Do you even motor control…

I’m hearing more and more therapists talking about ‘motor control’ exercises recently and how they think these help patients with pains and problems. Now I am not a fan of these kind of exercises, finding them over complicated, under dosed, and generally a waste of time. However, these exercises do seem to help people but often not for the reasons many think. I often hear therapists explain that these exercises help by improving or enhancing ‘normal’ coordinated and controlled movement, by improving muscle co-ordination, timing, and actions. But is this correct?

Well this sounds plausible, reasonable, and even sensible. We often see patients with awkward, restricted movement so it would seem wise to address this with motor control exercises. However, its not this simple and I really hoped we had moved away from using this kind of language and this kind of thinking when dealing with the wonderfully diverse and delightfully unpredictable human being, especially when in pain or distress.

Cause or consequence?

The first thing to consider is are these awkward, restricted movements in patients a cause of, or a consequence of pain, injury, fear, lack of strength, or even experience? In my experience people tend to move awkwardly because of their pain, fear, lack of strength, capacity, or experience. Therefore, in my opinion and experience if you address these things movement control, skill, and efficiency tend to improve on their own!
However, there is research that shows an increase risk of injury in those with so called movement abnormalities. For example excessive knee valgus and hip abduction with ACL injury or Patello Femoral Pain Syndrome (here), and loss of shoulder internal rotation and injuries in throwers (here).
But although these movement abnormalities have been found as risk ‘factors’ for injury, they are not sufficient to cause injury alone. There are many, many other factors that also contribute to injury that conveniently seem to be forgotten or ignored by the motor control exercise advocates and guru’s. For example, things like weather conditions, playing surfaces, foot wear, player fatigue, or state of mind are just some of the myriad of factors that also contribute to injury risk.
Yet despite these other factors I still hear motor control exercises being hailed as the wonder cure for many issues and problems, and unfortunately they are now being bastardised by many therapists to justify some absurd claims!

What does it mean?

Even the term ‘motor control exercise’ is confusing to me, just what the hell does it even mean? When I look to the literature for guidance even that doesn’t clear it up, with many confusing differing definitions and terms.
The best definition I can find for motor control is “An area of science exploring how the central nervous system produces purposeful, coordinated movements in its interactions with the rest of the body and with the environment.”
So has that clears anything up then! Well not really, because when I asked on Twitter what some people thought ‘motor control exercises’ meant to them I got some very varied, diverse and amusing reply’s such as…

A learnt movement or skill that can be performed with and without conscious effort : Sam Blanchard
Driving a car without crashing #MotorControl : John Doyle
Anything except motor out-of-control exercises : Diane Jacobs
Waking up a sloppy, lazy central nervous system that pain has inhibited: LegendPhysio
Its just a movement/exercise, with an emphasis on control and quality? : ChopperFizz
When you can’t move or change it as you wish, that can mean you have “poor motor control” Daniel Atkinson
Control = constraint and reduction of redundant DOF. I like abundance and increasing options. : Ben Cormack
Motor control = taking the smallest muscle involved and training it at 10% of MVC with every effort to turn off everything else with the view that this muscle is inordinantly important : Dr Anthony Shield

So you can see that even healthcare professionals have different ideas and understanding of the term motor control exercises, now imagine how confusing it is for the poor patients when we use these terms.
In my opinion, many therapists like to use terms like motor control exercises just to sound a little bit more sciencey and a little bit cleverer due to their own inadequacies. These terms mean nothing to patients and most sensible healthcare professionals and are just confusing gobbledegook.
Also can anyone tell me when an exercise is NOT a motor control exercise? If we are going to insist on being all clever, sciencey and shit shouldn’t we actually call all exercises Neuromuscular Proprioceptive Cognitive Functional Motor Control Exercises!

Stop it!

Unfortunately, these kind of bewildering and nonsensical terms do exist, but I beg you, can we please just stop it. Can we please just call all these types of exercises what they are… EXERCISES… Nothing more, nothing less. Adding confusing, conflicting, overly technical terms to exercises does nothing other than confuse patients, professionals, and me, and this causes a lot of miscommunication and misunderstanding.
Whatever your goal is with any exercise we should remember they are all just different ways to move, nothing more, nothing less. Why we choose an exercise for a patient should be based on many different reasons, such as do they need to do it to improve strengthen, endurance, speed, power, fear, threat, stress, anxiety, and of course co-ordination.
However, taking all these factors into account, we should remember that the most important factor that will influence which exercise you choose for a patient, is finding one that is suited to the individual in front of you, not based on your own beliefs or preferences, but on the patients ability and their beliefs and preferences and of course their goal.
So if you are choosing an exercise to make a movement more ‘normal’ for a patient based on your preferences, and that patient doesn’t feel normal doing it, then you are missing a fundamental rule of exercise prescription.
Basing the choice of exercise on what YOU think is normal for someone else is nothing more than guess work or may be from some research you have read, that has been incorrectly extrapolated, over promoted and over hyped by some movement guru.
Basically, we have very little idea how any one should move, normal movement is based on the individual, the task, and the enviorment, and there is no way to control for all of these variables.
The only way to know what is ‘normal’ movement for a patient is to ask them if it feels normal, that is to ask them if it feel painless, fearless, thoughtless and effortless for them.

Core stability crap!

This recent rise in the motor control exercise fad also appears to be an opportunity to rebrand the ‘core stability’ craze that infested our society and profession hugely years ago. This is when we got carried away teaching and telling people how to maintain ‘better posture’ and to isolate their deep abdominals, neck flexors or some other fancy sounding muscles, and do lots of small, irrelevant, low load exercises and movements in a belief this will help their aches and pains.
I think most of us are now aware that there is no superior effect of these types of exercise over any other type here. In fact core stability exercises most likely have made many worse by encouraging and promoting maladaptive protective muscular responses long after any back injury or issue should have resolved, and may have caused many to experience persistent pain unnecessarily.
I would argue that many of these motor control exercises currently be used also cause unwanted side effects, usually due to explanations that therapists give to patients as to why they need to do them. They often give patients the false and misleading idea that they should be looking to constrain movement towards a perceived ideal that in fact doesn’t exist.

We are all unique, we are all individual, so the way we move is unique and individual too, and despite many claims, there is little evidence that one type of movement is more normal than another, or that a clinician can tell what is or isn’t normal, and there is even less evidence that one movement is more risky or causes more problems than another.
The only bad movement, is a painful or fearful one.

Movement variability isn’t evil!

The belief that we should teach people to move the same way time and time again is just ridiculous. Variability in movement is fundamental for a number of reasons. First it distributes forces evenly and widely around the body (ref). The next is that we never, ever move the same way twice in normal everyday activities, so why do we think we should do this when we are injured or in pain?Variability in movement is good, its healthy, and its normal. The idea that anyone can tell what is abnormal just by looking at a patient do something whilst being observed, in a clinical environment, at that particular moment is just absurd.
Motor control exercises are often aimed to rehearse the same movement the same way, time and time again, in a belief that this is helpful, but there is little evidence that they are any more effective than any other method of exercise to reduce pain or risk of injury (ref, ref, ref)
There are some studies that do show motor control exercises maybe superior than general exercise (ref), but it does seem that those patients who get best results with motor control exercises are patients that believe, or have been lead to believe, that these exercises are best for them (ref). This highlights how important patients beliefs are to succesful outcomes of any intervention and not just the intervention itself.
However, there are times I do think ‘control’ of movement is a good idea, but its fairly common sense stuff. For example, when the body is under extreme loads or or experiencing high forces. In these situations I do think some element of ‘control’ is needed, but to improve the control of these activities they need to be rehearsing these activities, not doing silly isolated, low load motor control exercises.
So there you go, another Meakins rant against some long established thinking and practices within therapy and rehab. I hope the next time someone mentions motor control exercises, you will ask them what they mean by that term, and what the purpose of them is. I will leave you with the wise words of the late great Louis Gifford to ponder about the control of movement…

The notion of ‘bad’ movement is a danger to the spontaneity of our very exisitence

As always thanks for reading
Adam