Imagine being a passenger in a bus, standing because all the seats are occupied. When the bus driver suddenly steps on the break, your balance and equilibrium reactions are elicited, including automatic postural adjustments to prevent a fall. These automatic postural adjustments involve activation of the trunk musculature.

Now, imagine a medically complex patient, who requires maximum assistance to transfer from sit-to-stand, being moved by a PT during this task. Because the patient is being moved by an external force (like the bus braking), the patient engages automatic postural adjustments, engaging their trunk musculature. What about a scenario wherein due to prolonged immobility, this patient has acquired movement impairments, including impaired muscle activation (i.e. timing, sequencing, amplitude, etc.) while engaging automatic postural adjustments?

Anticipatory postural adjustments AND guarding are the same automatic physiological response, the former in response to both volitional movement and external perturbation, while the latter only from external perturbation.

Kinesiophobia is determined by patient self-report. This is not possible when dealing with patients who are medically complex and who are cognitively impaired. When patients "refuse" to move, we interpret some patient responses as a manifestation of kinesiophobia. Is it really kinesiophobia , or can it be impaired automatic postural adjustments (i.e. movement impairment involving automatic movement)?

Automatic postural adjustments is an automatic physiologic response for "self-preservation."

This highlights the need for PT's to understand patient response to being moved to effectively address immobility, especially during  transfer from sit-to-stand. Managing an individual with cognitive impairment limits our ability to instruct the patient. 

Can we differentiate between kinesiophobia and impaired automatic postural adjustments? Is active resistance against being moved kinesiophobia or is it an attempt to steady the body against an external force? What interventions are available to address these problems in the medically-complex patient? How do we correct impaired automatic postural adjustments? Is Cognitive Behavioral Therapy effective when dealing with a physiologic response (i.e automatic postural reactions)?

When treating a patient who requires maximum assistance, are we able to provide manual cues to correct the movement impairment when all of our effort is used in physically lifting the patient up? I have observed patients respond more positively when moved by an inanimate object (i.e. elastic potential), instead of another person (i.e. PT). The video below shows a patient with chronic stroke who has impaired automatic postural adjustments. He actively "pulls back" when another person assists him during transfer training. Using elastic potential to assist him during the task allows him to control every aspect of the movement, eliminating the "pull back" to counter the PT's effort.