Why I put strength on dysfunction

A common physical therapy axiom is to not put strength on dysfunction.  The idea behind it can certainly be viewed a number of different ways but I've always interpreted to mean that if someone has pain they just shouldn't ignore it, keep pushing and training hard and they should try to "fix" whatever the underlying cause of the pain is.

In the movement quality world it might mean that if someone has knee pain you should "fix" their breathing patterns, their core "motor control", change movement patterns/kinematics, activate their glutes etc.  Fundamentally, it is the clinical manifestation of regional interdependence.  Meaning if someone moves "poorly" then that poor movement has to be fixed for them to start doing their goal activities (running, strength training etc).

I would argue that for the most part (I recognize there must be exceptions) we don't need to do this.  I'm not saying people should be hammering into pain and ignoring what sensitizes them but I am arguing that we can adapt and what we consider to be flaws in movement can be quite irrelevant to pain.  I'd say that the thing the person most wants to do (e.g. running or strength training) doesn't have to be avoided until they are "fixed" but they can start doing those things immediately.

Let me give a few examples where everyone goes right ahead puts strength on dysfunction

1. Patellofemoral pain syndrome:  by all means you can change someone's gait, you can change how they go upstairs or you can change their squat pattern.  These are all temporary desensitizers that can allow the knee pain to "settledown" but you don't have to do these and they don't have to be done FOREVER.  While doing this you should go right ahead and start loading that knee.  With simple strength exercises both at the site of pain and at a distance (here).  We have plenty of good research showing that simple loading is helpful for knee pain and these effects have nothing to do with changing movement patterns.  Meaning someone can run with a tonne of knee valgus and that knee valgus does not need to be changed to get out of and stay out of pain.  Provided the therapist addressed other factors that lead to sensitization or did treatment that decreased sensitization and improved load tolerance.

2. Tendinopathy:  You better be putting strength on this dysfunction.  We have much more evidence that load management (meaning all of the stressors, bio and psychosocial) is important for treating these conditions than changing movement quality.  If your achilles hurts you load it everyday with strength exercises, you push it hard, you ask it to adapt.  You can keep doing your sport provided you don't "learn" to have more pain but poking the bear too much.  Strength training improves the capacity of the tendon to tolerate load, it functions as an analgesic and keeping the person doing the meaningful activity can also be considered a desensitizer.  We don't catastrophize about movement impairments instead we sell the patient on the fact that the body adapts to stressors.  That pain is normal and doesn't mean damage.  That it would be weird not to have pain.  That we can keep participating with pain and that they will get better as they adapt.  We look for all sensitizers in their life (stress, sleep, emotional health, beliefs about pain) and also consider addressing them.  

3. Even ACL injury prevention:  High load activities where the load on a tissue exceeds the tolerance of that tissue are areas where biomechanics and movement quality matter the most (IMO).  There is a better way to jump off a roof.  But even in these instances where movement technique matters we still have some surprising (to some I guess) research where basic strength is important.  We have some evidence that neuromuscular training can decrease the risk for ACL injury but this doesn't necessarily mean that the movement quality of the participants changed! Shocking.  If we look at the research by Zebis (2015) we see that the kinematics and kinetics related to movement did not change after the intervention.  So, here again we see that an intervention can have an effect that doesn't change the variables we so often think are important yet there is still a positive therapeutic outcome.  Erik Meira writes wonderfully on this

4. Shoulder: Just forget about correcting scapular kinematics.  Totally not necessary.  If the rotator cuff hurts then you train it.  Should you do scapular focused exercises? Of course.  Do we know why they are helpful? Of course not.  Do they consistently change kinematics? Nope. Do they consistently change firing patterns? Nope? Do they have to get a therapeutic effect? Nope.  This is awesome.  You get to just load the painful region locally and a distance.  This is therapeutic.  Maybe do some other stuff too.  I leave that to you.

Now, what about movement patterns?  

Am I saying don't change how someone moves?  No.  It has its place but its simpler than many would have you believe.  If something hurts I would say we have four choices:

1. Avoid it and load the painful region in neutral

2. Modify the movement and keep moving (e.g. change thoracic position for shoulder pain while lifting)  *this would be the approach most consistent with not putting strength on dysfunction.

3. Slowly poke into the movement and ask the person to desensitize (a graded exposure approach taking advantage of habituation called "Edgework")

4. Load the crap out of it and ask the shoulder to adapt (probably most relevant for low sensitivity conditions) 

With the movement modifiers in these cases many would say we should be changing the movement patterns to an "ideal" or better movement quality.  I would argue that we are just doing something different.  We are creating new movement options and that lets the body desensitize.  This would be done in conjunction with other treatments that address the multidimensional nature of sensitivity.  After awhile, you don't even need to do the new movement pattern you can go back to doing the old pattern that was once sensitive and is now not.  This approach is best illustrated in the Cognitive Functional Therapy literature.  Movement habits are changed but they aren't done forever.  Some nice examples are here, here and   The middle reference on rowers is quite interesting.  It shows that pain can be helped and there is no change in the spine movement behaviour during the meaningful task (rowing) even though many might consider it faulty.

Instead of viewing movements as faulty perhaps we should just view them as sensitive

A general theme here is that:

Movement preparation trumps movement quality

I know for certain that there are exceptions to this but in general I view the body as strong, robust and adaptable.  Provided the person prepares slowly and gradually they can adapt to the demands we place on them.
 

In other words, no one has to earn the right to run.  There is rarely, if ever something that needs fixing, to allow someone to start running again.  If you tell them that have poor movement patterns, that their breathing sucks, their mobility is atrocious etc, then perhaps you are setting them up stay sensitive.  Instead, we can look at their training, their lifestyle and all their stressors.  Anything that can sensitize the ecosystem.  Here we simple ask:

"What can make you healthier"?

We respect that adaptation takes time (thus no hammering into pain) but people can start doing the meaningful things without us telling them they need biomechanical "fixing" first.  Again, some of those biomechanical "fixes" can certainly be helpful.  I'm not saying they can't help.  It's just that they aren't always necessary.  Sufficient sometimes? For sure. And they can even be part of the global approach to desensitize the ecosystem.  But, I'm arguing they if you want to do them you can do them in conjunction with the graded exposure approach to meaningful activity.

And then maybe you can make the shift from feeling that you need to fix and instead its more important that we facilitate.