Movement Realism: Why Sports Medicine Can't Be Reduced To A Hashtag

It is hopefully uncontroversial to say that there is no such thing as perfect posture or ideal movement.  That perfect posture or ideal movement is, at best, a theoretical fantasy does not justify a prevailing sentiment in the rehabilitation and training world that any movement pattern that emerges under particular environmental constraints is beyond reproach.  The thinking here is that the body is a highly adaptable system that organically “finds” the optimal solution to environmental challenges. From a training or rehab standpoint, therefore, one need not do anything but regressively or progressively load the pattern that emerges in the absence of coaching or cuing.

Ideal movement isn’t supposed to exist but some commentators suggest that any motor pattern that allows for task completion is effectively ideal because emergent movement is always “best” even if they don’t use that word.  It’s “best” to them because they never consider that changing that pattern may help improve performance or mitigate the potential for injury. Instead, every training and rehabilitation situation is purely a load management issue.  Emergent movement can’t be “best” though if optimal doesn’t exist in the first place. The real question is whether the emergent movement is “good enough” or if a movement-related intervention is warranted. While errors of commission (doing too much) tend to pervade medicine, errors of omission (doing too little), to include ignoring alternative movement-related solutions, can also be quite consequential.

Ultimately evolutionary and environmental constraints only ensure that the solutions that emerge are sufficient to allow for survival, not that these solutions are superior to all other alternatives.  Moreover, the very point of rehabilitation and training is to modify the environment to elicit desired physiological and behavioral adaptations, not to leave every parameter besides volume and intensity to chance.  The emergent pattern itself may not achieve the desired endpoint, especially if the environment is highly specialized and insufficiently variable. Training that never deviates from the competitive or specific environment does not develop the adaptive reserve required to minimize the physiological and biomechanical cost of the desired task.     There are both internal and external environmental constraints that influence the movement patterns or behaviors that we observe.  Movement nihilists, those who believe the answer is always load modification (how much) and never execution (how), acknowledge only the latter type of constraint.  Internal constraints, the movement options or components from which the whole emerges, dictate what behavioral outputs will be available when the external environment imposes additional constraints.  

The movement patterns we observe in patients and athletes aren’t always a “choice”. A sprinter, as an example, might not be able to achieve the vertical torso position characteristic of high level competitors because he/she lacks sufficient hip extension in isolation.  Lack of hip extension, in this instance, is an internal constraint that limits the potential “solutions” that may emerge in a complex task (sprinting) under external environmental pressure (racing other competitors in a meet or evading an opponent in a field sport).  To be clear, restoration of hip extension in this instance might not yield any health and performance benefits or an observable change in sprinting technique all other things being equal. Not every emergent movement pattern is a “choice” though hence why “just load it” is not good clinical advice in itself.  Effective self-organization is contingent upon sufficient variability or available options. “Just load it” as a blanket statement is a neglectful, defeatist treatment paradigm. Conversely, suggesting that there is an ideal way to move regardless of the external environmental constraints is a dogmatic, paternalist one.

Movement realism lies somewhere in between movement nihilism and movement dogmatism. The load modification vs. “movement quality” discussion is much like the the one that compares part to whole training. While theoretical dichotomies and ideological tribalism make for great social media drama, the productive conversations are those that carefully navigate the overlap between the various paradigms.  Unfortunately, or fortunately if you enjoy the craft, no algorithm exists to determine the most effective ratio between load modification, degrees of freedom or variability, and technique alteration for every clinical scenario.  No matter how many times one recites the phrase “evidenced based”, clinical judgement requires some degree of tinkering and trial and error. We don’t always “know” how a system will respond to an input until we attempt said input.  There are plenty of instances in which attempting to modify an emergent movement pattern isn’t advisable. The risk-reward ratio here is contingent upon a patient’s goals, previous history, time available for treatment/competitive deadlines, and cultural factors.  Sometimes challenging the emergent movement order is advisable, however.

People don’t like the term “movement quality” because it is perceived as overly pejorative and judgmental.  Perhaps movement novelty or variety (having enough options) is what “movement quality” advocates are really after.  Totally rejecting the concept of “movement quality” is an endorsement that all solutions that emerge under the same set of environmental constraints are equally useful.  While measuring “utility” in such situations can be problematic, the inability to quantitatively distinguish between the various solutions doesn’t necessarily mean that they are all equally effective at achieving the desired task.  Just because we shouldn’t be telling people that their discs will explode if they slouch at the dinner table doesn’t mean that running mechanics aren’t relevant for some athletes. Rehabilitation professionals need not be cheerleaders for anything that isn’t harmful.  Sit-ups performed by a living, breathing human being aren’t the same thing as machine-induced, repetitive flexion/extension cycles in a cadaver spine of a different species. This distinction notwithstanding, sit-ups aren’t necessarily worthy of inclusion in a training or rehabilitation program.  “It’s not harmful” in itself isn’t sound justification for a therapeutic intervention.  We shouldn’t vilify particular exercises or ways of achieving a movement-related task.  Not every movement solution is worthy of a participation trophy though.

Celebrating and overvaluing any motor pattern that emerges without feedback from a coach or therapist does not negate the misinformation perpetuated by biomechanical dogmatists. It’s just alternative propaganda. Challenging an athlete or patient’s emergent, organic movement signature can be responsible and ethical medical practice.  One can provide feedback, even that which pertains to how one moves, without ruining a patient or athlete’s sense of self-worth.  In fact, physical medicine providers have a professional obligation to at least consider the extent to which how one moves influences a clinical presentation, just as they should consider how much he/she moves.  Deluding oneself into thinking that load management is the only thing that matters doesn’t do patients and athletes any favors. Rather, it’s a means of oversimplifying a complex issue into a package that conforms to character limits on social media.  Most challenges, including determining when to perform a movement related intervention, can’t be solved with a hashtag.

Tales of Usain Bolt’s “asymmetries” and “flaws” are greatly exaggerated. Doesn’t mean a slow, injured team sport athlete who runs like a cartoon character wouldn’t benefit from technique modification.  

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