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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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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. 

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Changing behaviour in low back pain

I use resistance training to alter movement patterns and recruitment strategies during low back pain rehabilitation and find it to be effective. However, outside of that training, helping to alter behaviours that you believe are contributing to a person’s pain is hugely important. These can be changes in thought process such as how someone responds to flare ups, or physical habits such as gait or posture.

I feel that it is important to provide education around why we feel the change should be made and the rationale behind it. If someone is able to understand the reasoning, and it makes sense to them, I think they are more likely to make changes. Once this understanding is in place, it is then possible to facilitate the development of an individual’s strategies and cues for how they may achieve the changes. 

Physical changes are often easier to make as it is possible to demonstrate to someone the difference in sensation in their back when, for example, they move from sitting in a very extended lumbar posture to a more relaxed neutral or central position. Encouraging people to label these positions and put reminders around their workstation or home to move into and out of these positions is then easy to do.

Depending on the change in thought process you are looking to help someone alter, and the individual themselves, this can be easier or harder to achieve. Something that seems basic like the lack of relationship between a patient’s MRI results and their back pain can be straight forward to explain, but will sometimes need constant revisiting in order to reinforce the message you are trying to get across. It can be easy to believe that just because a topic has been discussed that you have been successful in effecting a change. Regularly asking someone to talk you through what they feel to be the mechanisms behind their pain is important in order to understand whether you have been able to effect change. It is important to understand that sometimes these beliefs are very well embedded particularly if the message has been emphasised multiple times and/or by a person with high status to the individual. This can be the most challenging part of rehabilitation with some individuals.