Just a little summary of some of the posts I've shared on Facebook this past week and my rationale for doing so...
The Carpenter
The Subconscious
The Human
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Full disclosure: I stole this analogy from EliteTrack.
Anyway...I used to play whack a mole. When I first entered chiro college 10+ years ago, I immediately became certified in ART. Didn't know how to take a history, didn't know how to do a physical. But that's okay, I was certified! The traps, the erectors, the adductors...I used to play whack a mole. Then I learned how to assess patients. Orthopaedic testing was the you-know-what. Empty can, full can, Lachman's, Kemps. Find the positive tests, give the high and mighty diagnosis. Treat the MRI...I used to play whack a mole. I also learned how to manipulate. Oh you want your SIs adjusted? Go ahead and lay on your side...BANG...I used to play whack a mole. Lame rehab? That too. Weak glute medius? Clam shells...No core? Planks...Tight pecs? Doorway pec stretch...I used to play whack a mole. Oh, and I learned how to read radiology as well. Hey look, he's got stenosis! Here are your flexion-based stretches. Ooh, looks like you're developing a stress reaction, you should take a month or two off. Yup, I was right, you have a type 23 SLAP lesion. We need to get you to a surgeon...stat!...I used to play whack a mole. I no longer play whack a mole. But maybe I do. Only time will tell. . I've been doing a little bit of self-reflection lately, reflecting specifically on how I attack while I work in the athletic setting. Doing this has made me realize a few things. That 1) It's not easy to look at yourself from another person's viewpoint and 2) Sometimes this process is a good way to keep you in check.
Out of all of this, what I've come up with is a guiding framework of how I do what I do. Some may do things differently, while others might take a similar approach. But what matters most is that this framework is what works for me...at least for now. Starting with a technical model
Sticking with basic principles
Thinking motor learning
Knowing regressions and progressions
Not being a slave to my methods
Hope this helps. If not, here's another example by Patrick Ward and a complementary one by Mike Reinold. Two "thinking" posts here. The Secret to Learning Anything
“That is the way to learn the most, that when you are doing something with such enjoyment that you don’t notice that the time passes.”
Urban Illusions
While it would be philosophically degrading for me to to say that injuries in sport are inevitable, reality is that there are far too many variables involved to say that we can prevent them completely.
Minimizing risk or probability of injury has been discussed to no end but relatively speaking, much of what to do following injury can only be found in texts such as Brotzman's. Guidelines such as the ones he provides are "okay" to start, because you have to start somewhere, but in my opinion, this orthopaedic model is quite restrictive in its applicability. Following the SFMA model in my opinion is better, as it respects both functional movement (whatever that is) and the influence of pain on motor control, but truly the great clinicians treat in high definition. That is, doing the things few people actually even think about when it comes to musculoskeletal injury. Now this post isn't about teaching one how to fish, as I'm still in the process of learning myself, but what I can do is lead you to several of the bodies of water that I've recently been scoping out. As a primer though, here's some basic information about muscle healing and tendon injuries. Amongst the many considerations - and by no means will this be an exhaustive list" when it comes to taking it more "HD", some of the avenues I've gone down are as follows: Tissue Stress & Rate of Circulation
Neuromuscular Firing
Functional Medicine
Again, ultimately it's about taking recovery to the next level so if anyone out there has other suggestions, I'm all ears. We all want to get "high def" and what better way than sharing knowledge. . Here's a short video of Dan Pfaff lecturing that I recently found on speedendurance.com. In this lecture, Dan discusses the importance of being dynamic when cueing your athletes. I've talked previously about how we communicate with our athletes and patients and cueing is no different. There's a good amount of research on this topic - and I'm lucky to be seeing Gabrielle Wulf at Nike Sparq this weekend - but ultimately, no two individuals are alike. So we really do have to be cognitive about what we say because in as much a simple coaching cue or discussion may seem meaningless at the time, what you leave behind is what matters most. But back to the video, I think the first line is money! Having been schooled in Developmental Kinesiology, I've unintentionally learned to watch young humans move, play and interact. But as amusing as it can be, sometimes it can be equally frustrating. Especially since none of the children I watch are my own.
I've got 5 direct nieces and nephews with 1 on the way, have an infinite amount of very close relatives, and an endless supply of children walking into my workplace. So saying I see a wide variety of children would be quite accurate. Now when it comes to ACL Prevention Programs, through the research, we know that the neurobiomechanics - whatever that means - of the core, hip, knee and ankle are extremely important. Unfortunately though, even with implemented research-based ACL prevention programs, we are still seeing a large amount of ACL injuries. Knowing this, and seeing many children on a day to day basis, it makes me wonder if ACL Prevention Programs and intervening too late. Sure they are implement BEFORE injury occurs, but are we engaging in this process soon enough? Take the "W" sit for example. The "W" sit we see in children who may have missed key developmental milestones in the 1st year of life. Sure we see this every day, but as the Prague School would suggest, central coordination here is lacking. Do we have the research to prove this? Maybe not, but I do know that once I have children I will at least have my n of 1. I certainly will not make my 2nd child the control, but I will endeavor to make sure that this "W Sit" position doesn't even enter their motor skill vocabulary. Because if we're trying to prevent valgus collapse in 13 year olds, why aren't we trying to prevent it in toddlers? So how do we prevent it? Get rid of the bumbos and leave the kids on the floor to let them play. Patrick Ward talks about movement reserves and physiological buffer zones. A while back, I posted about variability for stability. McGill always considers load vs capacity. I can go on and on but ultimately it comes down to having some wiggle room to spare. And in manual and rehabilitative therapy, it is also important to have a shed of tools (treatment options) in order to be able to match the requirements - or presentation - of the individual you are working with in the event that your first choice of options aren't appropriate. Several weeks ago, I posted several foot-ankle exercises I had used with a young gymnast to improve foot and ankle control. Unfortunately, these specific exercises weren't appropriate for one of our soccer players so I had to think laterally - yet under the same principles - to match the exercise to the individual. Here are the ones I used. In 2010, I summarized the three phases of muscle injury & healing as described by Jarvinen (2005) in AJSM.
Now, a number of years have passed and a number of journal articles have been published since then but indeed, the science still remains relatively the same. Recent and relevant articles published:
Since my thought processes and clinical experiences have evolved over the years, what I would like to do below, is provide a brief summary of practical "healing method" applications (that have worked for me) to the phases as an update to my original post. My updates will be in red. . Destruction Phase: Initial rupture and necrosis of myofibers
Hematoma formation occurs between the ruptured stumps of the myofibers Blood vessels tear and release inflammatory cells
*Note: Repair and Remodelling Phases Are Concomitant – simultaneously supportive and competitive In this phase, my primary objective is to protect. For protection, I want to ensure that the hematoma between the ruptured stumps do indeed form so that the two "detached ends" can reconnect if you will. The simplest method is protect from further damage. In most cases, this occurs naturally (i.e. athlete voluntarily or involuntarily removes self from competition or training). In some cases, the athlete will continue but once the activity is completed, protection should be the first priority. Additionally, it is important to incorporate lateralizations and regressions in training to minimize deconditioning and facilitate positive humoral and hormonal responses. Relevant resources on training during injury:
Repair Phase: Phagocytosis of necrotized tissue
Regeneration of myofibers
Production of a connective tissue scar
Capillary in-growth into injured area
My next goal is to preserve. For preservation, my goal is to initiate the healing process as soon as possible and NOT prevent inflammation from actually occurring. Traditionally, we have been trained to think that inflammation is bad yet in order for step 2 (repair) to occur, inflammation is necessary. But more specifically, what we want is "good in, bad out". Only now are we gaining insight into the negative effects of rest, icing and cryotherapy on tissue healing rates and sooner or later we'll be enlightened with the negative effects of compression as well. Those who are well read already know the value of muscle contraction on lymphatic circulation and hormonal responses post-injury. My current approach is to promote as frequent muscle contractions as possible, in as safe and protective manner as possible. Whether via simple distal extremity ABCs, digit contractions, bicycle riding, or non-fatiguing electrical stimulation, my goal is to initiate the healing process rather than delaying it (by ice and/or compression). Recent and relevant resources on the role of inflammation on tissue healing: . Remodeling Phase: Maturation of the regenerated myofibers Contraction and reorganization of the scar tissue
Recovery of the functional capacity of the muscle
Last, but not least, my objective here is to promote remodelling. Thanks to my friend and colleague, Dr. Andreo Spina, I have gained a better appreciation for role manual methods in influencing tissue remodelling. Research tells us that cells turn over but respond secondary to stimuli. This is common knowledge. However, from a manual therapy standpoint, applied and controlled forces applied to tissue lead to chemical signalling, interaction and communication. So whether it be via force application with our hands or progressive angular isometric loading (or other), tissues are influenced and remodelled along the lines of applied stresses. Remodelling certainly does not end with manual therapy or isometric loading but from my recent experiences, I believe it should start there. What transpires next should be left up to the discretion of the rehab clinician and/or strength coach and based on the particular athlete at hand. Relevant resources on therapeutic application for tissue remodelling: Just a really quick post to show some exercises I implemented the other day. A coach asked me today where they came from, and the only think I could think of was that they're a conglomeration of various influences. Because truthfully, at that given moment I knew what adaptation wanted to achieve and had to think of what type of stimulation to get it. The toe spacers, I've been doing for quite a long time (see this post). The tennis ball from my friend Scott Howitt (taken from this paper). The three point contact (1st and 5th met heads + heel) from the Prague School and Charlie. And finally the theraband from Clare Frank's recent course in Calgary. Here they are. |