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Coordination and sensation in rehab

Having just listened to John Kiely’s Pacey Performance Podcast, I felt compelled to get some ideas down. John, as ever, discussed some thought provoking points (thanks John) some of which came up in conversation of the last week, particularly around coordination in injury. John talked about alterations in coordination and reduction feedback of sensation in injured athletes. This, I think, rings true for traumatic injury with ACL reconstruction especially coming to mind where the majority of training is focused on restoring, and hopefully surpassing, prior strength and movement qualities. My conversation around changes in more chronic conditions such as low back pain, athletic groin pain and maybe repetitive hamstring injuries was subtly different.

Instead of reduced sensation, it seems possible that these conditions present with the opposite. This left me with some questions that may be worthy of conversation:

  • What if every movement, common in chronic conditions, begins and ends with the thought ‘how does my back/hamstring/achilles etc feel’? Does that increase neural drive to that set of tissues?
  • Does that thought process, and potential alteration in recruitment, result in alterations in coordination that continue to drive these chronic conditions? For example bracing patterns in low back pain or hamstring driven hip extension
  • Could it be argued that the main effect of our addressing psychosocial aspects relating to these conditions is altered coordination and therefore altered loading on certain structures?
  • Do we slow down recovery in these conditions through continued drawing of attention to the painful structure? e.g. ‘how does movement that effect your back?
  • Can we speed up recovery by drawing attention to a different set of sensations?
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Psychology during rehab

A recent twitter debate/argument prompted this blog. When I studied for my BSc in Sports Science and Physiology, I had modules from 4 broad areas. Physiology (obviously), Biomechanics, Motor Control and Psychology. At the time and ever since, I have had phases of interest in each area as I read and applied something new to my practice or my own training/sport. As a Strength and Conditioning coach, where a large part of my work is focused on rehabilitation in active sporting and general populations, I am never addressing one single area.

I know that by altering a sit to stand or squat pattern and perhaps adding load to that movement I alter the neural drive to different muscle groups. I change the kinematic and kinetic variables about different joints. I can, over time, alter the fat infiltration and cross sectional area of the muscle. I can increase someone’s confidence in their ability to complete the movement without causing damage.

So when we talk about using movement we can be certain that we are addressing some psychological aspects, alongside the physiological, motor and mechanical aspects. In a similar way, when we address the psychology, we can also impact the other areas. Reducing fear can alter how someone moves. Although I would suggest we limit some of the possible neural, mechanical and structural adaptations if we solely take this approach. One point I would contend however is that movement doesn’t work because the literature doesn’t say so. If you look at the majority of Low Back Pain strength interventions for example(speaking here as a strength and conditioning coach critiquing programme design) they are poorly designed and described and lack specificity in their aims.

It is our job to assess the person in front of us and, using our skill set, help the person to address the areas we think are going to help them improve. For me, my approach is based around the development of different biomechanical patterns to alter loading throughout the body and increase strength through those movements in order to affect changes to the physiology, psychology, motor control and biomechanics as I believe necessary. This is because I am a strength and conditioning coach and they are the tools available to me. To me, the suggestion that graded exposure to training is a purely a psychological intervention is false, unless it is the primary outcome of it’s use. Otherwise, you would have to describe all training as a psychological intervention, which is clearly wrong.

The important point is to be clear of the qualities that you are hoping to help someone change and intervene in a way that gives you the best chance of changing it. If that is addressing pain related behaviours, then choosing to use counselling in order to do so may be a good option. If you want to alter someone’s movement, removing any psychological barriers and showing the person an alternative movement strategy may be a good way to go. Very often debates over Twitter slingshot people to either end of a spectrum, probably because it’s a difficult platform to write a coherent argument that fully represents all of your view. Either way, it makes fun reading.

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The importance of being wrong

I have just finished reading ‘Black Box Thinking’ by Matthew Syed and it has emphasised the need to embrace failure as an important part of developing my coaching as well as my methods and philosophy. It is natural to want to be right all the time, but it is a fallacy to believe that you can be or indeed should be. Operating under the assumption you are right all the time will also stunt your ability learn and develop which ultimately effects the outcome for your athletes and or patients.

It can be easy to fall into a pattern of continually doing the same things over and over because that is the way you do it and you think it is the best way. Formally challenging yourself to do things differently can be a way of staying away from this. I regularly place constraints on my coaching such as only using certain cue types (i.e. only verbal or never verbal) throughout a day or a week in order to help improve my ability to use them and to see how effective they are. I will test different cues for exercises in order to improve my ability to coach the changes I wish to see. I will remove or add certain exercises from programmes in order to learn how necessary they are, how effective they are and whether there are alternatives that are easier for me to coach and for people to retain. My coaching environment is one where trying to develop competency in movement is very restricted in terms of contact time and the ability to coach the movement quickly and make it resilient to error between contact times is the main driver behind my exercise selection.

Through regular reflection on this I continually try to learn from what hasn’t worked in order to put it to one side in my practice and further refine my exercise selection and coaching. I feel that having a mindset where I am not tied to particular methods and where I see errors and inefficiencies not as a negative but a learning opportunity helps me in doing this.