A new website brings opportunities to review content and retrieve some of the more popular blogs! Here is one that raised quite a bit of interest in February 2014….
Movement quality is a subject for great current debate, with some people coming down squarely in support of the maintenance of a neutral joint position, and others decrying this as limiting and unnatural.
Whether either is justifiable depends greatly upon the reasons for the opinion, and can be very much read through the filter of a person’s background and training. There may in fact be a third option which may build a common sense bridge between the two.
Firstly, it is important to decide what “optimal” might mean. Some parties choose to be reductionist about it, choosing to interpret the term as a fixed and non-variable movement strategy. I would venture that optimal instead means the most effective and least stressful solution for the task at hand. I would go further to add that optimal to me means the solution which best manages the forces involved, i.e. creation, control, dispersal and transmission, and which promotes the most effective neuromuscular patterns to that end.
Let us consider that a reasonable clinical or training aim is to expand an individual’s functional window, as explored in one of my previous blogs. The functional window represents how well prepared we are to meet the physical and functional demands upon us, including unexpected events. If our functional window is greater than or equal to our functional demands, all is well. If we are unable to respond or compensate adequately when the functional demands exceed our functional window, we are at risk. We therefore work towards increasing our functional window, otherwise known as building capacity.
This links to some now quite distant work from Panjabi, who described a concept of joint neutral as an arc which remains controllable and physiologically viable, with movement beyond this arc being potentially harmful. A simplified illustration of these scenarios may look like this:
Now let’s add a little something extra. Let’s say a person’s habitual strategy falls somewhere close to the centre of this arc. We will call this the reference point. Should a movement deviate from this centre line, it has a fairly equal range of potential safe motion in each direction.
What if, however, the person’s habitual strategy falls clearly to one side of this arc? Now they have a great deal of flexibility in one direction, but not much in the other. So, as long as any deviation they are called upon to withstand occurs in the direction where they have plenty of capacity, all will be well. If it occurs in the other direction, they are going to need some other compelling ways to compensate in their system.
How do we gain an impression of this with a patient or client?
Movement evaluation has many limitations, but overall gives an impression of the individual’s available strategies. It allows us a glimpse of what is habitual for the individual, especially if a strategy appears consistently across a number of tests. One consistent choice, for example a frontal plane collapse at knee and pelvis, may indicate that their habitual motion is biased towards one side of the functional arc.
When testing, I am interested in what the individual does automatically first, and then what they do with a little coaching. The first condition shows me their natural or habitual response to the task. The second shows me whether they have the capacity to do it another way. The coaching may involve a sensory cue, a redirection of their mind, a boost in their global activation levels, or at the most basic level, a mechanical cue. If the performance changes, I know that the basic capability is present within the system already. Our aim for these people is to help them to reliably access and exploit it into increased capacity. If the performance does not change however, then there is a limitation in the system. Identifying this limitation and addressing it becomes our start point instead.
Movement testing is of questionable value when no distinction is made between habit and capability in programme planning. Giving people programmes to build capability when it already exists is a waste of time. Taking advantage of that capability and expanding it into greater capacity is the goal instead.
People are tested initially under ideal circumstances. They are not fatigued, there is no environmental interference, and the movements are not complex. If they can manage forces effectively at this level, the challenge is increased to find out at what point significant compensations start to occur. Is it range of motion, speed of motion, proprioceptive challenge, distraction, fatigue or dissociation that triggers a significant compensatory strategy? This gives us pointers to where we might need to focus our attention in our programme, enabling greater specificity. We use movement testing to guide or our programme choice in an informed manner, but we can only do so if we have some reference point as a baseline.
An issue arises with movement testing in that it often does not progress beyond its baseline level. This can only give us best case scenario information, which may simply not be enough to create a targeted, individualised programme.
The next problem arises when movement assessment is misinterpreted as solely as right or wrong. It is not so much that the movement is flawed or incorrect, but that the person is only able to express one option, and this, as Moshe Feldenkrais said many years ago, can become a source of repetitive loading. A good mover has many options – they are not trapped in their single strategy. With multiple options, they are better equipped for adaptability and variability.
If an individual’s movement biases fall consistently and repetitively to an extreme in Panjabi’s potential arc of motion, their capacity for adaptability becomes quite narrow. For example, in many runners coming into my clinic with unilateral overload symptoms, the body weight is carried consistently to one side of a centre point. This weight positioning bias alters the potential symmetry of their trunk rotation, as well as the load bearing requirement on foot strike between the two limbs. Consider for a moment a situation where the runner with this issue unexpectedly catches a bump on the road which causes an inversion force on the ankle, as happened to me this past week. I could minimise the effect of this mechanical challenge because my weight was carried fairly centrally. My neuromuscular system was able to fire up to successfully get me quickly off that foot because my weight was not overcommitted over it. No injury was provoked, and I carried on. The runner who carries his or her weight consistently towards the side of the turning ankle has a bigger task to achieve – their weight is far more consistently committed over that ankle, so either they need even quicker reactions, more strength, or if their ability to compensate cannot meet the sudden demand, they may increase their risk of injury. The issue is therefore one of how a person creates capacity – we all have our own set of movement strategies and quirks, but in this case, with the body weight less committed to one side, the degree of physical compensation for that unexpected occurrence is reduced.
Without this understanding of the relationship between positioning and functional capacity, the idea of a centralised spinal position becomes a mindless rule.
The research on topics such as jump landings, knee injury and medial tibial stress demonstrate that certain key factors, such as decreased sagittal absorption in the knees, increased valgus positioning of the knees, and increased coronal plane motion in the trunk correlate to injury risk, and that programmes designed to train athletes’ landing mechanics can affect injury rate. These studies indicate that there is a movement strategy that is more optimal for handling vertical forces than others. This strategy represents the central reference point for this movement. Any athlete needing to land from a jump will have to handle potential deviations from this point due to individual and environmental fluctuations. The central reference point must therefore be challenged in a programme by adding a variety of neuromuscular challenges in order to build capability in both directions of the arc.
We are not therefore fixing ourselves in a single theoretically ideal movement, but establishing a foundation from which to progress. In achieving the capacity for a movement where forces are handled most effectively, we must then apply the 3 V’s, variety, variation and variability, to push them to either side of this baseline. The individual must have the available mobility to accommodate the deviation, and also the neuromuscular responses to successfully manage the loads imposed.
In doing this, we are not seeking to limit functional variability but to increase it. Variability studies indicate that high coordination variability, seen when learning a new motor task or as is evident in ACL non-copers, has a detrimental effect on performance. However, as coordination variability decreases, the chance of functional variability increases, bringing with it an increased flexibility to deal with perturbations and environmental fluctuations. Functional variability has also been theorised to be a normal mechanism for reducing focal repetitive loading on specific body structures. Early aims in a programme may then be to reduce coordination variability to create a foundation from which functional variability can evolve.
The common error is in trying to achieve functional variability without first having overcome coordination variability.
As a mini case example, let’s consider an adolescent girl who presented to me with bilateral medial knee symptoms. She plays a multidirectional sport but had been stopped by increasing pain. In gait, in sitting and in standing her hips internally rotate, her knees moved deeply into a valgus position and her feet rolled onto their inner borders. In any loaded position, the focal point for vertical forces is her medial knee.
What steps did we include in her management?
After the customary orthopaedic evaluation, which demonstrated no frank pathology nor any relevant restrictions, we:
1. addressed her generally hypotonic presentation with sensory input and simple activation tasks to achieve an effective start point.
2. helped her to make a sensory connection between foot, knee and hip
3. gave her a reference point to work to in order to enable independence and confidence in home exercise (the controversial neutral position, which was simply the position which created least stress on her structures and best management of vertical force)
3. progressed the new neuromuscular patterns through manipulation of load or skill
4. diversified the pattern to become adaptable and able to accommodate variability within acceptable ranges.
Result: a pain free, happy teenager able to return fully to sport.
Note that we did not start at the currently fashionable stage 4 – we set the foundations in place and gave her body a sense of a central reference point from which positional deviations were no longer so stressful on her medial knee structures.
Optimal movement and performance
From a coach’s point of view, optimal movement and technique are interchangeable terms. Specific coordinated body positioning relationships are involved to express and control force in technical sport. There is some flexibility involved depending upon an individual’s body dimensions and other physical features in how they achieve these relationships, but nevertheless at the moment of force production, certain body positioning relationships appear to be more effective in generating and directing force, as is evident in the body of work produced by those in the field of biomechanics. Dropping the hips in swimming, long ground contact times in running, and poorly timed coordination of the moving thorax over the pelvis in baseball pitching would be examples of detrimental movement issues from different sports. In this sense, some movement is functionally more optimal.
Establishing and maintaining a central longitudinal axis for example is a critical feature in top performers in many sports, such as hammer throw, discus and swimming (whole body rotation around an axis), running and cross country skiing (counter rotation around the axis) and tennis (spiral elastic rotation around an axis). This is therefore a productive position to achieve and learn to use as a reference point for the type of motion required in the task.
For the athlete below, the window for error is extremely small. I must ensure that she has optimal joint range, symmetrical timing and coordination throughout the kinetic chain, and strength from outer to inner range in her lower body to ensure that she can achieve the position which most effectively withstands high vertical loading. Although variability is still present, her goal is to minimise it as much as possible. There is an optimal movement to be aimed for here in order to exert and withstand such high force safely.
Of course, to a point in various activities, if you are able to compensate for less proficient technique through an extraordinary cardiovascular system, greater strength, superior reflexes or any number of other possibilities, you may be able to succeed until you hit your limit in exploiting these factors, or decide to increase training volume or loading beyond your capacity.
It is incredibly fashionable particularly amongst clinical practitioners to criticise any form of movement education discussing a theoretical neutral position. This exhibits poor understanding of how the concept can be constructively used to enable people of many backgrounds and stages of development to gain some sort of baseline through which they can understand what they see and feel. It also misses the point that technique, in very many functions, influences performance, and that aiming for precision is far from counterproductive as long as capacity to cope with deviations is developed. From an educator’s perspective, some basic guidelines for how and what to see speeds along the learning and increases confidence.
Rejecting all forms of movement guideline is not helpful. Explaining instead that certain positions represent a reference point from which movement can be interpreted, both in assessment and in training, gives people a flexible way to understand and develop their explorations in movement with confidence.
I would encourage that we don’t keep throwing the baby out with the bathwater every time a new idea comes along. Instead of using new research to automatically reject preceding concepts, maybe we should ask what new insight this new information sheds upon them. Sometimes they invite us to reframe and modify our understanding of current practises. This requires that we demonstrate the same adaptability in our thinking that we aim for in our clients or patient’s bodies.
Finally, I would submit that the issue is not one of whether we train “neutral” or not – it is whether this is used as a mindless rule without understanding its role and how it must then be challenged. Neither is it a case of just training in lots of ways without attention to movement quality, because many of the people we see simply don’t have any form of movement reference point to build from. The third option is understanding that there may be a continuum of motor learning which occurs from one point to another through intelligent progression.
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