Do you even motor control…

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.

Confusing?

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.

Gobbledygook

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.

Variability

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

Adam

 

 

24 thoughts on “Do you even motor control…

  1. Adam You are a good bloke! I’m glade you wouldn’t let me unsubscribe you and I’m so grateful for your help. You’ve just put me back on track again by sending the below email. It has really cheered me up. Regards, Yui

    Date: Sun, 18 Oct 2015 22:28:57 +0000 To: yuimustow@hotmail.co.uk

  2. I once told a high level functioning gentlemen with post polio syndrome to get rid of his bracing around the plantar flexed ankle. I told him to flex the extremely stiff, “circumducted” knee during loading phase of gait to maximize normalized, motor control. Well… He fell on his ass.
    We then established an “exercise” program to highlight his unusual gait pattern that reminded us we are all capable of becoming uniquely strong……

  3. Hey Adam, nice post. I agree with you that it is difficult to define/ operationalise motor control. If you Google ‘Albert Kozar motor pattern assessment’ you can download a pdf to see some of the heterogenous thoughts within the MC camp.

    If you look at literature re ankle sprain, it seems that some people cope with no ‘deficits’, whereas others have ‘deficits’ (joint position sense Yokoyama 2008; cutaneous sensation Powell 2014, etc). Or in the case of LB, O’Sullivan has noted subgroups (‘motor control impairment’). Hence, ‘deficits’ could occur in some patients.

    Depending on how you define ‘core stability’ (semantics?), I disagree that CS exercises “…promoting maladaptive protective muscular responses.” In my blog, I outline 3 major ‘camps’ re core (www.mbachiro.com/blog). In physio school, you would have heard about most of the ideas within these camps.

    I’m a chiropractor but have in recent times been exposed to one MC ‘school’ (Dynamic Neuromuscular Stabilisation). In DNS, postural reflex points are activated by the therapist and after a number of sessions, you can notice patients breathe with lateral abdominal expansion etc. Over time, their position sense improves and eccentric muscle stabilisation occurs (not sure of the mechanism – is it purely due to reflex point activation, etc aka ‘software update’ in plain English). If you ask me to cite a journal, I honestly don’t know. More research is needed (rct anybody?), but I can’t deny seeing improvement in patients and certainly no clinging on to ‘maladaptive protective muscular responses’.

    Just a few thoughts.

    • Just to kindly clarify: you are referring to Vaclav Voijta’s work termed, “Reflex Locomotion,” not DNS. Reflex Locomotion is taught (non-extensively) in some DNS courses, because it is based upon developmental kinesiology where the “postural reflex points,” (stimulation zones) which you are referring are the same zones of support used in patterns maturing in the course of postural development. In theory, It is used to illicit partial motor patterns, passively; a bombardment afferent stimuli to the CNS activating inborn physiological movement. DNS is a learning or training process of ideal movement by use of exercise in developmental positions.

  4. Thanks.
    We really need to know the science of motor control as it is the most important regarding movement.
    And if we want to improve motor control we should use motor learning principles. Most often then not we do not.

  5. Morning Adam,

    The best example of motor control I have is keeping my old T5 Volvo in a straight line when the roads are wet.
    Having spent twenty plus years in clinical practice now in various disciplines my observations are that people are still trying to sell s t as gold. It is quite easy to do really as people are still desperate for dysfunction, pain and treatment to have proportionality.
    I thank my lucky stars that I attended two Louis Gifford courses in the first couple of years of qualifying.
    As a profession I thought we were getting somewhere then but I cannot believe the backward steps we have seemingly made in the last ten years. People cannot let go of anything it seems.
    An amusing observation is how people often like to use the word theory behind such wording. I don’t think they have a clue what a theory is in real science. Basically it is something that stands up to total scrutiny and if found not to it is gone.
    A period of nihilism (temporary) is due. What survives may be worth having.
    Anyway, off to join a SIG to become basic, intermediate and then expert at a non proven, ineffective treatment.

    PS cannot help feeling that certain people may be waiting for you to slip up one day. However, remember; better to be hung for a sheep as a lamb.

    • Hey AMW

      Thanks for your comments, and the analogy, I like it, Volvos are like tanks for civilians…

      And regarding slip ups, I had many already and have been burned and I’m sure many more will come, but hey… life goes on, its only physiotherapy at the end of the day!

  6. I think it seems fairly clear now that pain disturbs motor cortical organization (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3157990/, http://www.ncbi.nlm.nih.gov/pubmed/21508892, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4331171/). Or at least that the two are correlated. That disturbance tends to take the form of excessive muscle activation (http://www.ncbi.nlm.nih.gov/pubmed/19683459, http://www.ncbi.nlm.nih.gov/pubmed/20026950 — these are walking, but I think the pattern holds).

    So we have altered motor control, basically, probably as a contributor to the persistence of the pain. And I think that Greg Lehman’s idea that patients can become sensitized to particular movement patterns makes sense too, and people can’t always easily figure out how to move out of that painful pattern. So if I’m spending time with patients trying to help them discover movement patterns that don’t hurt and are more specific/less generalized (can you push with your legs without lots of bracing of your back/belly/etc?), and my goal is to improve the patient’s skill in moving out of this bracing/painful pattern, what do you think it should be called? Just calling everything exercise doesn’t make sense – we’ve subgrouped forms of exercise based on intent for a long time. Distance running and olympic lifting are both exercise, and both movement, but they have fairly different goals, and are dosed differently. In this case the intent is to change movement skill and awareness. Granted ‘motor control’ is a really broad term, and often used as a replacement term for ‘stabilization training’, but I actually think it’s a decent term for exercise that is an attempt to address the neuroplastic changes in the motor cortex that seem to be a piece of persistent pain.

    • Hi Jay

      Thanks for you comments, and I see what you are saying. But isnt this really symptom modification exercise/movements/tests not motor control.

      My beef is the term control, as in control movement or function, if they were called pain control exercises I think I wouldn’t be as ranty

      • Well, it does boil down to semantics, and I’d say from a step back most of the exercises in a rehab setting generally are about pain control, or at least that’s why the patient is there. But the point I’m making is that if I think a patient has altered/impaired motor control (like I said, the support for that is pretty good, at least for persistent pain and probably for acute pain too), and I’m trying to address that impairment, then why not call it motor control exercise? I’m actually trying to **restore** normal ability to vary movement.

        So, it isn’t the same as what you’re describing motor control exercises as, and you’re probably capturing common clinical practice, but I think we should be trying to remind therapists what good motor control **is**, not abandoning any attempt to influence it. Good motor control is probably just the ability to move with variability, awareness, and specificity. Motor variability training maybe?

        • Yes I guess your right Jay, this is all down to semantics, but I argue the term motor control is confusing and misleading and maybe harmful to many therapists and patients, bit like core ‘stability’

          Lets simplify and use more reasonable terms, like movement variability training or something that describes what we are actually trying to achieve

  7. Hey Adam.
    I´m a Danish PT, so i´m sorry for the poor English 😉
    I like your blog and way of thinking on a lot of subjects. I just finish PT school in june this year, so it´s great to get inspired from different sources and way of thinking compared to what we are taught at school.

    On the issue motor control, I don´t see it as a form of exercise, but as a form of thinking in relation to postural control. I don´t know if you have seen the book “Motor Control” by Anne Shumway-Cook and Marjorie H. Woollacott, but it a book based on research and can help differentiate between different subgroups which all affects postural control. When you have identified, or think you have, you can use to target the needed exercise towards the patients problems.

    Well thats my way of thinking on the term motor control.

    Kind regards from Denmark 😉

  8. What are you referring to when you say, “motor control exercises?” I have an idea in my mind of what those are; however, the way you are discussing the topic, I don’t think were are speaking the same language. Could you give an example of a few exercises you would identify as, “motor control exercises?”

    In regard to your statements under, “variability,” you are completely correct that you cannot recreate a movement the same, even once. Even the highly sophisticated robotics, like a golf swing robot with the same exact settings in a controlled environment, produces slight variances in variability.

    If, “The idea that anyone can tell what is abnormal movement just by looking at a patient do something whilst being observed, in a clinical environment, at that particular moment in time is just absurd,” “there is simply no such thing as a universal standard or ideal movement for all of us,” and, “The only bad movement, is a painful or fearful one,” how can you reasonably say that, “the knee experiencing valgus during certain cutting, twisting or landing actions, these can potentially be harmful if experienced too much or too often.”?

    How do you know there is knee valgosity? Is that normal? If not, to what degree? How can you make that claim if there is no researched standard? If the knee valgosity is non-painful or non-fearful, is it then considered a “good” movement?

    Thanks for stimulating discussion!

    • Hi RJ

      Thats the issue, confusion amongst people when using the term motor control exercises no one knows what they are.

      I have seen the term used for Transverse Abdominus contractions when doing floor based exercises, I have heard it used for Scapula setting, humeral head snugging, for bosu ball wobble board balance work and of course single leg squats

      I also hear it used for things such as running and walking gait re-education.

      And you make a good point regarding knee valgus and I know it sounds conflicting that I say no such things normal one moment and then expect for the next… However there are papers that do show knee valgus during landing and cutting tasks are risky for ACL injuries and groin problems during sport, what is too much and how we can identify it well thats another topic completely and one I am not fully clued up on!

      • Thanks for clarification. If MCE is being used similar to how everyone is throwing around the term “functional,” then I completely agree with you that it’s an issue.

        Though there is no universal standard objectifying ideal movement and everyone does move differently, I do believe that you would ideally want to possess more controlled and balanced loading of joints in movement. For example a knee that tracks over the ankle and under the hip in a squat pattern w/o excessive, uncontrolled coronal and transverse plane deviations (i.e. tibial valgus). Even without research to reference, I think it’s safe to say this hip/knee/ankle stack in a squat pattern is a more “ideal movement” than a glaring tibial valgus moment.

        Gait observation and assessment, much like palpation, is extremely varied across clinicians, but there are some people that are just very good at assessing it visually, translating the info into treatments that get results (or so they say!). On the contrary, there are also clinicians that do these things, believing they see what they see because of bias or because they only know what they are looking for.

        Now it shouldn’t be the foundation of your clinical toolbox, but do you believe in an artistic side of MSK care that is molded by clinical experience? If it works for you even though the evidence may not show it (or not yet), is it still kosher to be rendering such therapies?

  9. Bless you Adam, you’ve made my day (as have the guys on Facebook). Confronted with a student putting the case for motor control exercises for a woman with common or garden “lumbago” (as Mike Stewart would say) and I was faced with a lengthy search around definitions, references, studies and whatnot, and here you go saying just what I thought might be the case. Thank you an awesome amount Adam!

  10. Hi Adam, great blog.
    Agreed that everybody is unique and movement is individual, but with regards to ‘normal movement’, can we not consider that specific exercises have a desired technique? For example, if an individual looks like a sh***ing dog when performing a back squat, but remains pain free and fearless, before adding load and building strength (which I can see you are a BIG advocate for), surely their technique must be improved to avoid loading a poor movement pattern? In this instance do you think that these “motor control” exercises (exercises to improve squat technique e.g with TRX) are useful interventions to improve movement patterns and in turn develop strength?

    • Hi Harry

      Thanks for the great question and making me laugh with the term ‘squatting like a shitting dog’

      I get this question a lot, about the risk and safety of performing loaded exercises such as squats or deadlifts with so called poor posture/position. The classic is doing these movements with too much spinal flexion or posterior pelvic tilt. And yes there is some research that shows shear forces are higher when performing exercises in these positions than compared with ‘correct’ positions.

      My preference would always to do these loaded exercises in ‘optimal’ positions for safety reasons but I am not a stickler for text book correct form. Again individual variation means not all can do text book lifts without pain, me included, my hip and ankle ranges means I have to squat and deadlift with what some would call incorrect ‘shit bag’ technique, many have said so, but I’ve no pains or issues, i can pull and squat 2x my body weight with the best of them, its just not text book, so what, with a graded exposure approach I have avoided any issues by allowing my body to adapt to my technique.

      I also think we need realise and recognise more that many tasks, sports etc cause the spine to experience loads/forces in not so ideal postures and positions, so allowing the body and its tissues to experience this from time to time may be helpful and preventative of injury and pains, may be its the ones who only do text book form and technique movements who are at risk of problems when they have no choice but to look like a shitting dog squatting.

      Cheers again for the laugh

      Adam

  11. Hello!

    Could you give your on Mark Comerford’s “Kinetic Control”-consept? Is it just BS or do you think that these low treshold movements are essential for helping people, who has pain when they’re performing low effort ADL activities?

    • Hi

      Having been on a kinetic control course many years ago I cant comment on them now. I wouldn’t say they were essential principles or exercises then, and I will say I dont use any of their exercises now

      Cheers

      Adam

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