On November 16th I gave a lecture at the RCCSS(C)'s Run Faster Conference in Whitby, Ontario. The objective for my lecture was to put forth a therapists viewpoint of treatment integration into a performance enhancement environment whereby my goal was to suggest ways we can make 1% of our interventions 100% better.
I started off by suggesting that every interaction between athlete and therapist is to be considered a “treatment” or more accurately, an intervention. That is, there is always an input - physical or not-physical, conscious or subconscious - with a subsequent output or adaptation by the athlete. Be it passive therapy, exercise intervention or communication, there will always be an after effect of each encounter. It is our job to understand this and do our best to ensure that every adaptation is a positive one.
I spoke about performance therapy - aka performance engineering - and that in a performance enhancement environment, that it may be important for us therapists to be able to wear many hats. Trent mentions this in a recent Q&A, that:
“In many ways, the applied sports practitioner has to become an “expert generalist” being able to link and apply many interventions across many scientific disciplines to optimize performance.” Because we may often need – and therefore know how – to play the role of an associate coach."
I also suggested that everything we do should be athlete centered. That all interventions in a performance enhancement environment will have the end goal of performance enhancement (obviously), cognitive resiliency and injury prevention.
The guiding framework and its application were discussed and in so doing, we must not be a be a slave to our methods. Being athlete-centered will minimize the opportunity for this.
I spoke about three key components of dynamically assessing the athlete: the neuromusculoskeletal, the cognitive integrity, and the physiological. For the neuromusculoskeletal, I generally like to think of assessing along a static-dynamic continuum where I’ll start with watching the athlete in action (dynamic) in order to know what I see and what I don’t see, then progress along the continuum toward the static if I want to know why I don’t see what I don’t see. It is important though, that we have a standard operating procedure to be able to decipher what’s normal, when we expect it to be normal and when we expect it to be abnormal.
Dynamically, I will also want to understand – assess though interaction, observation, etc – the cognitive integrity and resiliency, or mental hardiness, of the individual since mindset always differs between individuals. Understanding athlete physiology is important as well since levels of stress may vary at any given moment in time. Therefore, how we intervene in their current state should be kept in consideration. Athlete monitoring comes to mind when it comes to physiology but in my opinion, just being present should be the top priority.
As I mentioned above, if every interaction we have with, and every intervention we give to, the athlete is considered a stressor that results in adaptation – positive or negative – then we need to “pick our battles” and intervene where we think is necessary rather than all the time. Manual therapy, in particular, can be a negative input on speed/power days or prior to competition if performed either too aggressively or in too high of a quantity. Additionally, we must time our recovery interventions as Joel Jamieson explains in this video.
While many of the attendees at the conference were clinicians who specialize in clinical rehabilitation, part of my discussion was how we can implement traditional rehabilitation exercises into a performance enhancement environment. Especially during warm up and in general strength training circuits. Because whether it be rehab, corrective exercise, or skills coaching, my opinion is that it all falls through the filter of motor learning toward neuromechanical adaptation.
We do need to remember that there are two methods of attacking motor learning: 1) The Hard Disk via direct upload through automated subconscious control and the other; 2) The Working Memory via conscious control. Unfortunately, the latter – internally directed attention - often results in reinvestment (excessive conscious control of one’s skills) and may be more prone to breakdown in automaticity/fluency of performance through such means as paralysis by analysis so we must keep in mind that any of the techniques (physical or verbal) we employ can be positive or negative. And what we don’t want to achieve is paralysis by analysis.
Other methods to foster motor learning that I spoke about were implicit learning, good cueing and effective communication. Implicit learning is essentially presenting information at levels of perception below normal levels of awareness, whereby how we set up our intervention environment takes priority over verbal feedback. Again, verbal feedback can result in overthinking during motor executions and subsequently excessive conscious control of one’s skills. So often, we should STOP telling athletes what to do, LOOK – assess motor skills, and LISTEN to the athletes thoughts.
Effective communication essentially boils down to three main objectives: prevent paralysis by analysis, facilitate an optimal state of mind and readiness, and remove doubt. I shared my thoughts on effective communication through explaining what nocebos were (the same principles apply with Trent's Q&A above) and how we may be creating nocebos in our interventions. Again, we want positive adaptations and while many of us possess highly effective skillsets, it’s less about what we do and more about how explain it. Remember, it’s about the adaptation and it’s about what we leave behind.
I still think Steve Jobs was a genius, but if you look at the description beneath the video on the youtube page itself it says,
"Technology codes our minds. Changes our OS"
This got me thinking. With the advancement and abundance of personal technology devices, are we truly upgrading our neurological operating systems? In my mind, there's not doubt that new synapses are being formed and myelinated everyday but in a human sense, tradeoffs seem to be occurring.
Is this "new and improved" OS of ours - the neurological software - actually taking up more space on our hard drives - the neurological hardware? Especially subcortically? Is a tradeoff occurring?
Taken directly from the abstract of Kobesova and Kolar's recent paper, "Developmental Kinesiology: Three levels of motor control in the assessment and treatment of the motor system", we can see that:
'Following the newborn period, the subcortical level of the CNS motor control emerges and matures mainly during the first year of life. This allows for basic trunk stabilization, a prerequisite for any phasic movement and for the locomotor function of the extremities. At the subcortical level, orofacial muscles and afferent information are automatically integrated within posturalelocomotor patterns."
Those of you who understand DK know that this is a critical period of learning. Not only physically, but socially, emotionally, etc as well (read "How Smart is Your Baby"). But strictly in a motor control sense, the obvious is that technology is making us more sedentary.
The not so obvious, is perhaps such technology is also rewiring our neurological OS - the subcortical, the automatic - and deleting our "movement" programs. Thankfully, we know that paper is still better.
But my only hope is that we don't "empty the trash".
In general, swimmers generally possess hypermobile shoulders.
And by hypermobile, I mean greater than necessary ranges of motion and subsequently, often lacking synchrony of instantaneous neuromuscular firing in the scapulothoracic and/or glenohumeral joint regions.
As a result, we know that since the body will always find the "easy way out", compensatory patterns and presentations commonly occur.
And often, one of these presentations is reactive posterior cuff hypertonicity as a protective measure against further injury and/or pain. Whether it leads to bicipital tendon pathology, bursa irritation or other is besides the point. The main point, in my opinion, is why are some individuals still so enamoured by the sleeper stretch? I mean, for any given shoulder injury, presentation or diagnosis, out comes the sleeper stretch.
In my mind, there's a difference between stiffness and hypertonicity. And sure, the glenohumeral joint "needs" adequate mobility. But perhaps more important, the GH joint needs dynamic, instantaneous neuromuscular control. And when we go to town with the sleeper stretch, we get sloppy. ESPECIALLY in swimmers!
Because really, should we be treating the compensation or the cause?
In a similar light, swimming mechanics incorporate both open and closed chain movements. Or in a Prague sense, alternating both support and stepping/grasping functions (read this article if you're unfamiliar with what I'm talking about). Now it's quite common for me to see corrective exercise prescription for the latter - YTWL's, theraband internal/external rotations, etc - but what I rarely see is the former.
Coincidentally, here's a timely clip from Gray about motor control, stability and prime mover training:
Because from the catch to (at least) the end of the pull falls under the "support function" category, in my opinion of course. And since this is the case, closed chain exercises should be the primary focus. Particularly if this is where mechanics are most faulty during skill execution.
So my recommendation to other clinicians is this...
It's okay to think critically and ask yourself why. Why you are seeing what you are seeing. And why you are doing what you are doing.
For those of you that have attended conferences with multiple presenters, you'll know that some conferences hold a Panel Q&A to wrap up the weekend.
Well recently I attended the Canadian Athletics Coaching Centre's National Throws Conference and one of the topics during the Q&A was feedback during competition. The panel included all the presenters and was moderated by Coach Derek Evely.
Here are my notes on this particular topic:
Feedback During Competition
"The best were those who worked for, and obtained, 'intuitive consciousness'. Those who learned to blend thinking with sensing, knowledge with intuition."
- an excerpt from A.T. Still: From the Dry Bone to the Living Man by John Lewis
Back in 2011, I wrote about my observations when posted at the Gymnastics venue during the Pan American Games.
As I am currently at the 2013 World Championships in Antwerp, Belgium, I thought it would be a good idea for me to revisit this post and see if anything has changed. In normal text you have my original post, while in red, are my thoughts from the last 5 days.
Foam Rollers – There are none. Not one. Obviously I use them in practice but watching gymnasts prep for training and competition is making me think that such devices could be used less with proper preparation.
Warm Up – These gymnasts meticulously mobilize each and every joint in their body dynamically. They spend the time starting from distal to proximal, from specific to general, and in all planes and directions. We might be shortchanging our athletes without this attention to detail.
Stretching – There’s no shortage of it here. Warm up here comes first then stretching. Warm up aside, stretching went from static to dynamic and is in general, mini-ballistic.
Focus – Little chatting. Deathly stares. And full concentration. Period.
Crunches Flexion/Flexing Based Movements – Lots of v-sits, and lumbar flexion warm up exercises as well. I don’t think it’s a green light for all gymnasts, but it would be hard for me to flip on the red for half of them. I see integration of all joint and myofascial segments and load sharing from head to toe. Even see the joint by joint respected (think sternum crunch in a dead bug position). In this case, I think its ok. In the normal population, I’ll still set up a road block. Remember, it was warm up, not training and definitely not volume.
Bands – Plenty of resistance here during the warm up. Band pullaparts, straight arm pulldowns, etc. Great progressions.
Amazing feats of strength, mobility, and stability - Here’s an example of a commonly performed movement seen today. This video is obviously not by the gymnasts themselves as filming them warm up is not only prohibited but creepy. Naturally, the girls were much more precise than this video but he did a great job nonetheless. Note, the girls did multiple continuous reps.
All in all, watch some of the top athletes in the world and you’ll quickly see that generalizing rules of the human body to all populations is guessing at best.
More often than not, I prefer looking for the why.
Looking for the what is simple.
Looking for the why is not as easy but I think it's more effective. More often than not, you will find it in the history. But on occasion, you'll find it in the physical. If neither, you may need to go searching (in the gym, on the pitch, on the track, etc). But you need to go and look for it.
Because in looking for the why you may find the what.
It's rarely ever the other way around.
I have a keen interest in the role that magic and illusions play in the clinical environment.
Most of us are aware of the role of illusions in pain science. For those that don't, feel free to click on the previous link or read this review of a "pain" seminar I attended to get a better understanding.
What it ultimately comes down to is that all interventions should exploit the nervous system in some form or another. And in many cases, through the use of illusions.
Think about the last patient who stumbled through your door in severe acute pain. Or that individual under extreme stress with chronic pain. What sort of strategies did you use to get them on their way much happier and in less discomfort?
Like I alluded to above, it's not uncommon for me to utilize the power of illusions to care for my patients. Now this is not to say that treatment is all an illusion, but more so that illusions can be used as part of your "treatment" strategy.
Before we move forward, let's watch the following video:
As you can see, magicians utilize various known techniques to exploit neuroscience and influence perception. And for us clinicians, I don't think this should be any different. Here are some examples based on the video:
Misdirection of attention
Joint attention and mirror neurons
As you can see, the brain is limited in that it has a one track mind. And when someone is experiencing severe, acute pain or chronic pain, very often that one track = pain. So we need to know how to redirect their attention. Again, not as a stand alone treatment - otherwise we would all be magicians - but as part of our strategies when working in the clinic.
Remember, it's not just what we can do with our hands but also how we interact with our patients! And when it comes to humor, the first individual that comes to mind is Patch Adams.
For more information on what the neuroscience of magic reveals about our everyday deceptions, make sure you check out the book, "Sleights of Mind".
I've mentioned this previously, but one of the main reasons I keep this blog is to keep myself in check. To welcome constructive criticism.
Initially it's purpose was to summarize my notes in a relatively coherent manner so that I can revert back to them for studying purposes. It then became an avenue to share knowledge for the benefit of others (some of you might have noticed that I rarely write info pieces - not because they're not valuable, but more so because everyone else is doing it). Occasionally I'll summarize a research article and often I'll review or summarize a course I attended. I can't say I'm always proud of it, but if you've been here before, you'll know that some of my posts are rants.
But again, one of the main purposes of this site is for my own benefit. To seek criticism. If I've written something incorrectly or if my thought processes are off the mark, then (hopefully) someone out there will call me on it.
This is important. Not only for myself but for anyone and everyone I work with.
So for many of you out there, I humbly ask you to seek out criticism. Because as Debbie Millman states in the video below, the most important thing to know, is when we don't know what we don't know.