Helping people move better seems like a great idea—and it’s one that physical therapists, movement coaches, and trainers are passionate about. However, research indicates that corrective exercises often don’t deliver better results than a straightforward, basic exercise program like walking.
Let's talk about this in a short and off-the-cuff post, without delving into specific studies.
Music for today: Nação África from Camarão Orkestra
I can see two main reasons why corrective exercises don't work:
Many problems don't need corrections
Many corrective exercises are not corrective
Many problems don't need corrections
The whole 'ideal movement' idea needs to be nuanced in a few major ways. There is no ideal movement for everyone in every situation. It is more correct to say that for a specific person, in a specific situation, there are movement solutions that are more optimal than others. Theoretically, in that situation, there probably is an ideal movement.
But we know from many studies that there's a lot of variation between individuals. Even the most skilled individuals like athletes move in different ways. Moreover, an athlete performing the same movement repeatedly will still show subtle variability—a concept famously called "repetition without repetition" by Nikolai Bernstein.
If, considering all of the above, you think a movement pattern really deviates from a good pattern, you still don't know if the pain your patient has is a consequence of the 'faulty' movement pattern. It could be the major contributor, but it could be entirely unrelated. Maybe it is a minor part of the story. But it could even be the consequence of the problem: a way of moving caused by the pain/injury.
In the last case, the pattern can be adaptive, so promoting healthy behaviour and healing. This is often the case, and easy to recognise, in the acute phase: a person limps after an ankle sprain, a person holds his back stiff and upright because of acute low back pain.
But the way of moving can also be maladaptive, where there are no benefits to the change in movement patterns (less common), or where the once adaptive pattern has become unnecessary (more common). These maladaptive patterns do need to change. But the way to achieve this is maybe different than you would expect.
Many corrective exercises are not corrective
Let’s not dismiss the idea of optimal movement entirely. Clearly, some ways of moving are better than others. Children, for example, must learn to move well. Similarly, beginners in any sport need to coordinate their movements appropriately. You don't have to be an expert to see that some ways of moving are better than other. Try running 10 km, or even 200 m with your feet touching your butt every step. Try walking for an hour like John Cleese does in the legendary and hilarious 'Ministry of Silly Walks'.
I will avoid talking about how we could know what an ideal movement could be. Let me just say that it would be really good at achieving its goal, in an energy efficient way, and safe for the body. And it will usually look good, graceful and easy.
So there is a better way of moving, but physical therapists often do not achieve this: the simply use the wrong motor learning principles.
You cannot expect exercises for strengthening muscles, even if they target the 'right' muscles, to change movement patterns. You cannot expect the capacity of consciously 'setting the scapula' to transfer to real life. You cannot expect that tilting your pelvis (in whatever way you think it needs to), will truly change your gate.
We need to do better!
So, what works?
We need to focus on better methods, grounded in good motor learning principles. We know that learning = play, and play = learning, so we need to incorporate properties of play for deep learning:
Appropriate challenge (it has to be difficult enough to stimulate improvement, but not too difficult)
Goal oriented (external focus)
Variation (in task and environment)
Feedback (knowledge of result)
Minimal instruction (say 'what to do, not how to do it')
I've written on motor learning before:
These principles are basic motor learning principles, but unfortunately, many therapists don't know them, or don't apply them in practice.
When pain changes the game
But, interestingly, things change once pain/injury enters the story. The maladaptive movement patterns that we would like to change often are not learning how to move from scratch, but rather is an 'unlearning' of the protective measures. You could say a re-discovery of normal movement behaviour. And with normal I mean the way of moving before the pain/injury. A realization that code red can change into code green, or at least yellow.
I think the same properties of play apply here: appropriate challenge, goal-oriented, variation, feedback, minimal instruction. But the appropriate challenge is more targeted towards pain, whereas before it was a motor challenge.
We are also more concerned with safety: safety of the tissues, but mostly avoiding an increase in protection. That's why a more gentle exploration is really good for this. From this exploration, you can gradually build up to playful but hard challenges.
A thought to consider
If you change a movement pattern and the pain improves, does that mean the pattern is better?
Maybe. It could just only be different from the painful one. This still can be useful, albeit only temporary. Not convinced? Think of limping, or holding the spine stiff and upright. They decrease pain, but no person would suggest that these patterns are inherently better, no?
Unfortunately, both health professionals and patients think that keeping the spine upright and stiff is the best way of moving. Luckily, this viewpoint is slowly changing…
So, for the therapists reading this: some of the 'corrections' we do are maybe only different, not better. Thus, when the patient is better, forgets the do the exercises, and 'relapses' again towards the previous way of moving, this may not be a problem, but perfectly fine :-).
Conclusion
Many so-called "faulty" movement patterns are simply natural variations that don’t require correction. In fact, some patterns are adaptive responses to pain or injury, and trying to change them prematurely could do more harm than good.
That said, not all movement solutions are ideal. Some can and should be improved—but only when we apply proper motor learning principles, like the properties of play.
These principles hold true for everyone, whether they’re dealing with pain or not. However, for those in pain, a gentler, more exploratory approach often works best for rediscovering better movement patterns.
Thanks for reading.
Cheers,
Pieter
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