Is Movement Optimism for Movement Morons?

This is a good question – a tad insulting but lets let it slide. Because we should challenge Movement Optimism. But first we need to look at what Movement Optimism is (good old blog here).

Just fan literature on Movement Optimism

Movement optimism started as a rejection of the Kinesiopathological Model. Where the basic tenet of the KPM (link here) is that movements that deviate from neutral or prolonged extreme postures lead to pain or tissue breakdown in the future (e.g you will pay for it later).

This manifests in assessments that look at posture and movement patterns (kinematics/technique or mechanics) and argues that those should be avoided to minimize the risk of injury or pain. Examples would be correcting lower crossed syndrome/gluteal amnesia (blog here) , minimizing spine flexion movement/positions during lifting (blog here), avoiding tendon compression (avoid stretching and wrapping a tendon around its boney insertion during ankle dorsiflexion, hip flexion or hip adduction - article here), minimizing knee valgus/foot pronation during walking, running or squatting.

The basic argument is that overuse injuries occur due to the mechanical fatigue model of injury (See Edwards or Gallagher). This posits that increases in tissue load will exponentially increase the risk of tissue failure. Thus load management is important but if you can decrease the load on tissue 10-15% that could significantly increase the amount of load that people can subsequently adapt to. This theory makes a lot of sense on its surface. I’m getting ahead of myself but hasn’t been borne out with epidemiological research (e.g a longitudinal study showing that people who run with more hip internal rotation (something that might increase the load on the lateral patellar facet) are more likely to develop knee pain).

Adaptability has been the crux of this debate - but its not everything.

One large component of Movement Optimism is that we don’t worry about deviations from neutral or end ROM positions (e.g think of the runner with lots of knee Valugs like Priscah Jeptoo - video link here) because she has adapted to these movement patterns. So, what is most important is load management. Meaning if we get the dosage correct and help people create a healthy ecosystem (sleep, optimism, healthy beliefs, social connection) they are able to thrive and adapt.

Adaptability is Finite - checks on Optimism

However, most Movement Optimists will also recognize that adaptability is finite. I don’t think that everyone can run 100 km per week. I don’t think that I could adapt enough to jump from 5 feet and land in severe knee valgus. I recognize that there is some research (An IG post is here)where anatomical knee Varus alignment might slightly increase ones risk of medial compartment knee OA (knee valgus alignment seems to be a different story). We need to have these discussion on where our Movement Optimism should be checked. Nobody should view things in such absolutes. We need to ask when biomechanics or technique does matter. A follow up blog with try to find examples where mechanics and technique might be relevant for future pain and injury (a potential one could be hamstring strains during sprinting – have look here).

Movement Optimism is not just a belief that the human body is resilient and has an amazing ability to adapt.

That is certainly part of it but that suggests that we believe that certain movements (e.g spine flexion, increase foot pronation) have inherently more stress on tissues that can be injured.

Movement Optimism also recognizes that sometimes Biomechanics challenges Biomechanics.

What do you mean by that?

I mean that human function is pretty complex and we don’t fully understand it. We have very smart biomechanists trying to sort this out. An example is the old research suggesting that deep squats are harmful to your knees because simple biomechanical models suggested that patella loads were higher. Whereas, more recent biomechanical models would show that this isn’t true. Deep squatting is not where loads are greatest so the fatigue model of injury wouldn’t apply.

Another example are those who are worried about shoulder impingement with shoulder flexion and shoulder internal rotation (e.g upright rows). When we look at the acromiohumeral distance (a proxy for shoulder impingement or pinching) we see that the empty can test (i.e shoulder flexion and IR) DOES NOT have a decreased acromiohumeral distance or more “impingement” (link here).

Another contentious example is seen in the spine. Biomechanical models from the 1980s and 1990s suggested that lifting with a spine in greater flexion would increase the shear loads on the spine. This was due to interspinous ligaments being taken out of their neutral zone and creating anterior shear and because with greater spine flexion the muscle action to counteract that shear was less. Again, this assumes that increased shear loads will lead to future injury or degeneration because of cumulative fatigue model.

However, more recent biomechanical models (see here) that have been improved and updated over decades find a different conclusion. (Whether they are superior to the old models us clinicians can not judge. But, at the very least we have to acknowledge that these are leaders in the biomechanics field and they are providing a different narrative. It’s certainly not cut and dry.)

They found that at L5/S1 flexed spine (Kyphotic) postures have less shear and there are essentially no differences on disc strain.

Even if we believe that the body can adapt to wonky postures we can also argue that many “wonky” postures aren’t even problematic in terms of greater loading. Implying that these postures could potentially be ideal and functional for many people.

This leads us to the last piece to ponder.

Movement optimism was not a philosophy looking for research to support it. Rather it was a philosophy that emerged from a large body of research findings - you just had to piece the puzzle together. Many good research studies show the poor links between so called Faulty Movement Patterns and knee pain (Bazett-Jones, Peterson), between lifting technique training and low back injury reduction (one link here although I believe there are more - you can do your own labour :) TBF Caveat - one could argue that the training was poor. That these individuals did not change their technique while lifting as it is often not measured) or between spine kinematics and low back pain (Nic Saraceni’s reviews here and here)

Couple these research findings with simple observations of sport and movement where many people thrive with deviations in posture and technique (Usain Bolt running, Lamarr Gant lifting, Paralympic athletes, massive flexion seen in elite deadlifters, spine flexion being absolutely essential in many sports (My paper in Aspetar), massive knee valgus in skateboarding etc) and you can see that some other philosophy was begging to be born to help reframe and reconcile the good in the KPM model.

Because the KPM model has a lot of good.

It can be excellent at temporarily changing someones movement patterns from sensitive postures to less sensitive ones and then choosing exercises that build people back up to do what they love. You know, calm shit down, build shit back up. 90% of the time I see Squat University videos and think “this is great, I can use this”. I just don’t buy into their philosophy but I see the utility.

If you want a research example of this there are two excellent ones. The originators (link here) of the entire VMO paradigm have recently put forth an editorial that helps reframe their clinical success. Instead of viewing the cause of knee pain to be a dysfunction of lateral patellar tracking and poor VMO firing they have reframed their clinical approach/sucess as one of building up the person and the knee cap to tolerate the demands we place on it. They aren’t fixing VMO timing or realigning the patella they are asking the person to adapt and build tolerance.

In the shoulder (McQuade 2016 link here), there has been a rejection of scapular dyskinesis as a driver of dysfunction but instead of blowing up the scapular bus the authors advocate for what I call comprehensive capacity (link here). Rehab will build a robust shoulder system (get strong, get long, get functional) to help people do what they love.

The future of Movement Optimism - tear it apart

That’s enough. My challenge to Movement Optimists is to now steelman the argument against Movement Optimism. Try to prove it wrong. Try to find out when technique matters for future injury.

Help make the philosophy better.