Introduction
Humans are not the fastest animals or the strongest. We cannot outrun a cheetah or overpower a gorilla. What we can do is back flip, run for miles at a stretch, dance ballet, lift hundreds of pounds, do cartwheels, shoot long-range three-pointers, climb trees and cliffs, throw curveballs, swim through oceans and lakes, and play the harmonica. We are born to run, and also to walk, climb, dance, and do millions of other things. Versatility is our evolutionary superpower.
Yet somewhere along the way, most of us stopped using it. A sedentary lifestyle has been compared to smoking in its effects on general health. Chronic pain is the biggest source of physical disability in the world, and metabolic disorders affect almost a third of the U.S. population. Although our culture continues to produce spectacular athletes, sport is becoming less of a game and more of a business. Kids get most of their movement from organized classes, not unstructured play, specializing in a single sport earlier and burning out faster. Adults have “workout routines,” but the experience is often exactly that — work and routine. The average exercise program is not very fun or meaningful, which is part of the reason exercise feels like a chore, and why most people don’t do it with enough volume, variety, and intensity to get its beneficial effects. Everyone knows that physical activity provides the health benefits of a “miracle drug,” but few get a sufficient dose.
The problem is the framing. The mainstream approach to training and therapy is all work and no play — focused on movements that are boring, repetitive, planned, stressful, and done only to accomplish some external goal. This stems from a reductive mindset that views the body as a machine to be “fixed,” rather than an organic, self-organizing system that adapts and learns. What we need instead is play.
Play is a natural behavior that evolved to help animals solve complex problems in the face of uncertainty. Playing with movement means moving in a way that is fun, exploratory, variable, intuitive, and personally meaningful. All animals develop skill, resilience, and well-rounded fitness through play, not “working out.” The surest path to better function is also, paradoxically, the simplest: you don’t need perfect knowledge to resolve complex problems, because complex problems often have relatively simple solutions. Top experts in training readily admit that it is very hard to know how work in the gym will transfer to the field of play. The surest path to better sport performance is relatively straightforward — play the game, making sure to vary its intensity, frequency, and rules. The same principle reaches into every dimension of movement health explored in this book. Play is not a reward for getting fit. It is the method.
Chapter 1 — Movement Health
Hippocrates observed that it is more important to know what sort of person has a disease than to know what sort of disease a person has. That ancient medical wisdom points toward a truth that modern science keeps rediscovering: health is not a property of isolated tissues or organs but of a whole person embedded in a whole environment. The foundational equation is simple enough to fit on a Post-it note — stress plus recovery equals growth — but easy to violate. If you don’t fully recover, you can’t fully adapt.
The most popular forms of exercise — CrossFit, yoga, Zumba, Body Pump, and spin class — draw people back week after week largely through group dynamics. The communal energy of training alongside others converts something effortful into something enjoyable, and enjoyment is the engine that keeps people showing up. Environment operates by similar logic. Green fields, hiking trails, playgrounds, and dance floors all extend an implicit invitation to get moving. Other environments do the opposite: a town with wide streets and no sidewalks, a neighborhood without parks or green spaces, a job that requires constant typing, a living space with every couch aimed at the television — each of these tells the body to stop moving and sit still. Movement health begins with recognizing that these forces are real, and that changing your environment may be more effective than changing your willpower.
Chapter 2 — Play
Play helps animals build resilient bodies, develop physical fitness, learn movement and social skills, and become more adaptable and creative in general. All intelligent animals play, and the more intelligent the animal, the more it plays. Humans are the smartest and most adaptable animals on earth, and so they play the most. They also do the most playing at precisely the times of life when they need to do the most learning and developing. Philosophers from Rousseau to John Dewey have argued that children learn best when their natural interests are nurtured rather than suppressed. The word kindergarten literally means “garden for children,” and reflects the idea that child development is grown, not engineered.
Some of the all-time greats understood this intuitively. Wayne Gretzky, Ronaldinho, and Johan Cruyff have each specifically credited play and a pure love of the game as the basis for their success. They express real concern that overly regimented training methods — including early sport specialization — are counterproductive, that somewhere in the optimization process something irreplaceable gets squeezed out.
The psychologist Mihaly Csikszentmihalyi coined the term “flow” to describe deeply rewarding and meaningful experiences that occur when people are completely absorbed in an activity that requires skill and concentration to perform well. One of flow’s defining qualities is the feeling that effective actions are occurring automatically, spontaneously, or effortlessly, without the need for excessive self-consciousness or willpower. It is the opposite of grinding through a workout you hate.
Exercise that is unpleasant and meaningless might burn the exact same calories as exercise that creates a state of flow, but the psychology is very different, and this has important consequences. The most obvious is the decreased likelihood of showing up to do more exercise tomorrow, next week, or next year. Research confirms that people who exercise because they enjoy it, or because it gives them a personal sense of mastery, are more likely to adhere to their fitness plans than people motivated by “body reasons” like looking better in selfies or swimsuits. Adherence is also higher when exercise provides an immediate sense of gratification rather than a distant reward in the future.
Animals and babies generally stop playing when they are sick or stressed. If you haven’t eaten for several days, this isn’t a good time for roughhousing or capture the flag. Play, almost by definition, never compromises the recovery dimension of movement health — animals and kids have the good sense to avoid optional physical activities when they need rest. But competitive adult humans can get carried away. They love to run, dance, or do CrossFit so much that they may continue even when these activities have become genuinely stressful, undermining the recovery they need to adapt.
Play also functions as a form of tinkering. It means trying to resolve a problem by fiddling with different variables in a semi-random manner, in contrast to the workmanlike strategy that relies on precise planning. You solve a problem just by messing around, and things tend to sort themselves out. This playful attitude leads elite athletes to explore their sport well beyond what is strictly practical. Soccer players juggle balls on their shoulders and balance them on their heads; basketball players spin balls on their fingers and dribble two at once; golfers strike perfect drives out of mid-air after dropping the ball from their hand. These tricks have no direct practical value, but the attitude that led to their discovery is part of what allowed those athletes to master their sport. Tinkering doesn’t look like training, but it often is.
Chapter 3 — Complexity
A major challenge with complex systems is that they may have too many parts — or too many interactions between parts — to fully measure. Small gaps in knowledge can lead to large prediction errors. This is common in stock markets, weather systems, and political elections, where there is always major uncertainty about future events. Ask ten experts for long-term predictions in these areas and you might get ten different answers, many of which would not outperform common sense or a coin flip. A similar confusion appears with low back pain, where a single person may receive more than five different diagnoses and prescriptions from different experts. The lesson is that with complex problems, more data does not necessarily lead to better understanding. Looking too closely at the details can cause you to miss the big picture.
The big picture on human bodies is that they are like ant colonies. They are made of billions of cells that pursue their own local interests — taking in food, repairing damage, repelling invaders, sending communications to other cells — with no idea they are part of some larger plan to form an intelligent body. And yet somehow their interactions do exactly that. We are not machines but ecologies, and we operate according to similar logic. Physical activity is easier if we create the conditions that make the body want to get moving: meaningful activities, favorable social and environmental contexts, adequate sleep. The body will do the rest.
When we get injured, positive feedback loops quickly increase pain sensitivity. Tissue damage causes inflammation, which sensitizes nerve endings, which makes them more active, which causes more inflammation — this is why several hours after a sprained ankle, the whole area has become massively sensitive. Eventually, negative feedback loops restore normalcy: inflammation initiates healing, which reduces damage, which allows more movement, which creates more healing, which reduces inflammation. But what if the negative feedback loops don’t kick in properly, and the injured area remains stuck? Pain prevents movement, which prevents healing, which prevents movement, which reduces fitness, which prevents more movement. Playing with movement is a way to escape this loop. Introducing a new stimulus — even a random one — can shake up the system, reactivating negative feedback loops that may have fallen asleep at the switch.
Diversity makes a system resilient by ensuring all the eggs aren’t in the same basket. Machines are not variable, and this makes them fragile: when a key part breaks, they stop working. A car missing one tire can’t move at all. But a dog with only three legs gets along pretty well. Organic systems continue to function even after serious injury because their function is distributed across many redundant components. Playing with movement is about escaping well-worn grooves and exploring new territory — building that same kind of distributed resilience.
If the body’s organization depended exclusively on top-down direction from the brain, it would completely fall apart the moment the brain’s attention shifted elsewhere. We don’t crash the car when we stop thinking about driving. Coordination lives in the interactions between many different parts of the body, and it continues even when individual members are injured or distracted. Trying to impose strict top-down control over movement — consciously bracing the core or deliberately firing the glutes — is unlikely to improve that organization and may even make it worse. You can’t control a body in the same way you control a machine. The former problem is properly considered “complex,” while the latter is merely “complicated.”
For complicated problems, expertise and precise planning are incredibly important. Complex problems are different, because expertise isn’t necessary or sufficient for success. Raising a toddler is the classic example — complete amateurs succeed at it regularly. Toddlers are self-organizing creatures who will usually do just fine if given food, shelter, love, and attention. They are also unpredictable, so even an expert in child discipline might fail to get one to behave. And crucially, different experts recommend completely different child-rearing strategies — which is very telling. You will not see engineers arguing over what makes planes fly, but there are radically different opinions about the best ways to raise children, stimulate economic growth, or build peaceful relations between nations. When qualified experts have major disagreements over the basics of how to solve a problem, it is most likely complex.
Other examples of complex problems include eating a nutritious diet, finding motivation to exercise, developing basic movement skills, losing weight, gaining muscle, improving sleep, and minimizing emotional stress. In most cases, expertise will probably help but will not provide a quantum leap over common sense, individual experimentation, and a strong intention to succeed. Although complicated problems always require expert knowledge, solutions to complex problems might be deceivingly simple. You can lose weight by eating less and moving more. You can build strength by following any one of many resistance training programs. You can improve endurance by going out for a comfortable run and building mileage slowly. This is the idea underlying the KISS principle — keep it simple, stupid. As Paul Plsek observed, mechanical thinking believes “it is necessary to plan and control or there will be chaos.” That attitude can be counterproductive when applied to organic systems that need freedom to self-organize.
Thinking in terms of constraints offers a more useful alternative. If you want your kids to engage in productive activities, you could command them to go outside or read a book — good luck with that. Or you could use a strategy based on constraints: take away their computers, TVs, and iPads, and tell them they can do whatever they want. The result might be that they go outside, read a book, or find a better option you hadn’t thought of. Self-organizing systems perform best when given freedom within appropriate limits rather than exact instructions. Many personal trainers know this intuitively, using a “constraints-led approach” to teach movement. Because we cannot acquire full knowledge over complex systems, we need to remain humble in our interventions — acting more like a gardener cultivating growth, and less like a craftsman shaping an object.
Chapter 4 — Stress and Adaptation
All exercise, even play, is essentially a form of stress, and it can improve strength, endurance, mobility, and overall physical function. There is almost nothing about your physical wellness that hasn’t been developed by stress, or that couldn’t be improved further by more of it. Good stress — eustress — produces favorable adaptations. It usually involves a challenge that is short-lived, controllable, and maybe even fun: roller coaster rides, a quick series of sprints, rock climbing, a long walk, public speaking, or crossword puzzles. Bad stress — distress — is usually prolonged, unpleasant, excessive, and largely beyond your control: traffic jams, insomnia, abusive relationships, car crashes. Over time, or even instantly if the stress is extreme, distress can overwhelm the system or slowly deplete vital resources, leaving you weaker and less adaptable. This distinction helps explain why exercise is generally healthy while chronic emotional stress is not.
A good stress response is fundamental to life and involves almost every major system in the body — cardiovascular, immune, nervous, endocrine. Chronic stress therefore has the potential to overload the body in multiple ways simultaneously. Your muscles are the size they are, and not larger, because it would be costly to build and maintain a bigger set, and the body doesn’t want to pay those costs unless necessary. To encourage a change, you need to send a strong message that the current state of the body is not getting the job done. The same logic applies to building denser bones, thicker tendons, more lung capacity, and even better movement skills. The degree of stress that drives adaptation must be great enough to create a minor crisis. Fitness adaptations also have a “use it or lose it” nature — when the stress that creates them is removed, the adaptations slowly fade. That said, muscles seem to retain some “memory” of their prior level of strength and endurance, making it easier to recover past abilities after they are lost.
One of the most surprising illustrations of how stress interacts with recovery comes from research on injury prediction. You can predict injury rates in high school athletes simply by looking at how many hours they sleep. One study found that athletes who slept less than eight hours per night were 1.7 times more likely to get injured than those who slept more than eight hours. Recovery is not an optional add-on to training; it is the mechanism through which training produces results.
One of the deeper complexities of stress is that it depends heavily on perception. The magnitude of the stress response is not directly dependent on the magnitude of the stressor. Instead, it is the emotional resonance attached to the stressor — registering the stimulus as threatening or benign, stimulating or anxiety-inducing — that ultimately dictates the extent of the stress defenses mobilized. Stress depends on subjective perception, which in turn depends on past experience, expectation, and knowledge of your own skills and abilities. If you don’t perceive a challenge, there is no stress response. And if you do perceive a challenge, even if none actually exists, your body will react as though it does. This is why the same workout that energizes one person can exhaust another.
The one thing every good training plan has in common is a gradual progression in the level of stress, while making sure the kind of stress is varied. A useful way to visualize this is the stress bucket. The bucket is filled with stressors — both emotional and physical — relating to exercise, work, travel, relationships, finances, sleep, or illness. As long as your bucket is not overflowing, you can adequately respond to each stressor and fully recover before new ones arise. The right amounts and sources of stress can actually increase the size of the bucket, representing higher general health, resilience, and work capacity.
But if the bucket overflows, you will get immediate negative feedback — perhaps pain, fatigue, or anxiety that does not quickly subside after a reasonable recovery period. If it continues to overflow, your resilience will start to suffer and the bucket will effectively shrink, meaning you have less adaptive capacity. Over longer periods, chronic stress may awaken dormant vulnerabilities — genetic or environmental — to chronic pain, fatigue, anxiety, autoimmune disease, or insomnia. In the exercise context, excessive physical stress may cause overtraining, which can impair performance, decrease motivation, and elevate the risk of injury and psychological burnout.
When back pain suddenly shows up, it is tempting to blame the last minor stressor — a soft bed in a hotel room, say, or an awkward turn loading groceries. This is like blaming your bankruptcy on the last latte you bought before your account finally went into the red. The real cause is usually the accumulated overflow of the bucket over weeks or months. Thinking in terms of the bucket provides a more expansive and accurate view of cause and effect. The goal is not to eliminate all stress but to slowly grow the size of your bucket over time — increasing your resilience and general function, one well-timed challenge and recovery at a time.
Chapter 5 — Fitness
Asking who is “fittest” is roughly analogous to asking who is most physically “prepared” — it begs the question: prepared for what? Cold exposure? A punch to the gut? A zombie apocalypse? Since there are many different kinds of physical stress, there are many different kinds of fitness. An elite CrossFit champion, a world-class triathlete, and a top squash player may each be perfectly fit for their own domain, yet none would be close to optimally prepared for elite competition in the others. Fitness is always fitness for something, which matters a great deal when you are deciding how to spend your training time.
Physical activity is now considered one of the “big four” lifestyle factors — alongside smoking, nutrition, and drug abuse — that have major effects on health. In 2015, the Academy of Medical Royal Colleges published a report calling exercise both a “miracle cure” and a “wonder drug,” observing that regular exercise can prevent dementia, type 2 diabetes, some cancers, depression, and heart disease, reducing the risk of each by at least 30 percent — better results than many drugs. The evidence shows physical activity can prevent or treat symptoms from at least twenty chronic conditions, including high blood pressure, metabolic syndrome, diabetes, obesity, anxiety, depression, dementia, insomnia, Parkinson’s, osteoarthritis, chronic pain, cancer, and COPD.
General exercise — meaning whatever exercise you enjoy — is an effective treatment for low back pain, working just as well in most studies as specific medical interventions such as chiropractic adjustment, massage, motor control exercise prescribed by a physical therapist, core strengthening, or many forms of surgery. Contrary to popular belief, running does not accelerate knee osteoarthritis through “wear and tear” — in fact, it improves function and reduces pain. Resistance training improves pain in osteoarthritis of the knee and hip as much as NSAIDs.
Physical activity reduces the risk for dementia and improves its symptoms, even one year after the exercise program has ended. Aerobic exercise improves memory and increases hippocampal volume; in one study, elderly adults increased gray and white matter volume after just six months of walking. Several randomized controlled trials have shown that moderate aerobic exercise — daily brisk walking — can cut sick days in half. The effects of exercise on depression symptoms are moderate but probably as good as talk therapy or drug treatment, and several studies have found that exercise improves symptoms of anxiety as well. A recent analysis of more than 60,000 respondents found that exercising one to two times per week yielded a 30 percent reduction in all-cause mortality, with a 35 percent reduction for those exercising three to five times per week.
Bed rest offers a stark illustration of what happens when the body stops moving altogether. After about a month of lying in bed, inactive muscles lose about half their strength, ligaments lose 60 percent of their ability to bear load, and tendons lose significant stiffness. If joints are immobilized in a shortened position for two to three weeks, adhesions may start to form that impede full range of motion. Movement is like food in this respect. Nutrients are beneficial when consumed in a Goldilocks amount — not too much and not too little. You need a minimum dose of iron to avoid anemia, but too much is toxic. With physical activity, some minimum amount is essential, too much is toxic, and in between there is a broad range of happy mediums. Just as you need a well-balanced diet of many different nutrients, you need variety in movement. The bench press is a fine exercise, but if that’s all you ever did, you would become deficient in other areas of physical function.
Multiple governmental agencies — including the World Health Organization, the U.S. Department of Health Services, and the National Health Service in the United Kingdom — have published physical activity guidelines based on expert analysis of the research. They recommend at least 150 minutes per week of moderate physical activity, or half as much vigorous activity. The preferred amount of moderate activity is 300 minutes per week. Adding more exercise may continue to reduce mortality up to about 750 minutes per week, after which health benefits appear to flatline. Moderate activities are usually light aerobic exercise — continuous cyclic movements done at an easy pace, such as brisk walking, hiking, gardening, jogging, or easy cycling or swimming. Moderate exertion feels like you are working, but not in a way that is unpleasant or difficult to continue. Heart rate runs about 60 to 80 percent of maximum, breathing is elevated to a point where singing would be difficult but talking is easy, and you may break a light sweat without becoming significantly overheated.
Vigorous activity can provide similar benefits to moderate activity in half the time. A commonly studied model for high-intensity interval training uses four to six half-minute max-effort sprints on a stationary bicycle followed by four-minute recovery intervals. In one study, participants completed just three reps of twenty-second max-effort bicycle sprints, interspersed with two minutes of low-intensity cycling, three times per week for twelve weeks — and got similar results to a group working at moderate pace for 45 minutes per session. Many common activities challenge mobility and functional movement skills as well: dancing, swimming, martial arts, gymnastics, climbing, calisthenics, and classic compound strength exercises like pushups, pull-ups, squats, and lunges. If all you do is bike or run, you will not be challenging your mobility or coordination very much.
Anthropologists who study hunter-gatherer cultures observe that they generally enjoy excellent health and fitness, with low to nonexistent rates of chronic diseases associated with a sedentary lifestyle. Recent studies on the Hadza tribe in Tanzania show about 135 minutes per day of moderate to vigorous physical activity — roughly 900 minutes per week, just past the point at which additional exercise stops providing significant mortality benefits. Some days involve hard work but are usually followed by easy days. Importantly, activity levels do not decline much with age: 65-year-old Hadza elders keep up with the young adults. A good percentage of the total workload is simply walking 5 to 10 miles per day.
Walking deserves special mention. It provides substantial health benefits with only minimal risk of injury. More intense exercise offers a relatively narrow window between too much and not enough — the difference between a good workout and an injury might be just a few plates on the bar. But the margin of error with walking is huge. If you did nothing else but walk a lot, you would be in better shape than most Americans.
With exercise, working to improve a weakness probably has more general benefit than improving a strength. If you can already run a six-minute mile, getting your time to 5:30 won’t be a life-changer — it would take a lot of work and risk a repetitive stress injury along the way. But if you can’t do a couple of pushups, getting to ten would be relatively easy and might make a real difference in overall functional ability. It is low-hanging fruit. This principle seems obvious, but people ignore it constantly. Dancers spend their spare time doing yoga. Frail aging women would never consider weight training. Buff football players care only about their gym numbers. We have a tendency to train our strengths and ignore our weaknesses. Part of what keeps us playing with movement is the internal reward of mastery — but another aspect of play is the courage to try something new without fear of failure. A playful attitude doesn’t worry too much about the embarrassment of being an absolute novice. If you’re willing to bear that feeling for a little while, you might gain capacities that make a real difference in your functional life.
A healthy meal for one day is not a healthy meal every day. Similarly, a “meat and potatoes” exercise program — cardio, resistance training, and stretching — is great, but when repeated in the exact same way for years, a change might be exactly what’s needed. It would rest areas that are repeatedly stressed, direct work to blind spots that have been escaping challenge, and help avoid boredom. Good athletic coaches make sure to vary the training stimulus because you cannot continue making progress on the same program indefinitely. After a few months, returns diminish, athletes hit a plateau, and the workout becomes stale. Training should then be varied in a way that affords recovery from accumulated stress and stimulates new adaptations.
If you want to play with fitness as a way to improve general health, here are some simple rules of the game to keep in mind. Aim for at least half an hour and up to two hours of physical activity almost every day. Movement should be varied in volume, intensity, and type — most activity can be fairly light, and walking is the most natural and beneficial movement for human beings. Occasionally include high-intensity work that significantly challenges your strength, power, and capacity for short, hard efforts; climbing, running, and resistance training are logical choices. Include movements that challenge coordination, balance, and range of motion. Or put it even more simply: move around a lot at a slow, easy pace; frequently move with some urgency or pick up something heavy; and every once in a while, move like your life depends on it.
A few caveats. Consistency is more important than perfection — a suboptimal plan executed every week for years is far better than the perfect plan abandoned after a few weeks. Find a program that fits your schedule, abilities, social and environmental resources, and above all your personal interest and sense of meaning. Something is also far better than nothing: the difference between nine and ten hours of exercise per week is negligible, but the difference between zero and one hour is enormous. And the guidelines are not specific directions — they are landmarks you can use to stay oriented as you explore complex terrain. When you divide physical activity into abstract component parts so they can each be precisely measured and accounted for, the result may be a workout disconnected from fun, spontaneity, community, natural environment, or meaning. Do something you enjoy and that feels meaningful, even if it doesn’t check every box in the guidelines.
Chapter 6 — Environment
Cheetahs who live in zoos suffer from gastritis, kidney disease, high stress and mortality, and low rates of mating. You don’t need to be a zoologist to see that most zoo animals just don’t look happy. The modern environment for humans is something of a zoo as well, though far nicer in most respects, and usually with better Wi-Fi. We build our own cages, so we have a pretty good idea of how to keep them enriched — but not everyone has the resources for as much enrichment as they would like, and even when we do, we don’t always make the healthiest choices. Most people are living in social and physical environments that actively discourage healthy movement: a small apartment filled with digital screens, a neighborhood without safe or interesting places to walk, a long car commute, a job that requires heavy computer work, social relationships maintained primarily by smartphone. Everything about this environment tells you to stop moving and start sitting.
We tend to underestimate the effect of environment on our behavior, perhaps because we overestimate our self-control and agency. We like to think our choices derive from internal psychological factors — knowledge, rationality, discipline, or taste. But a small change in context can trigger a phase shift in behavior. You can go against the environmental grain if you are determined, but there is far less friction in life when you go with it.
People like exercising outdoors better than indoors. It leads to higher levels of revitalization, cognitive attention, and positive mood, and lower levels of anger, depression, and tension. People report a greater interest in adhering to “green exercise” programs and spontaneously select higher work rates when outside. One study showed that during self-paced walking in natural environments, individuals walked faster but reported lower levels of perceived exertion compared to walking on a treadmill indoors. Research shows that exposure to nature can have benefits even when you’re sitting still — natural environments promote relaxation, stress reduction, immune system changes, better sleep, and faster healing times. Hospital patients with a window looking into green space healed faster and requested less pain medication than those with a view of a brick wall. The benefits are not just about a good view but about smells, sounds, air quality, and the total experience of being outside.
James Gibson coined the term “affordance” to describe features of the environment that create possibilities for useful actions. Classic examples are the handle on a teacup or the railing on a stairway — each affords an easier way to perform a task. When affordances are perceived, they invite certain movement patterns. Couches invite sitting. Trees with low branches invite climbing. Escalators afford effortless ascent. Hiking trails invite exploration of physical space. The presence of affordances will continually shape your movement behavior, whether you notice it or not.
Why do people get so attached to CrossFit, Body Pump, or spin class? Part of what they love is the communal element and crowd energy — the social environment is itself an affordance, one that makes hard effort feel natural rather than forced. Home environments can be enriched by adding things that invite more movement: leaving soccer balls, kettlebells, or resistance bands in conspicuous areas; installing a pull-up bar where you can’t miss it. Pull-up bars are especially effective — it is genuinely hard to resist a few swings or hangs when one is within reach. Similar environmental strategies encourage other healthy behaviors: keeping junk food out of sight, or hiding smartphones and laptops near bedtime. People who know how to do basic lifts like squats, deadlifts, and cleans are far more likely to look at a gym and see a playground rather than a chore.
Some simple suggestions for playing with social and environmental constraints on movement health: put yourself into environments that encourage activity, especially outdoors, and enrich your indoor environment while noticing features that allow unique movement opportunities. Develop basic literacy and appreciation for movements that can be done anywhere — walking, running, sprinting, jumping, climbing, throwing, dancing, and gymnastics. You can’t spontaneously cartwheel on a free patch of grass if you don’t know how to cartwheel. Explore movements well suited to your current environment: live near a beach, learn to swim and surf; near mountains, take up skiing and hiking; near large fields or tracks, train your sprint time. Find social groups that encourage you to move and that make you feel like a valued member when you do — and avoid groups that make you feel guilty, ashamed, or incompetent. Finally, take advantage of what the modern world has to offer. With a few internet searches, you can find instruction in martial arts, juggling, yoga, capoeira, soccer, kickball, gymnastics, javelin, and kayaking. Hundreds of YouTube tutorials are ready and waiting if you want to learn a new dance step.
Chapter 7 — Structure
Because anatomy is right there ready to be MRI’d, foam-rolled, and scalpelled, people are quick to assume it is the key piece of the movement puzzle. This is especially true when the puzzle is pain, which is usually blamed on some form of structural damage — a bulging disc, torn rotator cuff, degenerative joint changes, or muscle knots. However, the correlation between tissue damage and pain is far weaker than most people imagine. Structure is overrated as a determinant of pain, and that overestimation leads to literally millions of unnecessary medical treatments. On the other hand, structure is underrated in its effects on coordination. The shape of the bones helps determine what movements are most efficient and comfortable for a particular person, and because everyone has a different skeleton, each person must explore to find what works best for them.
Although bones, tendons, and cartilage appear relatively static, they are always engaged at the cellular level in a dynamic process of adapting to their conditions. Every day they grow slightly more or less capable of making certain movements safely. These adaptations may take months or even years to yield meaningful results, but they are ongoing. Adaptations to structure are also specific: if you repeatedly contact a certain part of your heel during walking, that specific area will slowly grow larger and denser, much like developing a callus on skin. The current structure of your body is the result of its “efforts,” over many years, to adapt to the specific forms of mechanical and energetic stress it has experienced. The body’s redundancy supports this resilience — at least nine different muscles can help flex the hip, and if one is injured or fatigued, others take over. The same is true for almost any other basic movement.
There is a very important and optimistic message hidden in the research: structural damage does not always cause pain, and pain is not always the result of structural damage. Confusion about these facts is the cause of a tremendous number of unnecessary and damaging medical treatments. The evidence comes from two lines of research. The first is a series of studies showing that almost no matter where you point an MRI on a person over 30, you have a very strong chance of finding significant damage, even in places without pain. Disc degeneration is present in roughly 80 percent of asymptomatic 50-year-olds, disc bulge in about 60 percent, and disc protrusion in about 32 percent — all without a single complaint. As that research famously concluded, baseline MRI findings cannot predict future low back pain.
Dr. James Andrews, a nationally recognized orthopedic surgeon, scanned the shoulders of 31 healthy, pain-free professional baseball pitchers. He found abnormal shoulder cartilage in 90 percent and abnormal rotator cuff tendons in 87 percent. His conclusion: “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an MRI.” That tissue damage does not necessarily result in pain does not mean it is irrelevant — if you have a disc herniation or torn rotator cuff, pain is more likely. Think of structural damage as kindling for a fire that may or may not be lit by other factors.
Research has also found that many popular surgeries — though not all — work no better than a placebo, yet these surgeries are still performed at the rate of hundreds of thousands per year. Several studies have found that popular shoulder surgeries, such as acromioplasty, are no better than exercise. The medical establishment has real biases in how it treats chronic pain: it favors treatments based on simple structural explanations and tends to ignore the complex neurophysiological processes that may be more important. Patients considering surgery for chronic pain need to ask their surgeons hard questions before going under the knife.
Physical therapists, massage therapists, and chiropractors generally consider their view of the body far less reductionist than that of an orthopedic surgeon. However, many of their pain treatment methods are similarly focused on structure. Popular techniques like spinal manipulation or myofascial release are premised on the alleged ability of the therapist to make significant changes to hard structures — bones, muscles, and fascia — in just minutes, using nothing more than hands. Although these therapies can sometimes help with pain, it is unlikely that the mechanism involves meaningful changes to the targeted structures. Research shows that the pressure required to deform mature fascia is beyond what can be applied with hands, foam rollers, or even steel tools. We aren’t made of clay — if we were, our backsides would be misshapen after sitting on a park bench for a few minutes. Although myofascial techniques can increase flexibility and reduce pain, the mechanism probably involves changing neurophysiological processes related to perception or coordination, not structure.
Some chiropractors advertise the ability to change the alignment of bones, especially vertebrae — identifying joints that are “out” and cracking them back “in” with an adjustment. Although bones can certainly move at their joints, it is quite another thing for them to snap in and out of place like pieces of plastic in a children’s toy. When a joint violently pops from one position to another, this usually indicates an injury or dislocation, not a beneficial realignment. The popping sound from a chiropractic adjustment, called a cavitation, is probably caused by a small movement of the vertebrae away from each other and then back together. There is no evidence that cavitations create meaningful long-term repositioning of the vertebrae, and studies have shown that manipulation cannot change the position of the sacroiliac joint or the neck. More importantly, chiropractors are not able to predict which vertebrae will cavitate on a given manipulation — which tells you something important about the level of structural control they actually have.
Another widespread misconception is that “muscle knots” are a common cause of pain or stiffness — that muscles can contract into a palpable ball requiring deep pressure to release. Classic areas of complaint are the upper traps or between the shoulder blades. There is no doubt that muscles in these areas feel tight and sore after prolonged use at a computer, and pain may relate to associated muscle fatigue. But the subjective feeling of tightness is not the same as actual mechanical tightness. Studies looking for abnormal EMG activity in relaxed but sore muscles are mixed, and skilled massage therapists have been shown to be unable to palpate a client’s back and predict which areas feel tight to the client.
Structure does adapt dramatically when given the right stimulus. One striking example involves surgically relocating the fibula to where the tibia should be, directly under the knee. The fibula now bears weight, and in just a few years it transforms into a bone that looks just like a tibia — a remarkable example of adaptation and self-organization. We tend to think bone shape is determined by genetic code, but here the more important constraint is environmental. These extreme adaptations are only possible when you are very young and the body is highly plastic. Adults cannot make major changes to the shape of their skeletons, but they can make dramatic body transformations by adding muscle and losing fat. Dropping twenty pounds of fat will make you a better runner, just as adding it will improve performance in sumo wrestling. Strength training and greater muscle mass will protect you from injury during sport and probably assist power generation in power-dependent activities like baseball or football. But for the most part, the best way to develop the structural adaptations that will assist your performance in a particular activity is to do that activity. Training off the field provides important benefits, but is always more of a supplement than the main course.
Chapter 8 — Mobility
Cheetahs don’t deliberately train for mobility. You won’t catch them foam rolling or booking deep-tissue massages. Their lifestyle provides all the inputs needed to ensure the system self-organizes in an adaptive way, bringing into balance the whole orchestra of different variables that create functional movement. Most modern humans follow the cheetah’s plan for mobility development — at least for a while. From infancy until age six or seven, a child’s mobility is shaped mostly by unstructured play, and the results are pretty good.
As kids age, they tend to slowly lose their freedom of movement. By college, most will not be comfortable sitting in a deep squat for any extended period — assuming they can get into this position at all. Their movements up and down from the floor will have less variability and smoothness. By age 30, aggressive dance moves or karate kicks are inhibited by a realistic fear of hamstring or groin injuries. At 40, some people have difficulty getting their arms fully extended overhead, especially at speed or in combination with arching and rotating the upper back.
It would be a mistake, though, to think that losing mobility is mostly about getting older, although that certainly doesn’t help. Like many other qualities of movement health, mobility is relatively easy to preserve so long as it is used at some minimum frequency. People who habitually sit in deep squats — as is common in certain Asian countries and every hunter-gatherer culture — retain their ability to do so well into old age. Walking through the streets of Vietnam, it is easy to find 80-year-old men and women eating soup or waiting for a bus while sitting on their heels, able to move smoothly back and forth into this position from standing. In Western cultures, by contrast, we spend lots of time in chairs or couches and very little on the floor. We don’t often use the end range of motion in the ankles, knees, and hips, so we lose it over time. A similar pattern occurs in the upper body but more slowly — as we age, we reach more for the computer mouse or remote control and less for tree branches and monkey bars.
Babies are born with all the mobility they need and much more to spare. The bones at their joints are well spaced and the tissues holding them together are soft. As time passes, they gradually shed the flexibility they don’t use — and this is actually a good thing, because flexibility has a real price. People with genetic connective tissue disorders such as Marfan’s syndrome or Ehlers-Danlos have very flexible tissues, making them hypermobile. Their elbows and knees hyperextend, they can bend forward to put their palms on the floor with ease, and their skin is conspicuously stretchy. This allows amazing feats on the dance floor or in the circus tent, but it also increases the risk for joint damage and chronic pain. Hypermobility places more demand on coordination — when movement is not constrained by structure, the nervous system must work harder to provide control. Another cost of floppy joints is loss of efficiency and power. Just as a golf ball bounces higher than a deflated tennis ball, a tight muscle or tendon has more spring. This is why elite runners tend to have stiff hamstrings and ankles and relatively poor range of motion into a forward bend — they use their stiffness to bounce down the road.
It is commonly believed that improving flexibility is a good way to prevent sport injuries, the logic being that many injuries — especially muscle pulls — occur by exceeding the safe range of motion, and that increasing that range creates a protective buffer. However, research is mixed on whether flexibility in the hamstrings or adductors correlates with injury risk. More importantly, stretching programs have shown only limited efficacy in reducing muscle pulls, consistent with a large body of research on stretching that has failed to produce evidence of any meaningful benefit in reducing sport injury. What works better is strengthening, especially eccentric exercise — where the muscle works to prevent further lengthening. The Nordic hamstring exercise and the Copenhagen adductor exercise, which both improve eccentric strength in the target muscles, are effective in reducing hamstring and groin injuries in athletes.
Animal studies have shown that joints immobilized in shortened positions do not lose range of motion if they are extended for as little as fifteen minutes per day. Cats sleep twenty hours, wake up, have a quick stretch, and then move like cats. They maintain mobility by engaging in basic functional activities at some minimum frequency. What basic functional activities will maintain a healthy level of general mobility in humans? One answer is to look at the movements all healthy kids do spontaneously on a playground. Climbing, hanging, and swinging from monkey bars challenge the shoulders to push and pull at every conceivable angle. Every joint in the lower body gets a multi-planar mobility test by moving to and from the ground in variable patterns of squats and lunges. These specific activities are not necessary to maintain mobility, but they are probably sufficient. In fact, just climbing alone would keep you very mobile — imagine being on a climbing structure with many potential hand and foot holds and reaching for distant points in all directions with a hand or foot. You can use the same template without a climbing wall: get into any functional position — standing, squatting, all fours, lunging, sitting on the floor — and reach a hand or foot to a random distant point while keeping your other points of contact. Yes, this is basically the game of Twister. Extreme ranges of motion are best achieved by moving slowly, under control, and with a relaxed mind state — in other words, something like a yoga class.
Chapter 9 — Posture
Many common tasks require the eyes to focus in one direction for an extended period, which demands holding the same basic position. To reduce stress, posture is constantly varied in subtle ways to shift the burden from one place to another — this is why we sit in multiple positions, shift weight from one leg to the other while standing, and generally fidget whenever we spend more than a few minutes in the same position. In a dynamic context, postural demands become far more challenging. In gymnastics, surfing, and skateboarding, just staying upright is a major accomplishment. In sports with an opponent, good posture affords the ability to move in any direction at any moment, which is an overwhelming tactical advantage.
The best posture for one person is not necessarily the best for another, because everyone has a different structure. In fact, the best posture for you right now is likely different from the best posture for you in a couple of minutes, because by then you will have different levels of muscle fatigue in certain areas, different functional goals, and different accumulated stress in your joints. The postural system is highly sensitive and responsive — it will cause you to fidget to a slightly different position that is more comfortable and functional. This is not a design flaw; it is the design.
The overwhelming majority of research on posture and pain does not support a causal relationship. Studies examining jobs that involve postures thought to be awkward or stressful have found that sitting at work is not associated with low back pain; a systematic review of 35 studies found that occupations requiring lifting probably do not cause low back pain; a systematic review of 99 studies found no good evidence of a causal connection between back pain and occupations involving awkward postures, lifting, bending, and twisting; and although occupations requiring routine heavy lifting are associated with increased risk for back pain, the effect size is modest. These results are striking given that other factors correlating with low back pain — exercise, job satisfaction, educational level, stress, and smoking — are easily identified in research.
These findings may be surprising, but less so when you remember that people are living things, not machines. Unlike car tires, humans adapt to the stress of uneven alignment. Whatever posture you habitually use is probably one you have been using for many years — you have already done a multi-year, everyday workout to handle whatever stresses your posture currently causes. Body parts are not interchangeable Lego pieces or Ikea furniture made by factory molds. Wonkiness and asymmetry are part of the plan. While extreme deviations from symmetry are often a sign of a problem, this is not always the case — Lamar Gant, an elite powerlifter with a notably crooked spine, broke world records in the deadlift. Had he listened to postural experts warning about the dangers of loading a bent spine, he would have been told not to train at all.
Although core exercises can reduce low back pain, they work no better than many other treatments — including brisk walking, general exercise, or even exercises directed toward relaxing the core muscles, which is basically the opposite of bracing. People with back pain actually use more core activation during common movements. They brace their core muscles, making their movements into bending or twisting stiffer, slower, less variable, and more guarded. Bracing seems to be an instinctive response to pain — an apparent decision by the postural system to limit movements that may aggravate a tender area. This is probably a good short-term strategy, but it may have costs over the long term: bracing is energetically inefficient, it limits mobility and function, and it compresses joints in ways that may become a source of excess stress over time.
Peter O’Sullivan, a physical therapist and back pain researcher, argues that common advice to brace your core during everyday activities may be counterproductive. He often gets clients to feel better by doing less, not more, work with their abs. Instructions to brace yourself or stand up straight can impair the relaxation, spontaneity, and variability required for efficient body use. Research shows that fear of movement related to bending or twisting can predict excessive core bracing, reduced postural variability, and bad outcomes in chronic pain. As ecologist C.S. Holling observed, placing a system in a straitjacket of constancy can cause fragility to evolve. The problem with common postural advice is that it encourages people to put themselves in exactly those straitjackets, causing them to be more fragile and less resilient rather than less.
Good posture is complex, individual, dynamic, and contextual. It doesn’t make sense to measure it with a plumb line or try to improve it with one-size-fits-all rules. A better approach is to explore different postural options and find what works best for you. Movements that require good integration of the trunk with the limbs — crawling, walking, running, and swimming, all locomotive movements — tend to improve trunk organization. Balance-challenging activities like gymnastics, dance, or skateboarding also help. Practices like yoga, Pilates, or tai chi develop skills in maintaining a particular alignment under variable conditions. The Feldenkrais Method offers lessons designed to help you “remember” subtle movements in the spine and ribs you may be neglecting, expanding your range of options for staying upright. Strength and endurance may limit postural options when fitness is the issue — holding a safe posture when lifting a heavy weight or running at brisk pace requires genuine strength to resist the forces pulling you out of alignment — but fitness is far less likely to affect posture during everyday activities, which require surprisingly little core strength.
Chapter 10 — Skill
Arthur Lydiard, one of the most famous running coaches of all time, summarized his thoughts on running technique in three words: “Forget about form.” The advice is deliberately provocative, but it captures something important. Complex movements are best exemplified by skillful control of a ball or racquet, and elite performance in those areas does not come as naturally as the simpler movements controlled by lower levels of the nervous system. You need thousands of hours of deliberate practice and probably some coaching as well. You need to watch other great players and emulate what they do, because the optimal solutions to the relevant motor problems are not easy to find — you won’t just stumble over them with random explorations of the movement landscape unless you happen to be a prodigy.
Even movements that seem straightforward are counterintuitive once you examine them. Turning a bicycle to the right is initiated by turning the handlebars slightly to the left, which allows you to lean the bike to the right — and leaning right is what actually changes your direction. Would novice cyclists learn faster if someone explained this to them? Almost certainly not. The information would simply be confusing. In most cases, the best teacher is the activity itself. One study found that novices learn faster when they make more mistakes, because errors are “grist for the learning mill.” The game is the teacher. To make sure that learning is multi-dimensional and comprehensive, occasionally change the rules of the game — not so much that you are playing a completely different sport, but enough to challenge your abilities in slightly different ways, encouraging new adaptations and building robust solutions.
Because perception and action work together, you cannot effectively practice a movement skill unless you simultaneously practice the related perceptual skills. You would not train to catch fly balls by practicing running one day and stationary visual tracking the next. But similar mistakes occur constantly in athletic training. Agility drills where athletes run around cones in rehearsed patterns are a common example. In sport, agility is about changing direction in response to visual cues — an opponent’s movement, the flight of the ball. When you run around cones in choreographed patterns, the perceptual challenge is removed. The resulting practice might develop lower-body fitness, but it will not build the links between perception and action that are critical for real-life agility. Coaches influenced by systems thinking try to keep perception and action “coupled” — practice should look more like a game and less like a repetitive drill. In soccer, for example, small-sided games (four versus four) are preferred to choreographed passing drills.
Gabriele Wulf is a leading authority on the effect of attention on performance and learning. Her research examines the difference between internal and external attention. Internal attention is directed at the body — the wrist action during a throw, or the hip extension during a jump. External attention is directed outside the body — a target for throwing, or an overhead object to reach for during a jump. Wulf’s research shows that in a wide variety of circumstances, external attention is superior for both performance and learning. In one study, unskilled sprinters ran faster when they focused on pushing their feet into the ground compared to extending the leg behind them. External cues have also been found to improve performance in jumping, agility, and strength. They are associated with increased movement efficiency and running economy, and reduced heart rate, muscle activation, and perceived exertion — runners feel like they are not working as hard when they focus on distance rather than gait mechanics. External cues improve dart throwing, golf shot accuracy, balance, and posture. In each task, it seems better to focus on the end result rather than the specific body mechanics used to achieve it. Trying to control movement top-down interferes with bottom-up processes that are far more intelligent.
Research confirms that internal attention is associated with choking, even in experts. Excessive self-consciousness tends to cause paralysis by analysis and a freezing of degrees of freedom — as Nick Winkelman has pointed out, an expert who is choking moves like a novice who is learning. When the pressure is on, getting into a flow state is not easy, but the pathways for access are built during non-stressful play. This does not mean you should never use internal attention during performance or practice — it may occasionally be useful with novices or when learning complex movements with many different parts. Most professional golfers are well aware of exactly what their body is doing at key points during a swing. But during performance and most of their most useful practice, they focus on goals, not methods.
Based on this view, physical therapist Greg Lehman recommends spending less time worrying about subtle biomechanical flaws and more time improving the general health and function of the relevant joint — a strategy sometimes called “just load it.” Heel-striking, for instance, is not associated with increased injury rate and is the most energy-efficient way for most people to run. Close to 75 percent of elite half-marathon runners are heel-strikers. Trying to correct running form is unlikely to prevent injury and will often make runners slower and less efficient. That said, corrective methods are not completely without value. Although recommendations about the “right” way to move are usually not mandatory, they may point toward unexplored options. Squatting with a perfect neutral spine is not necessary — or even possible — but it is an interesting challenge that may improve body awareness and functional variability. Running on your forefoot is not something you must do, but it is a reasonable thing to try if your current technique is causing problems. The goal is always to expand your repertoire of movement solutions, not reduce it. Think in terms of options, not corrections.
Chapter 11 — Pain
There is no single “pain center” in the brain and no simple switch that can be thrown to stop it. Most pains arise in the following manner: a body part is damaged, the damage is detected by sensory receptors near the injury site, a danger signal is sent to the brain, the brain perceives the need for a protective response, and it reacts in a way that creates pain. Pain is the output of a highly sophisticated alarm system. Despite this complexity, not all pains present a mystery. Pain in your foot is easily explained by a splinter right where it hurts; a sore knee makes sense if you fell on it yesterday. Even when the cause is not obvious, a medical examination or imaging might find a broken bone or torn ligament. Not all pains are complex, and a straightforward biomedical treatment approach works well in many cases, especially those involving specific pathology. But the origin of some pains is more elusive — and on average, back pain becomes more prevalent until age 60 and then actually declines, suggesting that local tissue damage is rarely the full story.
The purpose of pain is protection. If you sprain your ankle while running, pain gets you to stop running and start limping so the ankle can rest and heal. Some experts view pain as one component of the stress response — a way of helping the body respond to a perceived emergency. The protective function of pain is clarified by imagining life without it. People born with congenital analgesia cannot feel any pain at all. They bite through their tongues while eating, get third-degree burns without noticing, and don’t realize a leg is broken until it collapses under their weight. They don’t fidget when sitting or standing, so their joints accumulate repetitive stress and develop severe degenerative joint disease at young ages. They often die young. These facts make clear that pain is not an enemy to be eliminated but a fundamental feature of health and survival.
Sensory receptors called nociceptors are located at nerve endings all over the body. They detect potential threats and can be triggered by mechanical force, temperature change, and chemical conditions related to inflammation, injury, or excess muscle work. When triggered, they send a signal that may or may not reach the brain, prompting it to consider whether pain is necessary to protect the area. Nociceptors have a firing threshold — a light touch to your arm won’t activate them, but a firm smack will. Nociceptive signals can also arise from the middle of a nerve trunk rather than its ending — what is called ectopic nociception, because it arises in the “wrong place.” This confuses the higher levels of the nervous system, which don’t know where the signal originated. If a nerve is irritated near its root, you might feel the pain closer to the nerve’s ending. This is one of many reasons why knowing where it hurts doesn’t necessarily tell you where the problem is.
In situations where the brain wants to encourage an activity that is creating nociception — during an emergency, or in a highly trained endurance athlete in the middle of a race — it blocks the danger signals. Pain educator David Butler calls this “the drug cabinet in the brain” — cannabinoid and opioid substances that descend the spinal cord and block the upward flow of nociception. These drugs are powerful enough to provide full pain relief from catastrophic injuries, which many people won’t feel at all during an emergency. Triathletes are known to have especially powerful pain inhibitory systems, which allows them to endure and even enjoy events that most people would consider the worst form of punishment.
The eyes are a particularly potent source of information about threat. Seeing is believing: when you watch a horror movie, your body reacts even though you are not the one being stabbed. In one documented case, a construction worker visited an emergency room in terrific foot pain after a nail went through his work boot — after removing the boot, it was confirmed that the nail had actually gone between his toes. Controlled studies confirm the connection: a red rod applied to the skin feels more painfully hot than a blue one of the same temperature, and needle injections hurt more if you look at the needle rather than the arm.
The sense of touch also has significant effects on pain, usually serving to reduce it. This is why so many different touch therapies are effective short-term pain treatments — massage, ultrasound, kinesiotape, foam rolling, or simply rubbing an owie. The mechanism is basically distraction: non-threatening sensory input gets the attention of the nervous system, especially if it is novel or interesting, diverting attention from nociception and making it more likely to be ignored. Chronic pain is correlated with persistent negative mood, and depression seems to predict the development of chronic pain. When people are induced to have negative moods in the laboratory, chronic low back pain increases and pain tolerance to a new stimulus decreases.
The way you think about your pain can change it. If you believe it is caused by a dangerous condition like cancer, it may hurt worse than if you believe it is part of a natural healing process. Expectation has a particularly strong effect. Placebo is nothing more than the pain-killing effect of expecting benefit from an inert treatment, caused partly by descending inhibition of nociception and partly by a reduction in anxiety. Nocebo is its evil twin — expecting pain acts as a self-fulfilling prophecy. Catastrophizing, or expecting worst-case outcomes, is a risk factor for transitioning from acute to chronic pain. But optimism and self-efficacy — the beliefs that your pain can improve and that you are the one who can improve it — are genuine predictors of recovery.
The processes in the brain that create pain are largely unconscious and therefore hard to directly control. We can hope to influence them through attention, education, mindfulness, and cognitive behavioral methods. Pain, anxiety, depression, and stress-sensitivity may be specific manifestations of a more general pattern of defensiveness and hyper-vigilance. There are few specific treatments for these conditions that work significantly better than general health interventions like exercise, sleep, and stress reduction. For chronic low back pain, the most effective treatments are exercise, cognitive behavioral therapy, and education about pain.
Recovery means executing the relatively simple — though not necessarily easy — strategy discussed in earlier chapters: expose yourself to a healthy level of physical stress, reduce mental and emotional stress, and maximize recovery time. Do everything you can to let your body know it is strong, safe, resilient, and capable. The most effective treatment for Achilles tendinopathy and many other tendon conditions is resistance exercise that stresses the tendon at an appropriate level so that it can adapt and become better at withstanding load. It is still unknown whether the treatment works by changing the structure of the tendon, the nervous system’s sensitivity, or both — but that uncertainty doesn’t diminish its effectiveness. The body adapts favorably to stress in the right kind and amount. A relatively simple strategy of “just load it” is often sufficient for treating pain in a local area when that pain is related to movement. You can also improve general health by getting adequate sleep, eating a healthy diet, avoiding excessive drug use or smoking, minimizing emotional stress, working to develop a positive attitude, and engaging in meaningful activities at home, work, and with friends. None of these interventions are likely to “fix” a specific problem, but they are all capable of helping the body evolve into a healthier state.
Complex problems, including those related to pain, are not necessarily hard to solve. Toddlers are self-organizing and gravitate toward healthy behaviors as long as you provide good common-sense parenting. Complex pains are similar, often resolving on their own after a few weeks of common-sense self-care. However, some complex problems are extremely difficult to resolve — what systems thinkers call “wicked problems.” Examples include poverty, political gridlock, the opioid crisis, or a failing marriage. The system is behaving badly, reinforced by feedback loops that make the dysfunction highly stable. Because the problem is multi-factorial, it is not clear where to intervene, and many interventions directed at fixing a single factor can have unintended consequences that make things worse.
Some persistent pains are properly classified as wicked problems. Physical activity tends to help with pain — but what if it makes pain worse? Sleep and a positive attitude are helpful — but what if pain makes them both impossible? Neuroscientist Herta Flor compares persistent pain to a memory that is hard to forget. The healing stimulus might be anything: a good massage, a weekend vacation, some yoga, a trip to the gym, lots of walking. The efficacy of these treatments is less about specifics and more about perturbing the system, getting it to reset to a more adaptive state — like turning a computer off and back on to fix a problem. If continued efforts to reset fail and pain persists, that suggests the new attractor well is relatively deep, or that pain has become a habit. Old habits die hard, but they can in fact die. Drug addictions may persist for many decades but can be overcome. Long-standing political conflicts can be resolved. Trauma can heal, and people who have suffered from chronic pain for many years can and do recover. Wicked problems can be solved — but they are not fixed with a single intervention. Positive change is slower, more organic, a process of evolution. Perhaps science will someday find a simpler fix for wicked pain. Until then, make sure to keep playing with movement.