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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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All coming out in the wash

I’ve been thinking about shoulders  and upper body in general this week but a lot of what I have been dwelling on crosses over to all exercise. I spent some time with some of the physios here at SSC talking about shoulder and thoracic mobility, scapular patterning and their importance. Having seen a number of people too where I’ve been working on addressing postural imbalances I’ve been getting my head around where this type of training fits into the training plan.

In the past, I’ve been guilty of letting some of this stuff  slide as long as the numbers a going up hoping that just by getting stronger it would sort itself out and would all come out in the wash. Some trap dominance during cable rows, maybe some scapular winging during a bent over row but my thoughts are shifting. Firstly, it’s reinforcing poor movements and engraining those patterns. Secondly, if it’s increasing their ability to produce force, if that force occurs through a poor pattern, their training could actually enhance the possibility of injury. I’m seeing that on a daily basis, and not just in the upper body (the large amount of groin rehabs that come through are testament to that).

It’s making me think carefully about my progressions. It’s making me think carefully about when those progressions occur. Education and feedback to the athlete is vital to create change though, otherwise they won’t buy into the exercises. Once they can see the mechanism responsible for the issue, they have a target. We use ipads and dartfish with everyone that comes in. I upload videos of their movements and what they’re looking to alter so they can look back at it and they get a reminder of what they’re working towards. It’s not just about pain/injury prevention though. I remind everyone what impact these alterations will have on their game. Ultimately they’ll turn sharper, run faster and jump and reach higher. That sinks in.