Is your exercise library good enough?
So movement is a funny old term. We all get people moving so in this sense we are all ‘specialists’ in movement.
Is there any difference between what we might see as an approach utilizing traditional strength exercises and a what we might term a 'movement' based approach? Both involve moving right?
Well yes, where they perhaps differ is the underlying concepts and application of that movement. Do we need both? Can they co-exist even within the same rehab or performance program? I would certainly say so (but of course I am biased!) This piece is certainly about adding to our repertoire rather than taking away from it.
With strength exercises we are often looking for the ‘right’ exercise performed in the ‘right’ way that can involve targeting the ‘right’ muscle for the job while exhibiting the ‘right’ posture. Now if your goal is to make the target muscle bigger and stronger then spot on. Body builders have been doing this for years with great success. The strict form they exhibit is perfect for the job but is our movement really like that?
These exercises are often also used in therapeutic programs and are great for building muscle & tissue and also affecting our tissue tolerances. The aim is on improving the anatomy, that after all is what they were designed to do.
The aim of a movement based approach is instead to improve a movement or movement in general and how the nervous system interprets and subsequently tolerates that movement or a variety of movements. Progression would involve how an increase in speed, load and range of movement are tolerated.
Increasing the size and accuracy of the brain areas involved with movement capacity, we know they are affected by pain *Here* and movement has an effect on these areas *Here*, is also a consideration.
Any exercise or movement prescription must involve as much of a reasoning process as any other part of assessment, treatment or training.
How does this movement relate to the person standing in front of me?
What is it trying to achieve?
What is the mechanism by which it will help and is that relevant to the problem?
Variability
An exercises aim is often to decrease the variation in the movement to increase the specific affect on the target area. This maybe precisely the opposite of what the nervous systems may need in a theraputic context with motor system responses designed to control and protect in place *Here*
A variability approach is designed to recalibrate the nervous system to decrease the protective sensory, motor and associated psychological responses to movement.
As we have started to switch our focus from the structure in pain we may also need to start thinking about this in movement too! Kids learn how to move through exploration and play with a focus on a rich tapestry of experiences. That’s why things such as early specialisation have been touted as problematic. Can we learn from this?
Movement variability is an important neuromuscular skill that has been implicated in rehabilitation, prevention and performance *Here*, *Here* & *Here*.
‘Motor control’ exercises often fall into the same category with the ‘correct’ precise activation patterns and sequences touted as the ‘right’ way to avoid or beat pain. Instead we see muscle activation as a pretty individual thing *Here* and the ability to vary that activation actually being reduced by pain *Here*. Muscular co activation is specifically tied to the task depending on the tasks direction and load *Here*. I like to think of freedom rather than control in problems such as LBP. There maybe a possibility the muscle you have reliably tried to activate never actually activates consistently the same way when you move anyway!
A specific or 'correct' role for a muscle led to the targeting of the TvA. This has proved to be a pretty fruitless endeavor as the muscle responsible for back pain as have the specific and strict exercises promoted to best target it *Here*. In fact strength or the muscoluskeletal system in general seems to have little impact on LBP *Here*
Trying to change a specific movement can actually be pretty important. It may change the load to a tissue or activate a different neural pattern than the one that is currently associated with a pain response.
We have to ask ourselves who is the movement really relevant to, you or your client/patient? Is their problem one of anatomy or pain? Do we need to actually change the anatomy through exercise/movement or change our movement habits affect on the anatomy and physiology?
Strength
If you are trying to change a movement then a focus on a specific muscle and its strength maybe less beneficial *Here* *Here* as we see here with the mechanics in running. We have seen the same approach with the neuromuscular skill of landing and cutting in ACL rehab and injury prevention *Here* and a focus more on the skill of the specific movements. The thought process here involves context and applicability.
This has also lead to a rise in gait retraining approaches that are less interested in the proposed role of a muscle or general strength but instead more in changing the skill of a how a movement is performed *Here* , in this case running.
Relaxation and coordination in relevant movements are equally if not more important than generating force.
How do you know a muscle is weak in the first place, have you tested it?
How did you do that?
Is the weakness a cause or an effect of pain?
How much strength do you actually need in this situation to be ‘healthy’ and does restoring strength improve the outcome? *Here* is an interesting piece on normalising.
Could it be in fact poor endurance or control?
Will strengthening help if it is poor endurance or control?
These are some questions to ponder rather than using the well worn phrase “it needs strengthening - 3x10” Does that even get you stronger?
Our approach to stretching may need equal scrutiny.
Is it really tight in the first place or have you just assumed?
Is this tightness a structural issue of the muscle or a protective response of the nervous system?
Strength and flexibility as we see with the stretch & strengthen model are component parts of achieving a task through movement rather than individual properties and are highly contextual.
Being a good weight lifter does not mean automatically you are a good javelin thrower. Equally being flexible for yoga may not mean you have less pain or are better at football; in fact being too flexible could be detrimental to moving quickly or generating power.
I am mindful that we must also be careful to not throw out the baby *Here* as specific exercise focused on the hamstring has brought about reductions in injury. The focus here is on the eccentric element, this is a departure from the traditional strength view of concentric muscle action and focuses on the functional demands placed on the hamstring, especially in a sports environment.
Strength training and motor skill are associated with different changes in the CNS *Here* Strength in itself is a neuromuscular skill, think strength changes prior to hypertrophy, and to be most affective may need to be coupled with a specific motor pattern as discussed earlier in the piece.
The aim here is not to malign the importance of strength or its relevance in pain and rehab but instead question the application of the concept of strength and strengthening.
Fear
Specific exercises come with specific instructions to do them in the ‘right’ way sometimes with fear of them being ineffective or even dangerous if done in the ‘wrong’ way. In this way they can become contrived and controlled, strict and inflexible. An example of this would be the classic neutral spine or stiff core that seems to be on the instruction list of a whole bunch of exercises.
Would this be an applicable for someone with lower back pain? In fact they may already have a stiff strategy in their trunk, precisely what we may want to change *Here*
A traditional weightlifting/exercises approach in this situation may reinforce precisely what we should be focusing on breaking down. That is the fear of moving the back coupled with the protective motor responses that accompany them. The fear of slipping or blowing out their disc in a deadlift or squat if performed incorrectly, a message that can be perpetuated by some therapists and strength coaches/trainers can be a pretty lasting and sticky one. After all we know that words can hurt *Here*
Doing up your shoe laces comes with some lumbar flexion, should we teach people to avoid doing that or actually helping them over come the fear of going into low load lumbar flexion? Lumbar flexion happens all the time I doubt it can ever be stopped, so instead how it is tolerated could be an aim of therapeutic movement although many demonise it.
A question I ponder is why do we have so much movement in that area, especially in flexion and extension, if we are not meant to use it? Perhaps it is a fault in our design or perhaps not!
We often we take exercises that we know and love and they become our staple go too’s, we have to also see movement in a client or patient centred sense as well.
What are their movement demands rather than our go to’s. We may love to get people squatting but is a just a traditional squat position a good go to for someone bending over to prune their roses? Is that performed with a neutral spine? Should it be? Do we do it with no spinal rotation or neutral foot positions?
In fact here you believe it is an ischemic irritation then a varied squat program reaching to different positions with differing foot positions maybe just the ticket! Simple movement cueing, skill, novelty and variety maybe more important than strength to certain people (a lot!)
The health of the physical element of the central nervous system needs good blood flow. This can come from varied tension and compressions on the nerve, especially across multiple joints, and muscles that are not under constant contracture causing a tourniquet effect.
A reinforcement of a constant position of the lumbar spine through an attempt to keep in a neutral spine, as per a traditional squat, may just exacerbate the issue. Any constant position of the spine may prove to be problematic.
Associated terms
Aims and words that maybe associated with an exercises/strength approach:
Stretch
Strengthen
Controlled
Targeted muscles
Strict
Isolate
Posture
Neutral
‘Correct’ form
Improving movement skill may have a different set of aims and words:
Freedom
Flow
Integration
Variability
Variety
Capacity
Coordination
Context
Now does this all mean that picking an exercise with a strength focus or muscle focus is a no no? Well absolutely not. But we have to ask ourselves in our reasoning process is it really giving me all of what is needed and applicable to the person standing in front of me. Our exercise prescription needs a reasoning process too rather than just being the throw away bit at the end on a printed sheet!
There is no reason why in our program design we cannot contain a traditional strength/muscle focus with the added element of movement skill and variety or in fact movement skill with load added in too!
Is that truly a mind and body approach?
