators and only one provides internal rotation (subscapularis), and often it is this muscle that is greatly inhibited and weakened during pushing actions causing dysfunction and pain.

The other two key muscles are:

Serratus Anterior (pictured above to the right)
Lower Trapezius

These two muscles play a pivotal role in keeping the scapula attached to the thorax and in optimal alignment. And also providing the upward rotation and posterior tilt needed for optimal stability. Without these muscles firing together correctly, your body will find another way and this is when postural adaptions occur such as the winging of the scapula, stiffness, and trigger points and ultimately pain will surface at the end.

Now that you know what the weaknesses are you can also begin to see where the movement you need to "feed" for RNT is - EXTERNAL ROTATION! Here are some of the exercises I might use to overcome this problem.

Dumbbell Row with Band Pulling Backwards

The dumbbell single arm row is a very simple exercise to strengthen the upper back muscles of the trapezius and rhomboids. The simplicity of the exercise makes it a great choice to combine some RNT with it. This exercise helps to engage the weakened subscapularis as the band attempts to pull the shoulder into further external rotation. The internal rotator being subscapularis “feels the mistake” and attempts to correct it by activating against the pull.

This is a great exercise to use in the early stages as the skill level is very low so there is very little the person can get wrong. This can set a good foundation moving forwards with the more difficult and complex standing exercises to come.

Watch the video below from the 4:30 mark to see this exercise in action.

Cable Row with Mini-band Pulling Inwards

One of the biggest mistakes with rowing movements is people keeping their elbow too close to the body and excessively retracting the scapula. This does not cause pain this movement but it completely ruins pushing movements and causes a stack of trouble to the timing of the scapula.

When people are told to really pull the scapula down and back and with rowing movements you will see elbows stuck in really close to the body. Many therapists still prescribe tons of scapula adduction exercises in the belief that these muscles are too weak and more the better. All this leads to is scapula downward rotation and eventually the depressed shoulder. This is very common with the person with some good training experience and really aware of posture.

When elbows are held out about an arms width from the body this shows good scapula form and muscle balance.

This exercise is another example of using a band to "feed the mistake" by pulling the arms in too close to force the person to correct it by pushing the elbows out.

To read more about the technique for pulling actions refer to this article - How to correctly execute pulling movements for optimal shoulder function

The following exercise is a great stability drill to prepare the body for pushing movements and helps to engage the SERRATUS ANTERIOR.

Single Arm Stability

This is a regression of the push-up exercise with the sole focus of trying to restore optimal scapula function and protraction during a pushing movement. Once again, minimal strength is needed to complete this exercise, but maximal stability and timing of the scapula is required.

The band around the wrists tries to feed more retraction of the scapula during a pushing action forcing the brain to adapt and apply a protraction correction which requires the use of serratus anterior. This can be quite difficult to do for the person with pain and you have to be careful of over-using it in the early stages. Combined with trigger point release and the use of simpler exercises like the wall slides can help you tackle this. But it can be a great way to progress to the more difficult push-ups and chest press which we will look at next.

Chest Press With Tubing for Subscapularis Activation

Once you have worked your way through a shoulder rehab program and you try to implement pushing exercises again you can often come up against some problems. Many people find the chest press very hard to do again and feel very weak in this action. They are very likely to still have a faulty movement pattern at play, and if they go back to what they were doing they will end up in pain again! All of your hard work will go down the drain as you aggravate the shoulder again. Ignoring the exercise is not a good idea either for the weakness in the pushing action needs to be addressed to get rid of the problem for good.

One of the best ways to overcome this is using this RNT technique.

Using tubing during the exercises helps to activate the often overpowered internal rotator subscapularis, by feeding the external rotators, which gives the shoulder more space and freedom to work. It also helps to activate the lazy but very important serratus anterior. A great exercise for teaching your shoulder how to move correctly again. It is amazing how different people feel when you add the tubing to their hands. You may need to use it for some time until the brain remembers to switch on the subscapularis and the serratus improves with overall strength.

Watch the video below from the 11:30 mark.

Overhead Press With Tubing For Subscapularis Activation

A follow-on exercise from this is the overhead press with resistance seen in the video below. Once again we see the band attempting to pull the shoulder into further external rotation to force activation of subscapularis. Just like the chest press it is amazing how the tubing can instantly stabilize the joint and remove stiffness and pain.

Watch the video below from the 5:30 mark to see this in action.

You can read more about serratus anterior and pushing actions in the two articles below.

If You Need More Help With Shoulder Pain

Obviously there is a ton of additional things you need to do to fully rehabilitate your shoulder but this is a big start in the right direction. You will find all of the other mobility, stability, and strength exercises I regularly use in my training in the detailed report shown below. You can instantly download this 90 page PDF report by clicking here.

Okay, so we have looked closely at the shoulder, what about the hip and knee?

RNT for the Hip & Knee

If you have read any of my articles about the knee then you will know that anything that happens at the knee most likely started at the hips or the feet first.

Knees are exposed to tremendous pain and problems whenever they are forced into a twisting or bend sideways, (eg ACL tear) known as valgus or varus, and lastly if they hyper-extend. This joint is more or less a hinge, it cannot twist and rotate itself, and it cannot bend the other way either. The knee needs to have some mobility which many people lose through tight quadriceps and hip muscles, but it needs a great deal of STABILITY to prevent the dangers of twisting and rotating that will ruin the knee.

The rotation of the leg must come from the two joints above and below the knee, being the HIPS and the ANKLES. Both of these joints have the ability to move in almost every direction but if either of these two joints lose their mobility guess what? That is right the knee will be forced to make up for the loss of mobility and try to twist and rotate! It is a bit like being caught in a crossfire.

This is where the RNT comes in as it attempts to feed the poor movement of the hip, usually internal rotation, and the poor movement of the foot which is usually excessive pronation. There is a detailed article I published a while back that looks at all of the exercises for the knee in great detail - How to isolate the VMO in an integrated movement

Here are some of the RNT exercises for the knee starting with the simple ones.

Hip Extension with the Band Pulling Inwards

This is a very simple exercise and it introduces you to the feeling of the femur being pulled inwards that places the knee in the point of "no-return". This is an exercise known for building strength into the glutes and hamstrings and is a great way to unload the knee joint. This is useful in the early stages when inflammation and pain may still be present and in combination with the mobility exercises for the hip and the quad it should allow your pain to settle.

The glutes are a real important muscle group here and they will be heavily used in the upcoming single leg exercises to come, so this is a great introduction to learning hip control.

Stability is not compromised in any way with this exercise as it completely removes the feet as a factor which is fine as it allows you to focus mainly the hip. Later on we will use an exercise to focus mainly on the foot, and then eventually you can put everything back together.

Lunge With Band Pulling Inwards

The lunge is my preferred next step as it does not require a lot of ankle dorsi flexion or knee flexion as seen with the squat that can often cause pain. The lunge also shares similar body position to walking and running where we usually see the patella-tracking problems arise the most.

The concept behind the band pulling the knee inwards is to force external rotation from the hips via activation of the glutes. They are one of the keys to eliminating the problem once and for all and the band is forcing your body to adapt. The band is really trying to make you do it wrong so your body has no choice but to respond.

This is the first time we see the feet become involved and is also where you may start to see the cracks appear and what could be underlying cause of the problem. The glutes must be heavily engaged here but be careful you MUST NOT squeeze your glutes too hard and end up sucking your butt under, also known as gripping. This will lead to faulty hip mechanics and create a new set of problems, usually into the lower back and the hip itself.

Stay as neutral as possible throughout the exercise and carefully move up and down on the spot trying to maintain a perfect alignment through the foot, knee and the hip.

Click here to see the video with this exercise. Watch from the 2:25 mark to see this in action.

Improving Foot Stability With RNT

Improving Single Leg Stability With RNT

When I finally progress to the single leg stance 95% of the time I will focus on the single leg deadlift before the single leg squat. The reason for this is that it is often much easier for people to develop the single leg skill and strength with the deadlift than the squat. Often there will be tremendous weakness with the quadriceps near the knee joint in the squat and it can make things difficult to progress. The deadlift action removes this problem and allows the person to focus on maintaining that alignment we are looking for.

This is also the BEST exercise to strengthen the glutes bar none! The most difficult part of this exercise is trying to maintain the anterior pelvic tilt that is absolutely critical for switching the glutes on during the movement. You MUST NOT lose this anterior pelvic tilt at any point.

Read this article to see more on this - Why anterior pelvic tilt is so important to hip function

Any weakness at the foot or hip will be instantly revealed in this exercise. I would expect to make many mistakes the first few times learning this movement as the body struggles to move without its cheating mechanism in place. I prefer to use a Swiss ball to rest my foot and not a bench as this will again expose the lateral cheating movement that is the underlying cause of the problem.

If you feel you are making too many mistakes you could hang onto a stick or place your foot on a bench instead. But I would prefer to try with the Swiss ball first and make the mistakes so your body is forced to solve the puzzle.

Partial Squat with RNT

This exercise is the first time we are truly trying to strengthen the quadriceps and the VMO in a big way. This is deliberately reducing the range of motion of the squat to a partial range so that you can focus solely on the area of weakness in the quadriceps which is just above the kneecap itself.

Once again we introduce the band pulling the femur and hip inwards to force external rotation contraction from the glutes and therefor maintaining the optimal alignment of the lower limb. The stability this time is assisted by using a bench to allow for greater workload with the quadriceps.

It is important in this exercise to not lean forwards as you would normally do so with the squats and deadlifts. By removing any hip movement it forces all the work into the knee itself which is normally a bad thing to do, but in this case we are trying to create a bigger workload to the weakened quads. As long as you finish off learning good form with full range of motion these exercises are beneficial. Where they backfire is when people think this is the better way to squat.

CLICK HERE to watch this video.

Box Step-up with RNT

The box step-up is one of the hardest exercises for the legs and certainly for the person with knee pain. It requires a massive recruitment of the glutes in order to effectively stand up with one leg. If the person is quadriceps dominant and the glutes are not functioning to full capacity you will see a massive energy loss. Finding a way to get the glute to fire within this pattern is essential and using the band is a great way to do this.

I often start with a very small box to give the person maximum leverage when first trying this. As time goes by I might add small dumbbells before eventually increasing the height of the box.

Using RNT to Improve Gait

This last drill tries to put it all together. I could have also used a second band pulling the knee inwards at the same time that the band is pulling the hip backwards. Maybe I will do that video for you next time.

The major difference with this exercise versus all the others is that it is on the move, just like the way we move when we walk and run. This is also where the foot becomes more of a factor as it must pronate in during the transition to single leg stance. If it is unable to pronate as it wants to cheat, or if it pronates excessively you will find a loss of stability and alignment of the lower limb.

There is many moving pieces here but this is a critically exercise in restoring the pattern of movement that most likely has developed a permanent dysfunction. This drill is a great way to "unlearn" this faulty motor program and redesign the correct sequence of muscles and joints working together. Anyone who has patella-femoral pain from running this will be an exercise you will need for a long time, if not forever to ensure your compensation does not return.

Click here to watch the video. Watch from the 3:24 mark to see this video in action.

It is not just rehabilitation and corrective exercises where RNT is useful. Even agility exercises and sports specific training can use this this method to great effect.

If You Need More Help With Your Knee Pain

While these RNT exercises are great there is obviously a lot of additional exercises I would explore for knee pain and this article only touches on them briefly. For more help you will also find our Knee Pain program shown below which I highly recommend getting a copy of if you are struggling with knee pain right now. This includes a 60 minute video and PDF report to show you how to implement the assessment process to identify mobility & stability restrictions along with movement pattern dysfunction creating your knee pain. These programs provide over 70 exercises and teach you how to design your own program based on your test results to correct your weakness.

Click here to go straight to the online shop or on the image below to see more.

Agility Training Using RNT

Below is a video showing how I might use over-speed and reactive training to force the athlete to react with the right response during a complex movement used in sports. I show you 3 different exercises you can use with RNT to enhance braking skills and agility.

This drill demands lightning quick foot speed and acceleration with a focus on minimizing preparation time between movements. Explosive changes of direction and nearing top-end speed in the shortest amount of time possible will ensure success in any dynamic environment. Adding on top of that the random instructions to go forward and back while the slingshot resistance band pulls you into over-speed creates a perfect exercise for simulate sporting situations.

The over-speed tries to make her screw up her movement and makes her find a way to effectively decelerate. This is very difficult to master and like all the other exercises, many mistakes are made.

There are many ways I might use the slingshot and heaps of variations with agility exercises you can check out in this article - The Top 25 Agility Drills to Improve Change of Direction

Summary

There are many other exercises I could include here but I think you get the idea of how effective RNT techniques can be. At first it appears to go against your instincts or logic of what to do as it appears to be making you do the exercise wrong. But when you apply this to the training you quickly see how effective it is at forcing the right correction. Obviously you need to be certain you can perform the basic movements first before attempting the more difficult ones, and you have to remain very patient during the learning stage as you will make many mistakes. You will even anticipate the mistake and still make it for the brain takes time to figure out what it needs to do.

Remember this type of training is not about just changing muscles, it is more concerned with how the brain coordinates the muscles during movement. I hope this helps you overcome an injury or helps to improve your movement and strength if you are stuck in a rut with your training right now.

For more ideas and information on specific topics I may not have covered in detail be sure to check out our INDEX PAGE on the website that has over 300 of our best articles. These are all sorted into categories for quick reference so you can find what you are after more easily. You can also subscribe to our FREE fortnightly newsletter by clicking here.

If you do need specific help with your exercise program please feel free to reach out to me for help and we can set you up with your individualised program.

About The Author

Nick Jack is owner of No Regrets Personal Training and has over 16 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specialises in providing solutions to injury and health problems for people of all ages using the latest methods of assessing movement and corrective exercise.

References:

Movement - By Gray Cook
Knee Injuries In Athletes - by Sports Injury Bulletin
The ACL Solution - by Robert G Marx
Understanding & Preventing Non-Contact ACL Injuries - American Orthopaedic Society For Sports Medicine
Corrective Exercise Solutions - by Evan Osar
Back Pain Mechanic - by Dr Stuart McGill
Diagnosis & Treatment Of Movement Impairment Syndromes - By Shirley Sahrman
Low Back Disorders - by Dr Stuart McGill
Ultimate Back Fitness & Performance - by Dr Stuart McGill
Core Stability - by Peak Performance
Athletic Body in Balance - by Gray Cook
Anatomy Trains - by Thomas Meyers
Motor Learning and Performance - By Richard A Schmidt and Timothy D Lee
Assessment & Treatment Of Muscle Imbalance - By Vladimir Janda
How To Eat, Move & Be Healthy by Paul Chek
Scientific Core Conditioning Correspondence Course - By Paul Chek
Advanced Program Design - By Paul Chek
Twist Conditioning Sports Strength - By Peter Twist
Twist Conditioning Sports Movement - By Peter Twist
Functional Training For Sports - By Mike Boyle