The wedge that divides: movement optimism versus the kinesiopathological model

The Kinesiopathological Model or the “Movement Quality” model might be viewed as the opposite of the biopsychosocial model of pain and injury. But I would say like most debates this ends up being a false dichotomy. I’m of the opinion that most agree that the biopsychosocial (BPS) model is relevant for pain and injury AND most therapists would also agree that biology/biomechanics are sometimes relevant for people in pain. But the true debate might fall into two related areas where people will fall somewhere on a spectrum:

  1. How relevant are each of the components of the BPS to a person/population.

  2. We all can believe biomechanics are important but we can disagree on how they are important (aka. You’ve rebuked the KPM model because you often don’t care about poor spinal hygiene, knee valgus etc).

It is the second spectrum that I wanted to delve into because I actually think this is where most of the debate is in our profession. The first debate is a bit of red herring. What usually happens is that someone challenges another clinician’s view of the KPM model or the relevance of “movement quality” and then that person is subsequently tarred and feathered as just a “psychosocialist” who doesn’t think biomechanics matters. When in fact, that person might just view the utility of mechanics in a different way than you.

For me, the debate is not whether biomechanics matters it is HOW, WHEN and WHY it matters.

Movement Optimism versus “You are going to pay for it later”

I am huge critic of the Kinesiopathological Model of pain and injury. At its simplest, the KPM suggests that there is an ideal way to move with corresponding ideal postures, muscle activation profiles, joint stiffness etc.. Deviations from these postures/movement patterns are proposed to cause pain, injury and even future “wear and tear”. It is very much a structural view of the body that argues for proper alignment. It manifests itself in the “Movement Quality” approach to life. Arguing for trying to keep a neutral spine during lifting, lifting and lounging (can’t do it, but see the article here), correcting hip adduction during gait, squatting and jumping or finding and addressing scapular dyskinesis. The alternative to the KPM has not been codified and is not a monolith but they are examples out there. They aren’t the PsychoSocialists. Rather, they are the Movement Optimists. OK, I know that is unfair because now it makes proponents of the KPM look like movement pessimists and that sounds bad but I do believe that this is the crux of the debate.

What is the Movement Optimism Approach?

I’ve written about this before in terms of Symptom Modification. Paper in JOSPT here. You can also see it in a Twitter Moment here about finding the good (or the Active Ingredient) in the KPM. Or you can see it in practice for the shoulder here. The most well researched approach that I know of would be the Cognitive Functional Therapy approach. Those of us who practice like this still change movement patterns, still advocate exercise, still advocate changes in posture, develop biomotor abilities, challenge our patients to resume meaningful and physical activities and don’t ignore the physical. We aren’t afraid of pain (when it is understood) and know that sometimes doing painful movements can be helpful. We also know that sometimes avoidance of painful movement (by changing how people move or managing all loads) is appropriate as well. In other words, we work on mechanics. But our clinical decisions aren’t driven by the philosophy of the kinesiopathological model. We will let people flex their spine, we might encourage training into knee valgus, or lifting an arm with the shoulder elevated or even have a runner switch to rear foot strike.

In essence, we don’t think joints have to stay in neutral to be healthy - or if we advocate for neutral its under certain conditions. We don’t think the KPM model should drive our clinical decision making. Our clinical decision making might be driven by symptom modification, ease of movement, the demands of someone’s goal tasks or the belief that people have this amazing ability to adapt and thrive.

And it is the last point where I think pinpoints where people fall on this spectrum of Movement Optimism and the KPM. I am going to create a dichotomy here where I would argue your view on Movement Quality importance is inversely related to confidence in the ability of people to adapt:

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Finally, you think. I’ve gotten to my point. Reasonable people see the same research and the same clinical populations but make different decisions. I think it comes down to our inherent views on how adaptable someone is.

A movement optimist might see someone with knee valgus and think “that’s fantastic, they are probably great at rock climbing and playing goalie in hockey” then you’ve made the assumption that that person is fine and safe and will not pay for it later. You might even be familiar with some of the research that argues that hip internal rotation can increase the loads on the lateral patellar facet by 30-70%. But then you also think “big deal. Load is what causes me to adapt. Load is good. Load is the catalyst for mechanotransduction and how I get jacked”!

Or as a KPM adherent you might see someone with a slouched spine and think “oh no, that’s some sloppy spinal hygiene. The discs will slowly delaminate over time, the nuclear material will push its way to the back and although they don’t have pain now they will have pain in the future. If they couple that posture with heavier loads and have a thicker spine and a certain disc shape they will be predisposed to disc damage. I know plenty of people can have disc damage and not have pain but we have cadaveric and modelling study evidence that these postures put increased stress on that portion of the disc. It might be worthwhile to teach this person to avoid those positions because there could be a potential for injury and possibly pain”

A movement optimist might be aware of the same research but diverge in how they view it and act on it in two potential ways:

1. Posture/loads might actually stimulate a disc to adapt in a positive way

2. Even if those postures/loads negatively influence a disc that change in the disc may have a poor relationship to pain. More on that here

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Again, the crux of this comes down to your view on adaptability. If you lean towards viewing a person as having a massive reserve on how they can adapt then you will probably fall on the end of the spectrum where Movement Optimism reigns. If you view the person as having a finite and a smaller capacity to adapt then you might fall somewhere towards a more extreme KPM or Movement Quality approach.

I would argue that we have such differences in opinion because we are now at the limits of our knowledge. We actually don’t know how well we adapt. We don’t know how well an individual will adapt because that adaptability is driven by a numerous factors (here is where the Biopsychosocial becomes extremely relevant). If we knew better how an alive disc with a responsive nervous system truly adapted to flexed postures and loads we probably have fewer disagreements on how people should move.

Last, there is also another viewpoint here.

Rebuking the KPM from within: When Biomechanics challenges Biomechanics

I often say that it is not “pain science” that challenges the tenets of the KPM but biomechanics itself. One way we see this is that a lot biomechanical research is conflicting and proposed biomechanical risk factors for injury/pain aren’t regularly supported. But there is another way to also look at this. You could be a “hard core” biomedical dude/dudette, consider loads and postures to be very important for pain/injury but still disagree with the common views espoused in the KPM model.

Spinal flexion is a perfect example. Somehow and some point in time the dominant view became that the spine is safest when the loads applied to it are experienced while the spine stays within the neutral zone. 30-40 years ago there was a raging “stoop versus squat” debate but in the biomechanical world that debate seems to have fizzled. But it probably shouldn’t. 20 years ago we had superb biomechanical researchers like Patricia Dolan arguing that the safest position for the spine to tolerate loads is somewhere between 50-80% of MAX FLEXION. Hell, they even won an award for this work. Here we have biomechanists, using sound biomechanical arguments for a flexed spine.

Or where a flexed lifting posture leads to decreased anterior shear loads on the spine versus a weightlifters squat that had less flexion and more shear. Link to the Kingma paper here

We also see this in debates around achilles tendinopathy rehabilitation. Somehow, compressive loading caused by dorsiflexion has been an accepted biomechanical bogeyman, yet you will see biomechanically minded clinician researchers like Geoffrey Verral advocating for not only heavy loading but static stretching of a tendon as part of rehabilitation (a combination that would produce high levels of compression).

Or we might see this in knee pain/injury prevention and treatment. Clinicians might suggest that movement quality is a distraction in that we might be focusing on the wrong biomechanical parameter. We see this in the argument maximize leg extension strength as opposed hip adduction minimization. Take a look at Erik Meira’s numerous posts on this topic

Crudely, the Movement Optimism approach might concede (although not always) that loads on certain tissues is higher in positions consider to be of “poor movement quality” but we aren’t too concerned because of our respect for adaptability. But this alternative view doesn’t even acknowledge that. It suggests that in some people “poor movement quality” might actually be good movement quality and could even lead to lower or better loads on the person. And this ultimately is now a debate for the biomechanists.

Concluding Remarks

When you are a movement optimist its not that you think biomechanics are irrelevant. Its that you have different view of biomechanics and what they mean for the person who is injured or in pain. Rebuking the traditional Kinesiopathological Model does not mean you rebuke all mechanical interventions. Its just that we disagree with your interpretation of when and how mechanics are relevant.

Greg Lehman