I have been hearing more and more therapists talking about 'motor control' exercises recently and how they are thought to help those with pains and problems. I hear many explain how these exercises are designed to enhance 'normal' coordinated and controlled movement, by improving muscle co-ordination, timing, and actions thought to be deficient in those with pain or dysfunction.
Now this all sounds plausible, reasonable, and even sensible. You see a patient with awkward, restricted movement it would seem wise to address this. However, often its not this simple and I really had hoped we had moved away from the thinking that we know what 'normal' movement is when dealing with the wonderfully diverse and delightfully unpredictable human being.
However, there is research that does show increased risk of injury with so called movement abnormalities. For example knee valgus and ACL injury or Patello Femoral Pain Syndrome (here), or loss of shoulder internal rotation and shoulder injuries in throwers (here).
But although these movement abnormalities have been found as risk 'factors' for injury, they are not necessary nor sufficient to cause injury alone. There are many other factors that conveniently seem to be forgotten or ignored by the motor control guru's that also contribute to injury. For example, weather conditions, playing surfaces, fatigue, foot wear, state of mind, etc are also can and do contribute to injury risk.
Yet despite these other factors I still hear and see motor control exercises being tauted as the cure all method for many issues and problems, and unfortunately they are now often bastardised by many to justify some absurd claims.
Even the term 'motor control exercise' is confusing to me, what the hell does it even mean? When I look to the literature for guidance even that it isn't clear, with many confusing differing definitions and terms. Latash et al (2010) is propably the clearest paper I could find, they define a motor control exercise as…
An area of science exploring how the central nervous system produces purposeful, coordinated movements in its interactions with the rest of the body and with the environment.
So has that cleared anything up then! Well not really, because when I asked on Twitter recently what people thought 'motor control exercises' meant I got some very varied, diverse and amusing reply's such as…
A learnt movement or skill that can be performed with and without conscious effort : Sam Blanchard
Driving a car without crashing #MotorControl : John Doyle
Anything except motor out-of-control exercises : Diane Jacobs
Waking up a sloppy, lazy central nervous system that pain has inhibited: LegendPhysio
Is it not just a movement/exercise, with an emphasis on control and quality? : ChopperFizz
When you can't move or change it as you wish, that can mean you have “poor motor control” Daniel Atkinson
Control = constraint and reduction of redundant DOF. I like abundance and increasing options. : Ben Cormack
Motor control = taking the smallest muscle involved and training it at 10% of MVC with every effort to turn off everything else with the view that this muscle is inordinantly important : Dr Anthony Shield
So you can see that even healthcare professionals have different ideas and understanding of the term motor control exercises, now imagine how confusing it is for the poor patients when we use these terms.
In my opinion, many therapists use terms like motor control exercises just to sound a little more sciencey and a little bit more clever to others. But these terms mean nothing to patients, or many therapists and are just confusing gobbledegook terms.
Also could anyone tell me what movement or exercise doesn't involve an element of motor control? When is an exercise not a motor control exercise? If we really are going to insist on being all sciencey and shit shouldn't we call all exercises Neuromuscular Proprioceptive Cognitive Functional Motor Control Exercises.
I can just see the trademark and official weekend courses being designed right now… Level one NPCFMC exercise certification only £399, click here for more details etc!
Unfortunately, however these kind of bewildering and nonsensical terms do exist, but I beg you, can we please just stop it. Can we please just call all these types of exercises what they are… EXERCISES… Nothing more, nothing less. Adding confusing, conflicting, overly technical terms to exercises does nothing other than confuse patients, and cause miscommunication and misunderstanding between therapists.
The best exercise is the one being done
Whatever your goal is with any exercise we should remember they are all just different and novel ways to move, nothing more, nothing less. Why we choose an exercise for a patient should be based on many different reasons, such as do they need to do it to improve strengthen, endurance, speed, power, fear, threat, stress, anxiety, and of course risk of injury.
However, taking all these factors into account, we should remember that the most important factor that will influence which exercise you choose for a patient, is finding one that is suited to the individual in front of you. Not just based on your own beliefs or preferences, but their physical ability and their beliefs and preferences. Simply put if a patient doesn't think or feel the exercise is right for them, then they wont do it.
So if you are choosing an exercise to make a movement more 'normal' for a patient, and that patient doesn't feel normal doing it, then you are missing the first rule of exercise prescription.
Basing the choice of exercise on what YOU think is normal for someone else is nothing more than guess work, based on your own biases, may be some research you have read, and perhaps influenced by some movement gurus, or other misinformed people out there.
Basically, no one knows how any one should move, no one knows what is abnormal, therefore no one knows what is abnormal. Normal movement is based on the individual, the task, and the enviorment, and there is no way to controlling for all of these variables.
The only way to know what is 'normal' movement for a patient is to ask them if it feels normal, that is ask them if it feel painless, fearless, thoughtless and effortless for them.
History repeating itself
Also this recent rise in the motor control exercise fad appears to be used as a opportunity to rebrand the 'core stability' craze that infected our society and profession deeply years ago. This is when we got carried away teaching and telling people how to maintain 'better posture' and to isolate their deep abdominals, neck flexors or some other fancy sounding muscle, and do lots of small, irrelevant, low load exercises and movements in a belief this will help their aches and pains.
I think most of us are now aware that there is no superior effect of these types of exercise over any other type here. In fact core stability exercises most likely have made many far worse by encouraging and promoting maladaptive protective muscular responses long after any back injury or issue should have resolved, and may have caused many to experience persistent pain unnecessarily.
I would argue that many of these motor control exercises cause unwanted side effects, usually due to explanations that therapists give to patients as to why they need to do them. They often give patients the false and misleading idea that they should be looking to constrain movement towards a perceived ideal that in fact doesn't exist.
We are all unique, we are all individual, so the way we move is unique and individual too, and despite many claims, there is little evidence that one type of movement is more normal than another, or that a clinician can tell what is or isn't normal, and there is even less evidence that one movement is more risky or causes more problems than another.
The only bad movement, is a painful or fearful one.
The belief that we should teach people to move the same way time and time again is just ridiculous. Variability in movement is fundamental for a number of reasons. First it distributes forces evenly and widely around the body (ref). The next is that we never, ever move the same way twice in normal everyday activities, so why do we think we should do this when we are injured or in pain?
Variability in movement is good, its healthy, and its normal. The idea that anyone can tell what is abnormal just by looking at a patient do something whilst being observed, in a clinical environment, at that particular moment is just absurd.
Motor control exercises are often aimed to rehearse the same movement the same way, time and time again, in a belief that this is helpful, but there is little evidence that they are any more effective than any other method of exercise to reduce pain or risk of injury (ref, ref, ref)
There are some studies that do show motor control exercises maybe superior than general exercise (ref), but it does seem that those patients who get best results with motor control exercises are patients that believe, or have been lead to believe, that these exercises are best for them (ref). This highlights how important patients beliefs are to succesful outcomes of any intervention and not just the intervention itself.
Exceptions to the rule
However, there are times I do think 'control' of movement is a good idea, but its fairly common sense stuff. For example, when the body is under extreme loads or or experiencing high forces. In these situations I do think some element of 'control' is needed, but to improve the control of these activities they need to be rehearsing these activities, not doing silly isolated, low load motor control exercises.
So there you go, another Meakins rant against some established thinking and practices within therapy and rehab. I hope the next time someone mentions motor control exercises, you will ask them what they mean by that term, and what the purpose of them is. I will leave you with the wise words of the late great Louis Gifford to ponder about the control of movement…
The notion of 'bad' movement is a danger to the spontaneity of our very exisitence
As always thanks for reading