History
In the 80s, we rehabbers stretched all the muscles related to the affected part, commonly doing this in all directions in a classic shotgun approach. We imagined that everything that was hurting was too stiff and needed to be stretched. We now know that a vast array of self-inflicted wounds can manifest as a result of moving too much (hypermobility). At that same time, we imagined that the muscles around an affected area were too weak, so we prescribed strengthening exercises—same shotgun approach, different ammunition. Fast forward to the 21st century and we still strengthen everything related to the affected part, hoping that stronger muscles will stabilize the affected area.
But continuing this hallowed tradition of assuming that the unstable part will automatically get stable when the muscles around it get stronger is as dubious a proposition now as it was then. Chronic ankle sprains and patellar pain were not banished with the acquisition of a stronger fibularis or vastus medialis (circa 1960s) and low back pain is not automatically cured with the assiduous development of a six-pack transverse abdominus or a bulging gluteus medius (new century/same mirage).
Classic therapeutic exercise implies that the exercise will spontaneously change behavior. Just put in the reps and progressively load more weight and that weak muscle will joyfully come to its senses and leap back to the work for which it was hired. Credit Joseph Pilates (and many others) with pointing out the fact that bodies are integrated and that muscles work in synergistic relationships. So how did improvement happen in the good ‘ole days when we thought we were doing isolate and localize exercise? Probably because some-to-many (but not all) people were unconsciously stabilizing in the presence of a muscular contraction and pelvic, trunk or scapular perturbation. Some aspect of their consciousness was probably paying attention, even while inwardly agonizing over what wine to serve with dinner that night.
Living the Dream
Truth is, there never was such a thing as isolate and localize. We were living a fantasy. We simply assumed stability. We inferred that something would move relative to something else that wouldn’t move because of the way we learned anatomy (origin and insertion thinking). We perhaps even wished it so because things would just be so much easier, so cut and dried, so logical. The fact that bodies move as an integrated entity was there to be seen, but we didn’t see it. Maybe we thought it was too messy or too complex, and thus averted our eyes. Maybe we thought our patients were too dense, that they couldn’t learn and wouldn’t practice complex exercise or pay attention to their own bodies. Maybe we ourselves were more comfortable with algebra than with calculus—Newtonian physics was fine but quantum mechanics was, and maybe still is, spooky.
But, like it or not, bodies are complex. It is difficult to affect a positive change in motor behavior or to optimize motor planning—but that is the task we have before us. Integrating or coordinating exercise is harder to wrap your head around and harder to teach than localizing and isolating exercise, but one approach is reality and one is illusion. Probably, we just weren’t looking for integrated relationships because we just hadn’t considered the possibility—we weren’t looking in that direction. In what direction should we have looked? Where should we have made our observations about how bodies are (best) coordinated/integrated?
Sources of Inspiration
Where should we have sought inspiration about rehab-related movement and optimal movement principles? To living, moving human beings who move well: children at various stages of the developmental sequence, dancers, athletes, martial artists, yogis. Millions of years of evolution. Thousands of years of master-level movement practices. A treasure trove of potential rehab content patiently waiting to be opened and gleefully examined.
Where did we look instead? Where did we get our inspiration, our template for understanding the glorious complexity of human movement? It used to be the cadaver lab—which provided us good intel on parts but left us in the dark about coordination and optimization. But those days of localize and isolate thinking about exercise are (slowly) passing, and something else is taking its’ place. Assumed stability is fading and trained stability is ascendant—with Joseph Pilates as a charter member of the brain trust.
Onward & Upward
Now, instead of developing rehabilitation related exercise based just on anatomy labs and cadaveric minutia, we base it on flu patients in hospital beds—at least we are heading in the right direction. This was Joseph Pilates’ inspiration for the core stabilization exercises and movement philosophy that so influences our professions today. But while as a fitness exercise it marvelously tones and sculpts, it is not an adequate rehabilitation model for many/most of the things we want to do. Perhaps jarringly, I am suggesting we move beyond this way of understanding movement too. There is another way, a better way of understanding movement, prescribing integrative exercise and training movement optimization. Another level of understanding—past old assumed stability thinking and past current trained stability thinking to movement training paradigms based on fluid or dynamic optimization principles and on very different assumptions about how the body actually works. See next blog for competing styles of integration.
Gordon Browne, PT
