Coordination: Why rehab doesn't last

One of the most frustrating aspects of the fitness industry today is that rehab modalities often don’t work and, at best, only offer transient, temporary relief. Identifying why this is the case is what has lead to my framework of coaching and so I’d thought I would try to explain why this is typically the case.

Why do we even need to do rehab?

Have you ever wondered why is it that on a superficial examination of the human race we all seem to be born with some form of physical dysfunction? How has a billion years of evolution left wild animals with largely flawless movement mechanics, and yet us poor humans present constantly with tight calves and hamstrings, anterior pelvic tilts, limited hip internal rotation, lordosis, kyphosis, scapular winging, underactive glutes, weak rotator cuffs, etc? Maybe, those are all symptoms of a consistent underlying issue. Instead of treating the local pathology of a painful scapular wing, we should focus on the flaws of the integrated system and how it came about.

If we reverse engineer the problem, we see that treating muscles, or joints in isolation doesn’t address the underlying fundamentals of faulty movement. Muscles, after all, are slaves to position and intent. If I give you a weight to hold with an elbow bent to 90 degrees, you cannot help but use biceps. Many other things may contribute but you cannot tell me that the bicep doesn’t “fire” or is too weak to activate. You don’t have to do 1 hundred banded curls before jumping into barbell curls to “activate” your biceps. It’s strange that the only muscles evolution hasn’t blueprinted to just fire when needed seem to be the glutes and the rotator cuff!? That’s the message most rehab professionals are spreading anyway. It’s hard to convey sarcasm through text sometimes so I want to explicitly state that evolution doesn’t make these mistakes. We make a mistake every time we think that glutes or rotator cuff muscles need activating. The truth is that if we are never in a position that provides glutes with the leverage to operate, they simply won’t. If we don’t have the appropriate intent for movement solutions then the glutes might not be recruited as much as say: calves, hamstrings, lower back, quads. All these muscles can contribute to the overall goal of “extension” and without the proper strategy it can appear as if the glutes have forgotten to play a part. If you test someone’s hip extension and it is limited or weak- is it surprising to see that they likely have a movement strategy that actually doesn’t even require hip extension? Many people think they are extending at the hip when squatting, deadlifting, or walking, but the reality is that in observation of most powerlifters we bias extension from the knees and lower back.

This is one clue as to the source of the problem: most people don’t use hip extension when they move. At least not without compensation. Most people who are intending to train hip extension are usually reinforcing these compensations. Consciously squeezing the glutes at the top of a hip thrust does not mean the glutes are learning how to leverage their action into movement. You probably won’t find many gymnasts that are thinking: “squeeze the biceps” when they perform a chin up. The muscle is recruited in response to the demands of the movement. Squats and deadlifts definitely look like hip extension (and it’s facetious to say it isn’t happening at all) but in the context of moving forwards through space those loading techniques will likely make you worse at extending through your hip with the glutes. They will likely bias you towards quad or lower back reliance.

The other aspect of testing hip extension is that it is done in a table test with no transferable context to movement realities. Without integration, gravity, and direction, the test is largely meaningless. And here we can answer the first question of why rehab interventions do not last: all the glute activation with single leg bridges and banded clamshells in the world will not suddenly teach your glutes to fire when walking or running. The initial pump of the session may have a significant analgesic effect to make things feel better in the short term, but you haven’t addressed the root cause of the pain. The muscles are slaves to positions and having a bigger bum isn’t going to make a difference if you don’t change those positions during movement.

If muscle activity is secondary to skeletal positioning, then surely all we need to do is manipulate the skeleton? This indeed is the approach of chiropractors. And it works: we often get clicks and pops as part of an effort towards “realignment” and typically feel significant improvement; in the short term. But over the course of hours, days, and weeks, we return back to the same positions that create the compression. Suddenly you have a situation where you are paying for regular chiropractic appointments for YEARS. It would be easy to blame chiropractors and put them in the same category as the pharmaceutical industry: it doesn’t make financial sense to fix problems. But I genuinely think in the case of most practitioners it simply comes down to the wrong model of movement. The bones are in the wrong place because the muscles have put them there. But wait; if muscles respond to position, and position is a result of muscle activity, then just what is the deciding factor? Chicken or the egg?

Why coordination matters

The reality of the situation is that the coordination pattern is the superseding element of the posture and movement picture. If we are concerned about skeletal positioning and muscle activity (strength and length included) then coordination is therefore the centre piece and should be the focal point of addressing of pain. Specifically, coordination means the way you manage your centre of mass as you stand, sit and move. The way you do this is in response to sensory inputs and reference points. Fundamentally you need to keep your eyes level, face forward, and use the least amount of energy to do so. These basic concepts lead to the postural distortions we see so commonly in our culture. Once our movement demands change from the intended blueprint (usually once we start school and sit still for >6 hours every day) we shift our strategy. If you are moving through space on two feet it is easier to breathe and see your intended focus in an upright posture. At a desk this is easier when slouching. This isn’t necessarily a bad thing but if it becomes the predominant task of every day then your sensory inputs, and movement strategies will shift. Your body will adapt to its strongest or most regular input.

When I see a client for the first time, I will simply observe their strategies in a couple of scenarios (standing and walking primarily). Where is their foot pressure? How do they create downforce into the ground? How do they keep their head forwards when moving? The most common situation is compression from the back shoving everything forward. This creates some passive downforce and forward trajectory and isn’t necessarily a bad thing in small doses. Most athletes will present this way to some degree. However, to stop from simply falling over forwards, some things need to shift backwards. This may be the knees in hyperextension (common in powerlifters). It may be the rib cage resulting in a dreaded “kyphosis” (use of the word dread is also sarcastic by the way. Also, tight pecs did not cause this posture). These shifts are the skeletal positions I referenced earlier. They create the context upon which your muscles produce movement. As an example to feel the impact that shifts in skeletal position can have upon mobility and muscle activity try the following: Stand on both feet and shift your hips as far forward as possible so your weight is in the front of your foot and you are arching your back. If you lift one leg and try to internally rotate your femur you won’t get very far, and you will feel the TFL becoming crampy near the front of your hip. Now bend forward and shift your hips behind you and do the same. You will have suddenly gained access to rotation, as well as a preferable pattern of muscular recruitment with the adductor picking up better leverage. With so many people experiencing compression from heavy loaded training methods, it is not wonder we have strong people whose glutes “don’t fire”. You can’t move into a space you’re already in. When the pelvis is pushed forwards it is nearly impossible to drive genuine hip extension. You’d probably just fall over. You likely feel your glutes being squashed, or even gripping to try and hold you back, as well as a very tight lower back.

My process of correcting issues for clients is then one where we spend time with drills that teach a new strategy for managing centre of mass. This requires reference points for foot pressure and relative positions. The muscle activity here is not the direct goal, but ,more of an indicator that we are in the correct position. If we can slow down and spend time in these positions, the client can learn what they need to feel at what times during movement. Sometimes this is a subtle introduction to new muscle activation pattern, sometimes it is a strong stimulus that creates a lot of fatigue due to novelty. Once we have the coordination and sensory inputs, we transition into more fluid exercises. Most movements should not be associated with enormous tension or overwhelming muscular sensation or fatigue. Hopefully now we have created a new strategy. This promotes a use of different skeletal positions, and this prompts the desirable muscle activity.

It is often not as simple as moving through these phases in linear fashion for a few reasons. The client may not want to do low threshold drills on their back with their feet on the wall for 10 sessions. They are also likely still doing some activity that is reinforcing some of the old, less than desirable patterns. And of course, sometimes my judgment of exactly when to move into different phases will be incorrect (if there is indeed a perfect time to do so (which there isn’t)). Long lasting changes are the result of changing the sensory aspect of movement strategies. The skeletal positions and muscular recruitment follow. The reverse does not work in the long run, and this is why we have endlessly repeated bouts of rehab, a cycle of injury, rehab, prehab, training. All of movement, even the basic task of walking, is a skill. To teach and learn a new skill takes time. It takes deliberate intent and integrated understanding. Releasing a muscle can be part of how we introduce someone to the new strategy, but unless you can address why that muscle got tight in the first place you are doomed to find yourself back there soon.

If we look at how we approach other skills, we can decipher which approaches truly make sense. Let’s say we want to learn how to juggle. But you keep dropping the back outside your right hand. Would you assume the right hand is in the wrong position because it lacks external rotation? And then correct this by strengthening the rotator cuff before going back and juggling again? Likely, no. I expect you would simply try to adapt the whole movement pattern to make the successful outcome more likely. You would probably develop a cue for earlier in the juggling cycle to ensure the hand has the best opportunity to get into the right position. The rotator cuff would be active in this process; but would be far from the deciding factor.

What does the research say?

As a biomechanics guy I am certainly biased towards this approach. And those with the ears to the ground of the consensus of the literature will be quick to point out: movement patterns ad coordination have been shown to have minimal correlation to pain and injury. To that I say we haven’t even been able to ask the question properly. Who within these studies is deciding what which movement patterns to pay attention to? And how you define if that movement pattern is done well in a measurable and objective manner? The context of movement is spectacularly layered and complicated and to reduce it to degrees of internal rotation here, and limited hip flexion there is never going to encompass enough variables to predict dynamic outcomes. This doesn’t mean that biomechanics is irrelevant to pain. It means that we are poor at wielding it as a tool. I don’t think the productive response to this acknowledgement is to throw our hands up and go back to static stretching and glute bands. But it’s easy to shy away from the difficult task of codifying human movement when we can simply blame patient adherence, or the psychosocial model, or the inevitability of injuries when “pushing our boundaries” for our interventions not lasting. Whether deliberately or not, we are fostering a population that blames themselves for not doing their rehab drills “enough” when they relapse. To this I say that if our approaches were to offer genuine solutions you would not need to do them ad infinitum. Dogs do not need to do prehab or activation drills before they run around the garden in the morning. This is because they have the appropriate strategy available to them and they do not go out of their way to inflict arbitrary changes on their structure with compressive movements and flexibility training. We should aim to be the same way.

Much like the way that Health Care is actually sick care, the fitness industry treats symptoms rather than causes of pain. Without changing the why of what has gone wrong we can’t expect to see resolution. And the cycle of injury, rehab, prehab, train; injury, rehab, prehab, train continues.