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Starting Off on the Wrong Foot

 

In last month’s blog, the topic was pelvic control—one of the two primary differences between static and dynamic integration philosophies. This month we’ll address the second characteristic of dynamic integrated movement, which features another major divergence from static practices. We’ll talk about how the limbs (arms, legs and head especially) ‘should’ move relative to the trunk, or how distal parts ‘should’ move relative to proximal parts.

 

The early history of rehabilitative exercise was characterized by ‘isolate and localize’ thinking (Isolate vs Integrate blog May 2020). This inaccurate vision of human movement was likely created by the way we learned anatomy, where ‘origin and insertion’ language short-circuited a more realistic assessment of, and a more dynamic vision of, how people actually move.

 

Origin & Insertion Thinking

 

When learning our anatomy ABC’s, we described movement relationally. ‘This moves relative to that’ is common to all three movement visions—isolate/localize, static integration and dynamic integration.

• • In our ‘isolate and localize’ days, we were either unaware of limb to trunk relationships or took proximal stabilization in the presence of limb movement for granted. Assumed stability.

• • • Supine, prone and side lie straight leg raises—the leg/insertion moves relative to an unconsciously immobile pelvis/origin.
    • Glenohumeral internal and external rotation with theraband, bicep curls—the arm/insertion moves relative to an unconsciously immobile thorax/insertion.
    • Cervical ROM exercises or static isometric strengthening—neck moves/thorax ‘shouldn’t’.

 

• • We are now in our ‘static integration’ phase, where we are (somewhat) aware of limb to trunk relationships, and where we are actively encouraging deliberate stabilization of the proximal part. Intentional or trained stability.

• • • We now know that the pelvis ‘would’ move when you lift a leg (as above) so we now train our charges to be intentionallystabile. Same origin and insertion thought process as ‘localize and isolate. Same abdominal muscle control of the pelvis as ‘localize and isolate’.

 

• • We now know (or should know) that the scapula ‘would’ be dragged into anterior tilt and the thorax ‘would’ be pulled into flexion when you reach an arm forward—so we train our folks to straighten their back, pull their scapula down and back and intentionally stabilize while moving the arm.

• • • Same origin and insertion thought process as ‘localize and isolate’.

 

• • The upper thoracic area naturally flexes and extends when a toddler looks up/down and LR. But we have discouraged this natural integration (see SFMA guidelines for assessing cervical movement).

• • • We have labeled any movement other than the neck as ‘substitution’, ‘compensation’ or ‘cheating’.

 

• • Static integration thinking is essentially a re-boot of origin and insertion concepts, with intentional vs assumed stabilization as the primary difference.

• • • We even have a nifty mantra that encapsulates this mindset:

 

‘Proximal stability facilitates distal mobility’

 

Minority Report

 

But maybe instead of trying to understand movement through the study of inert anatomical structures (featuring people who have donated their body to science), we could look at living people as they actually move (especially people who move well—dancers, yogis, martial artists, athletes, etc). For these folks, the head/neck and arms/hands most commonly move as an extension of a dynamically moving thorax.

• • We encourage progressing to a ‘dynamic integration’ phase of understanding, where proximal structures are not automatically immobilized in the presence of limb movement. Dynamic or ‘proportional movement’ stability.

• • • The pelvis can move to assist the movement of the leg. (Kicking a soccer ball, large side step, swinging a leg when walking).
    • Both scapula and thorax are encouraged to move to assist movements of the arms. (Throwing, punching, reaching forward, across, behind or overhead).
    • The thorax is encouraged to move to assist head and neck movements. (Star gazing, checking your blind spot, contemplating your navel).

 

Stabilization Through Movement Re-Distribution

 

This concept of proportional or appropriate movement distribution is a paradigm shift for us. We have historically taken the position that if we want something to be stabilized, we need to prescribe exercises that strengthen the muscles around that joint.

• • Multifidi stabilizes the lumbar spine.
  • Longus colli stabilizes the cervical spine.
  • Infraspinatus facilitates glenohumeral centering/stabilization.

 

Thinking of these scenarios relationally, maybe we could ask why these areas are hypermobile or unstable in the first place:

• • If the lumbar spine is hypermobile/unstable, look for hypomobile areas elsewhere.

• • • Simultaneously coordinate TrA/multifidi with hip and thoracic mobility work.
    • Relate the exercise functionally to bending, turning, walking, pushing/pulling and other potential lumbar hypermobility stresses.

 

• • If the neck is degenerative, encourage a re-direction of movement stresses elsewhere.

• • • Simultaneously coordinate longus colli/rectus capitus with thoracic mobility work.
    • Relate the exercise functionally to looking (up/down, LR, etc), eating, drinking and other potential cervical hypermobility stresses.

 

• • If the GH joint is unstable, invite proximal structures to assist.

• • • Simultaneously coordinate the rotator cuff with dynamic scapular and thoracic mobility work.
    • Relate the exercise functionally to reaching, throwing, tucking in a shirt and other potential glenohumeral arthrokinematic stresses.

 

‘Proximal mobility facilitates distal mobility’

 

This is consistent with other emerging rehab principles.

• • Regional interdependence.

• • • ‘This is connected to that’, and limitations or dysfunction distally can have negative effects locally.
    • Addressing these distal issues can have positive effects locally.

 

• • Relative flexibility.

• • • Shirley Sahrmann’s ideas of ‘path of least resistance’. Movement happens in looser places, while lack of movement elsewhere encourages further stiffening along ‘path of most resistance’.
    • Need exercise that simultaneously mobilizes the stiff part while stabilizing the loose part.

 

Bottom Line

 

So if you are prescribing cervical mobility exercises, then longus colli strengthening exercises, you are sending mixed messages. If you are having your patients develop their six pack TrA, then doing hip mobility work, you are missing an opportunity. If you are pumping up the rotator cuff, then doing thoracic mobility work, please think again. In all these scenarios, according to the transfer principle of motor learning, the two functions (stabilization of the targeted joint and mobilization of potential allies) need to be done simultaneously.

 

Just like pelvic control, limb to trunk relationships need to be better understood in the rehabilitation community. Reflexly following static integration concepts and prescribing static integration exercise is no longer the only option—there is another choice. Time to up our game and educate ourselves on another, more realistic and more effective movement paradigm.

 

The Boss

 

Who’s in charge of moving the pelvis? Who calls the shots concerning pelvic stability? Who’s the boss when it comes to balancing the pelvis, both front/back and left/right? Where do we point the finger of blame if the pelvis is moving too much or is not moving enough? Who wears the pants, so to speak? For purposes of this discussion, pelvic stability relates to anterior and posterior tilt, to rotational and obliquity movement, stability and balance. In this light, what kind of exercises do we want to teach to control these aspects of pelvic movement or positions?

 

The answer to this question depends on what the pelvis moves or is stabilized relative to. If you believe that the pelvis moves mostly at the waist, that the pelvis moves relative to the trunk, then the abdominals, quadratus lumborum and back extensors are your crew and static integration is your game plan. If you think that the pelvis moves primarily relative to the thigh bones, then it’s time for a shift change and a blueprint swap.

 

The somewhat ambivalent answer is that either sets of muscles, waist or hips, can and do control the pelvis. Either set of muscles can move, stabilize, constrain and balance the pelvis—in certain circumstances. The question is not a one or the other binary question, but a question of when we should train our folks to do it one way and when we should be training the other way.

 

The Choices

 

To answer this question, we need to ask about and observe for when, during daily or functional activity, does each strategy come into play. Let’s start with a partial list of examples of when the waist muscles might control the pelvis—what we might call top-down control:

 

• • Whenever there is no body contact with the ground—sky diving, zero-gravity, trampoline or gymnastics aerials, dolphin kick in swimming, springboard diving.
  • When the pelvis and/or trunk is on an unstable surface with legs and arms off the ground—sitting or kneeling on a Swiss ball or lying on a foam roll without limb contact and doing astounding feats of balance.
  • Whenever the arms are contacting the ground and the legs are not—handstands, pommel horse, gymnastic rings or bars, Roman chair.
  • Whenever the arms are contacting water through the intermediary of a paddle—canoeing, kayaking, paddle boards. The water is the ground, the arms interact with the ground, the waist controls the pelvis, the hip muscles transmute pelvic control into boat control.
  • Whenever the chest or upper body is on the ground and the legs are not—some wrestling or grappling moves, the horizontal mambo, lots of Pilates and core stabilization exercises. This is why so many core exercises are done lying down.
  • We could be missing some categories, and there are certainly many more examples we could come up with that would fill out the lists, but in essence, that’s it. Not exactly a who’s who of common daily activities.

 

The Relevance

 

Why does it matter? Why not just strengthen all the muscles around the pelvis and call it good?  Because the twin training strategies of specificity principle and transfer principle says that our training activity should mimic our targeted movement pattern. In this case, this means that whenever we train an activity or postural modification, we need to analyze this aspect of pelvic control as it occurs in our target activity or posture. We then should be training pelvic control in that way throughout the whole range of exercise progressions. Start them early and they ripen to maturity through a steady diet of consistent messaging.

 

If the hip extensors will ultimately be controlling anterior tilt in standing, they should be trained to create posterior tilt in supine, side lying, hands and knees and chair sitting as well. If the hip flexors will ultimately be controlling posterior tilt in sitting, they should be trained to create anterior pelvic tilt throughout all of the varying positions you train your patient in. And if the hip rotators and adductors will drive pelvic rotation in standing, we don’t prescribe supine knee tilts and control the pelvis with the abdominals.

 

The Right Tool for the Job

 

Again, this is not an either/or. Simply identify where you are going and train pelvic control in early or beginning exercise in the same way you want the pelvis to be controlled in the finished product. Five categories were listed above where the pelvis is or has to be controlled by the muscles of the waist. Let’s look for examples of when the hip muscles might have an opportunity to control the pelvis—what we might call ground-up or bottom-up control:

 

• • Everything else.

 

Moving the pelvis while walking, bending, turning, kicking, getting up and down from the floor, getting in and out of bed and running. Balancing the pelvis in sitting and standing. Stabilizing the pelvis when pushing, pulling, lifting, carrying heavy objects or riding in a car.

 

When the foot, knee or thigh is in contact with the ground and the chest and arms are not, there is no choice but to use the legs. Think this through! When the chest/thorax, which is the anchor for the abdominals when moving/controlling the pelvis in static integration exercise, does not either contact the floor directly or contact it indirectly through the arms, the pelvis cannot be controlled primarily by the waist. The ground is the mother of all movements, and to take on the job of controlling the pelvis, you will need to be in contact with it.

 

The Gut Check

 

So besides acknowledging that for the vast majority of time and for the vast majority of people the legs are in control of the pelvis, we could ask ourselves a related question. What might be some of the drawbacks of over-training the abdominal muscles or asking our patients to constantly tighten their core? While the transfer principle and pattern specificity suggests we do train the abs to control the pelvis in astronauts, sky divers, swimmers, gymnasts, wrestlers and others, we might inquire as to whether we really need to lavish such loving attention on them.

 

Realize we are talking about using the waist muscles to control the pelvis here. This is not to suggest we excise them from the body as some muscular equivalent of the appendix. The stomach muscles have an honorable and utilitarian role in movement, it’s just not usually the right tool for the job when it comes to pelvic organization or control. We need also be clear that what we sometimes define as the core muscles, the transverse abdominus (TrA) and multifidi, do not control the pelvis in any meaningful way.

 

They are primarily intersegmental stabilizers, in that they control the relationship between vertebrae. They don’t have a major role in moving or preventing movement of the pelvis into anterior or posterior tilt. They don’t move or prevent movement of the pelvis into rotation or lateral tilt. This has been a source of confusion and misunderstanding within our ranks for many years. We call an exercise core stabilization and think we are training these itty-bitty muscles to rein in the gargantuan pelvis, when what we are really doing with these types of exercises is training the obliques and the rectus abdominus to stabilize the pelvis.

 

Why not tell our folks to contract their abs to create posterior tilt—either supine or standing?

 

• • The abs pull the thorax down and forward. These muscles, like nearly all muscles, are two-way streets. They not only pull the pubic bone upward, but also pull the sternum and chest downward.
  • The thorax is pulled into flexion or kyphosis, with attendant unintended consequences, or the back extensors have to provide a counterweight and we set up a co-contraction.
  • The abdominals are closely wired to the anterior intercostals and pectoral muscles, so the shoulder girdles are often pulled down to their doom as well.
  • The chest and ribs need to stiffen to provide a stable base, thus rigidifying the thorax and potentially contributing to cervical and shoulder girdle problems.
  • Diaphragmatic breathing is inhibited. This can lead to upper chest breathing with associated neck and shoulder girdle issues or respiratory complications.
  • Abdominal contractions are part of the somatic reaction to fear or anxiety. Do we really want to throw gasoline on the fire in our patients who already exhibit evidence of high sympathetic tone and muscle hypertonicity?

 

The Career Change

 

So if the abdominals aren’t supposed to control the pelvis, what is their role? The job of the abdominal and waist muscles becomes one of controlling the relationship of the pelvis to the thorax or chest:

 

• • Controlling balance reactions—abs work to flex the trunk when ‘falling’ back and the back works to extend the trunk when ‘falling’ forward. They are reactive or secondary to pelvic position/movement.
  • Falling along diagonals facilitate these muscle groups asymmetrically or along diagonals— and they can be used to help balance the left and right abdominal antagonists.
  • Controlling rotation between pelvis and chest—pushing/pulling laterally or with one arm, ballistic rotational movements.
  • Stiffening the trunk to assist stabilization with lifting/holding/carrying weight or to absorb a lateralized shock—keeping chest neutral or aligned with pelvis to keep low back neutral.

 

We then have three layers or three aspects of lumbar stabilization:

 

• • The hip muscles to control the relationship between thigh and pelvis—pelvic stability.
  • The stomach/waist/back muscles to control the relationship between pelvis and chest—trunk stability.
  • The TrA and multifidi (along with diaphragm and pelvic floor) to control relationships between vertebrae—intersegmental stability.

 

To have intersegmental stability, you need to have trunk and pelvic stability. To have trunk stability, you need to have pelvic stability. And, to dig the rabbit hole a whole new wing, to have pelvic stability in standing or sitting, you also need knee, ankle and foot stability. This is an entire stabilization system and no one muscle or group of muscles can claim precedence or exclusivity. This is an integrated system where everyone has a role to play, where everyone contributes according to his particular abilities and relative strength.

 

This being the case, does it make sense to continue to teach people to do a supine posterior pelvic tilt from their stomach, knowing where this eventually leads functionally? Is this the right tool for the job? Are we to continue to teach control of pelvic rotation from the obliques? Will we continue to assign deep and superficial abdominal muscles the role of kingpin in this integrated stability system, or can we now delegate them to a more appropriate role as respected members of the supporting cast?

 

Time to Put it to Rest

 

Movement always needs to be described relationally. Something moves in a particular direction relative to where it started—we need to have two points of reference to define a direction of movement. Additionally, something needs to move relative to something else:

 

• The head moves relative to the trunk—cervical movement.
• The femur moves relative to the pelvis—hip movement.
• The humorous moves relative to the scapula—gleno-humeral movement.
• The talus moves relative to the tibia—ankle movement.

 

Back in the golden age of physical therapy, when patient visits were unrestricted and documentation requirements were minimal, we were blissfully ignorant of the fact that bodies are integrated. When doing a bicep curl, we presumed scapular stability because it was the origin bone and, by definition, wouldn’t move. We took for granted that the hip flexor would flex the thigh (insertion) relative to an immobile pelvis (origin) because it was written in plain language and in black and white in the anatomy books. With classic therapeutic exercise, we assumed both scapular and pelvic stability.

 

Assumptions Dropped

 

Thanks to Joseph Pilates and others who observed what can, and often does, happen to the scapula (anterior tilt) with a biceps curl or to the pelvis (anterior tilt and rotation) when a leg is lifted while supine (hip flexor contraction), we know/realize/take into account the fact that muscles are actually two-way streets. They act upon and have the potential to move either or both bones that they are connected to.

 

Though in reality either or both bones could conceivably move, by convention we have assigned the role of stability/origin to the more proximal bone and the role of mobility/insertion to the more distal partner:

 

• The trunk is the origin—the head is the insertion.
• The pelvis is the origin—the femur is the insertion.
• The scapula is the origin—the humorous is the insertion.
• The tibia is the origin—the talus is the insertion.

 

New Assumptions Made

 

We have consequently developed an entire system of exercise based on dubious assumptions:

 

• The trunk should not move (stays stable as an origin) when the head does.
• The pelvis should not move when the legs do.
• The chest or scapula should not move when the arm does.
• The tibia should not move when the foot does.

 

We have even coined a modern-day mantra to codify this belief in unmoving origin and moving insertion— proximal stability facilitates distal mobility—anything else is cheating, substitution or compensation. This is a common collective belief about the relationships between limbs and trunk that lures us away from more promising possibilities. It’s not that it’s not true, it’s just not always true, or even mostly true. In functionally relevant, real-life movement, it’s only occasionally true.

 

Controlling Interest

 

Additionally, there is a special subset of origin/insertion thinking that has led us astray in the most fundamental manner. This is the question of who is/should be in control of the pelvis. Joseph Pilates famously stated that the waist or core muscles are the powerhouse of the body, then designed exercises that trained pelvic control from the waist. When you define the pelvis as the origin, when you state either explicitly or implicitly that the pelvis should not move when the hip muscles contract or when the lower extremities move, you have no logical choice but to use the waist muscles to stabilize the pelvis or to prevent it from moving.

 

There are then two major characteristics that define static integration principles:

 

• The pelvis is or should be controlled by the muscles of the waist—this is a corollary of origin/insertion thinking that also has its roots in therapeutic exercise. We have been teaching supine posterior pelvic tilts utilizing the abdominal muscles since our first rehab ancestors emerged, goniometer in hand, from the primordial ooze.
• The (arms/legs/neck) limbs move relative to a stable trunk—something moves in relation to something else that is stable or static.Origin and insertion thinking, plus the luggage it engenders, carried forward from old localize and isolate ideas. 1960s therapeutic exercise with a veneer of intentional stabilization of the proximal part.

 

Today’s Heresy is Tomorrow’s Orthodoxy

 

How could it be otherwise? Isn’t this the way it has always been? Isn’t this the way it’s supposed to be? Isn’t this what everyone keeps saying? Not necessarily. There are other ways of thinking about movement that precede our modern ideas of static integration. While not always explicitly stated, there are exercise systems or movement traditions that imply very different ways of optimally organizing the body.

 

We can call these dynamic integrated movement systems, or we can say that they embody competing dynamic integrated movement principles. And, these exercises have been just lying around on the ground, preceding our arrival on the scene, free to the taker, patiently waiting to be discovered, analyzed, modified, justified, medically articulated and utilized to the great benefit of our professions, our patients, and all of mankind. Look for a description of these concepts in next months’ blog.