That’s​ not how it works…

Recently I have seen a resurgence of the ‘don’t load a dysfunction’ message being promoted by some influential social media therapists (see the images below) and it frustrates and annoys the hell out of me. I know my mate Greg Lehman has talked about this a few years ago here, but unfortunately, this message still continues to be endorsed by many today. So I want to add my thoughts to this debate and explain why I think this message is not helpful for therapists or patients.

The main issue I have with these messages is that it promotes a false belief that we as healthcare professionals know and agree on what is, and what isn’t ‘dysfunctional’ movement. We don’t. When it comes to assessing movement, as the saying goes “beauty is in the eye of the beholder” meaning what looks ugly and problematic in the eyes of one person can look perfectly acceptable to another.

The notion that us so-called movement experts can tell what is good or bad, normal or abnormal, functional or dysfunctional movement just by looking and observing people is utter nonsense. This overly simplistic and reductionist way of thinking about human movement needs to be questioned and challenged.

To put this as simply and clearly as I can… ALL human movement is highly variable from individual to individual due to many factors. And despite common assumptions, we have very little idea of what is good/bad, normal/abnormal, functional or dysfunctional.

Human movement is a highly complex dynamical system that is influenced by many things such as, but not limited too, an individual’s anthropometric factors, the task they are doing, and the environment they are doing it in.

The Individual 

When assessing movement we need to recognise that not all of us are built the same and therefore we will not all move the same. Variations in skeletal geometry such as bone length and angulation will affect how a joint moves. For example, femoral length and shape, as well as pelvic geometry will, among other factors, affect how an individual can squat (ref, ref).

Just because some functional range conditioning guru with a touch of hypermobility can fold up like a cheap piece of furniture when they squat don’t think you will ever be able to if your bony geometry won’t allow it!

It’s no different in other areas such as the shoulder girdle, just because some supple leopard can reach up between their shoulder blades and scratch the back of their own fillings, don’t think you will ever be able to if your gleno-humeral bony geometry won’t allow it (ref, ref).

It is important to recognise that what may look like a ‘dysfunctional’ movement could be due to non-modifiable skeletal factors. This is very hard to determine clinically without detailed, expensive, and unnecessary scanning and imaging, but it should always be considered none the less.

Now, of course, soft tissues will also influence how a joint moves and these can be modifiable over time with training, but we can’t forget or ignore the non-modifiable factors as well. Unfortunately, many of the movement gurus do forget or ignore these, and so get their so-called ‘dysfunctional’ patients to work on things they will never be able to achieve, which is clearly not helpful and possibly even detrimental as patients get frustrated and disheartened by their lack of progress.

The Task

Human movement is also affected by the task being done, and again this tends to be ignored or forgotten but the movement gurus. For example, how an individual bends over to pick up a box of tissues of the floor will be vastly different from how they bend over to pick up a heavy object from the floor.

Having someone move the same way regardless of the task is simply batshit crazy, yet often promoted by the movement gurus. You just do not need to bend over the same way to pick up a box of tissues as you would if you were about to deadlift twice your body weight. You also do not need to concentrate on setting your scapulae before you reach into the cupboard for some chocolate biscuits, you also do not need to keep your knee in alignment when walking up and down some stairs, etc etc, ad infinitum.

However, the advocates of ‘functional’ movement tend to promote that everyone needs to keep their movements perfectly correct and aligned for everything and anything. Rather than helping this message can actually make many people hypervigilant and focused on small, tiny, innocuous things that are just not important or an issue, and tends to detract away from the things that are.

Movement variation is actually something we as physios don’t get taught much about, or feel comfortable with, or rarely promote to our patients. This is a shame. Movement variation, within reason and depending on the task and loads is far more useful in most circumstances than movement restriction and correction (ref, ref).

However, this is NOT to say that we should NEVER give our patient’s any movement constraints or guidance and we can let them move around like headless chickens all the time. In some situations, in some circumstances, it can be very helpful to advise a patient how they can move more ‘efficiently’ or ‘safer’ during some tasks such as when moving heavy loads or doing repetitive tasks.

Although, even here some of our common assumptions are being challenged, with some studies in occupational manual handling showing that our postural alignment and lifting advice may not be as helpful as we first thought. (ref, ref, ref, ref)

The Environment

Finally, we also need to consider the environment and the observer principle as confounding factors when we assess an individuals movement. As clinicians, we often assess people move in controlled, constrained, and ultimately false environments. Therefore any of the so-called movement dysfunctions we may or may not see, may or may not occur in another setting or environment. We need to recognise that just the effect of observing a subject move will affect how they move.

For example, how normally do you think a patient will be moving when being scrutinised in a cubicle, or gym when they are half undressed and feeling a little anxious or nervous? Do you think you will see the same movement strategies used when a patient is asked to perform drop landing off a box in a gym, compared to when they are on a cold wet pitch trying to head ball whilst dodging an opposing player?

As for everything we do and see context matters!

It’s not that simple!

As you can see, how someone moves is based on many factors and so it needs to be recognised that what we may think are abnormal or dysfunctional movements or positions may actually be normal due to structure, the task, or the environment.

We also need to recognise that the evidence tells us that many of the so-called movement or postural ‘dysfunctions’ we see in people with pain and disability are often seen in those WITHOUT any pain or disability. Things such as lumbar spine lordosis, thoracic kyphosis, scapula dyskinesis, knee valgus, femoral head deformities,

What we often think are movement ‘abnormalities’ or ‘dysfunctions’ may actually be optimisation strategies in the presence of pain, fear, or a lack of tolerance and capacity. Personally, I think this is the bigger issue, and this is what we should be focusing on more.

Often it’s not the movement that needs to be corrected, its the lack of tolerance to the movement that does.

This is why I often load so-called ‘dysfunctional’ movements. I have come to realise that if I focus more on increasing an individuals tolerance to a painful, ugly looking, so-called ‘dysfunctional’ movement often the individual self-organises and what was a painful, ugly, ‘dysfunctional’ movement soon isn’t anymore.

However, I have found that the ‘ugliness’ of the movement sometimes does not change, but I don’t really care. As I said at the beginning ‘beauty is in the eye of the beholder’ and who am I to say what is an ugly movement or not. As far as I am concerned these days you can have the ugliest looking biomechanics as long as you have the capacity, both physically and psychologically, to tolerate them!

Summary 

So that’s my two cents on why I load so-called ‘dysfunctional’ movements and why I disagree with many of the social media functional movement gurus on this topic.

First, we have little idea or evidence to say what is and what isn’t dysfunctional movement. Next, despite the gurus before and after pictures we often don’t see movement or postures change significantly, and if they do, they don’t last. And finally labelling people dysfunctional just isn’t helpful. Asking patients to try and achieve some so-called ideal alignment or movement strategy is often unattainable, unrealistic, and often becomes detrimental as they start to feel demoralised, frustrated, and hypervigilant.

For me, the most functional movement anyone can do is one you don’t have to think or worry about.

As always thanks for reading

Adam

9 thoughts on “That’s​ not how it works…

  1. Hi Adam, interesting post as always. Whilst I agree with the majority of what you have said, I think that it’s worth making reference to the population that you are working with. The majority of the ‘movement guru’s’ on social media are working with an athletic population, seeking movement efficiency/performance/optimal biomechanics. Therefore their content should not be taken out of context and applied to an average joe with no desire to AMRAP a deadlift at 2 x their bodyweight. I think that some of their messages are important, for example, how many physiotherapists in the U.K. are coaching (and loading) a hip hinge pattern properly? Not specifically to pick up a tissue, but a heavy toddler maybe if that is their LBP trigger.

    I think that it’s great that more physio’s are talking about coaching/cueing/movement, just need to make sure that clinical reasoning is applied and the individual is taken into consideration.

    All the best.

    be taken in to context with the

    • Hi Harry, thanks for the comment! To be honest I dont think it matters who you are working with, the rules of assessing movement that I mention still apply regardless if your a couch potato or an olympian. Movement is a dynamical system and we can not say what is good or bad due to so many variables and confounders! Thats my point. Cheers Adam

  2. Couldn’t agree more! I always find it interesting that when you improve someone’s strength/endurance the “dysfunction” either improves or the pain disappears.Begs the question “should you correct a ‘dysfunction’ in the absence of any pathology …… my answer to this would be No – leave it alone. They’ve probably loaded their body with that pattern since being a toddler.

  3. “the presence of pain, fear, or a lack of tolerance and capacity.” are surely why movement patterns are important. Anyone can see if somebody has a limp, without having to be a Guru, does that mean you would load up a heavy squat, or deadlift for that person without understanding the reasons behind their limp? If someone is in pain, you would load that pain to make it disappear? Most people when they watch for arguments sake, athletics, can without being a physio, or Pt, tell if someone is moving well. They might not be able to tell you why, or how, but they can identify good or bad movement. I agree don’t fix what’s not broken. If any movement is acceptable, why are you assessing movement? Why not just count reps?

  4. Hi Adam…

    Nice reading, thanks for sharing you thoughts….  
    I definitely share many of the thoughts about “dysfunctional movements” you present here.. ..

    Though – I don’t agree completely with this;

    “What we often think are movement ‘abnormalities’ or ‘dysfunctions’ may actually be optimisation strategies in the presence of pain, fear, or a lack of tolerance and capacity. Personally, I think this is the bigger issue, and this is what we should be focusing on more”….

    Maybe sensations and emotions like pain and fear do have the potential to influence movement behavior/strategies in an non-optimal manner. At least sometimes..? If these factors influences movement strategies negatively, it seems (to me) reasonable to focus on this as part of a “multidimensional, BPS intervention” like P. O’Sullivan et al (2018) in this text about Cognitive Functional Therapy; https://www.ncbi.nlm.nih.gov/pubmed/29669082

    Fx;
    “Exposure with control is a process of behavioral change through experiential learning, in which sympathetic responses and safety behaviors that manifest during painful, feared, or avoided functional tasks are explicitly targeted and controlled”.

    Maybe things aren’t so black and white – but more greyish..
    Maybe this is what we should be focusing on more….?

    Well, just a thought.
    Again, thanks for the post.
    Regards
    Jeppe

  5. I recently left a professional sports environment where the desire was for the ‘perfect / optimal functional movement pattern’ as determined by specific non-modified tests regardless of size or shape. I think that after 10 years of testing they’re still searching!
    Now i find myself in a kind of occupational role at a factory – they too teach one movement pattern for all lifting tasks, reinforced by hundreds of reminder posters on walls so not to be forgotten.
    Both environments – young, fit, healthy, v older, deconditioned, sedentary – have a high percentage of back pain patients.
    I fought and lost against the S&C ‘experts’ now running all sports but slowly changing opinions here in the real world – we are what we train – unrealistic demands of perfection causing break down, or years of heavy manual work that demands some compensatory adjustments.
    So, yes, I agree – load what you have, it’s capacity to perform that matters.

    Always a good read Adam

  6. I fully concur with your comment. We have a similar problem in neurorehabilitation where a generation of physios has been trained to re-educate “abnormal movement patterns” and discouraging any form of compensation (e.g., abnormal synergy). The problem with this approach is that we are throwing the baby with the water, as compensations, are often a major contributing factor to achieve functional goals in patients (e.g, post-stroke; see a recent review by Jones 2017). Sometimes, we (as physios) behave as we know better than the CNS how to achieve motor goals, to paraphrase an excellent opinion paper By Anson and Latash (1996, a must-read for anyone interested in the problematic of “normality” in motor control). We should be a bit more humble and accept the notion that variability is not a nuisance but an essential characteristic of motor behaviours.

    Ref.
    Jones TA (2017) Motor compensation and its effects on neural reorganization after stroke. Nat Rev Neurosci 18:267-280 doi: 10.1038/nrn.2017.26
    Latash, M. L., & Anson, J. G. (1996). What are “normal movements” in atypical populations?. Behavioral and brain sciences, 19(1), 55-68.

    • Hi Francois… many thanks for that earlier paper of Latash’s… I missed that and what a fantastic read. It is however disheartening to see he wrote that nearly 20 years ago and not much has changed in the world of physiotherapy thinking and movement. Will it ever???

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