Today's Guest Post is from Dr. Dave Tilley, of The Hybrid Perspective. I think it's important for regular readers to hear a similar and sometimes slightly different take on my current core tennets of The Eclectic Approach.
Thanks Dave!
A lot of people have asked me how concepts like pain science, motor control, and working with the naturally hypermobile athlete all tie together in terms of injury. Through the last few years I have dramatically changed my approach to both coaching and patient treatment based off of all these realms mixing together. I figured a post on some ideas that I have learned about or that float around in my head might be interesting for some people. Warning, its a little long and a lot nerdy.
First, I want to make sure I give credit to where I have learned from and also point people in the direction where they can learn more. Not intended to be a endorsement list but if interested be sure to check out…
A lot of people have asked me how concepts like pain science, motor control, and working with the naturally hypermobile athlete all tie together in terms of injury. Through the last few years I have dramatically changed my approach to both coaching and patient treatment based off of all these realms mixing together. I figured a post on some ideas that I have learned about or that float around in my head might be interesting for some people. Warning, its a little long and a lot nerdy.
- All the great pain science works of Dr. Lorimer Moseley, Dr. David Butler, and Dr. Adrian Louw(Explain Pain, Therapeutic Neuroscience Education, The Protectometer Handbook
- Motor Control and movement concepts from the Functional Movement Systems group ( Movement, SFMA 2 Advanced more specifically related to motor control taught by Dr. Greg Rose)
- Dr. Charlie Weingroff and his work (Lateralizations and Regressions, and yes his awesome “Random Thoughts” type post had inspiration to this)
- The work of Dr. Mike Reinold and Dr. Kevin Wilk for their work in the laxity/instability realm (The Athlete’s Shoulder, Kevin Wilk’s Shoulder Instability DVD, Functional Stability )
- The great gymnastics resource, Handbook of Sports Medicine for Gymnastics edited by Caine, Russell, and Kim
Keep in mind this are just my thoughts and opinions based on where my brains at.
- Pain is produced by the brain in response to threat or the perception of threat (get more here and here). We have danger receptors called “nociceptors” in our body that can transmit things like chemical, mechanical, and thermal nociceptive information to our brain. Tissue damage and chemical inflammation can heavily influence the CNS leading to more sensitization and pain output. But, ultimately the decision is up to your brain based on it’s evaluation of the situation and perception of the “state of the tissues”. Think about phantom limb pain in amputees (no tissue damage with lots of pain) or in the opposite idea soldiers to have significant injury with no pain (lots of tissue damage with no pain). The work of Adrian Louw is an excellent resource for people to look into. If the brain evaluates the situation and believes you’re in more danger than safety, it will produce pain or may change motor control to protect you. This is not to say tissue damage doesn’t matter, more on that below.
- Laxity and hypermobility (non pathological) are different from instability (pathological). Someone can be congenitally lax and have no issues related to perception of threat or pain output. However if someone has a huge range they can’t control or has high force going through a joint frequently that can’t be managed, that may become an issue. Joints being cranked into huge ranges the brain doesn’t feel safe about may be pretty threatening. I think this carries over quite a bit to ideas about flexibility training , active versus passive ranges, and methods being used to increase range.
- Short term changes in flexibility or range of motion can be rapidly seen, but making long lasting changes that show carry over to movement patterns is really the jackpot. There is some great resources available on the theories behind why changes may be more neural and not tissue change related. To quote Dr. E “the nervous system is easily tricked, but not easily convinced“. If your brain and nervous system perceive a threat with a large range of motion, it will restrict your access to use it during movement patterns. Also, if you don’t actually use the range of motion developed during skill work, the changes will likely default back and may further contribute to compensatory movement strategies as the nervous system attempts to get the job done. I think making changes stick comes down to knowing the theories behind why fast changes happen, building the new range into movement patterns with training, convincing your brain its non threatening and to use the range, fully sculpting the sensory-motor homuluncar maps for movement, and then train in the range to get strength/control.
- At the end of the day your brain aims for surviving and saving energy. It will happily sacrifice performance and movement quality for your well being, both consciously and unconsciously. When you get into a fatigued or chronic sympathetic state, this may amplify things even further.
- I do think faulty biomechanics and aberrant motor control can play a big role in localized joint overload, tissue damage with chemical irritation, and pain experiences. Poor intersegmental kinetic chain coordination can create quite a bit of trouble related to local overload, or “relative compensatory flexibility” as Shirley Sahrmann calls it. The biggest example that comes to mind is the gymnast who lacks mobility and/or the use of the available motion in their shoulders, thoracic spine, and hips during hyper extending movements. If the lower back is making up for the lacking motion or use of available motion it may create a huge hinge point in the lumbar spine that becomes subject to high force/high rep skill volume. This could lead to the perception of threat and pain with overload at that area, especially in the developing athlete who may be hitting their peak height velocity for growth who has less tissue loading tolerance.
- The large uncontrolled range of motion under high force may in fact cause tissue damage and create chemical irritation with repetitive microtrauma. This could then lead to an increased threat perception, pain output with certain movements/skills, peripheral sensitization, and an overall reduction in movement/pain thresholds. I also think that poor dynamic stability as well as technique is a big factor in joint instability and repetitive microtrauma contributing to threat in sporting environments like gymnastics. This is usually a part of my conversation with patients of this population for the “pain isn’t all in your head” idea.
- When you start to move into the realm of tissue level problems like seen with Ehlers-Danols Syndrome this really has to be considered. A lot of naturally mobile gymnasts (or dancers, or other sports) who borderline on having EDS make their way into gymnastics through a natural selection type process. With this in mind we always have to consider motor control, strength in full range, and monitoring tissue load/training volume to tissue recovery ratios in an effort to steer clear of problems. Due to their inherent lack of static stability they need exceptional dynamic stability and motor control to help support joint function.
- I think non pathological hyper mobility starts to become pathological instability and the brain’s pain output when someone has large ranges of motions without dynamic stability and/or strength to back it up. On both the perception of threat and possible tissue damage front this can cause problems. Under high force, high training volume, and lots of training it can start to snowball.
- Pain changes motor control in all sorts of ways. The work from Hodges in his new book and many other great researches with current theories (here and here) includes the concept that the nervous system may redistribute and reallocate the function of certain muscles in response to threat/tissue injury. They also suggest how changes happen on multiple levels in the nervous system. There are many great parts to the book but Lorimer Moseley has a fantastic chapter that really helped me put the pieces together. This is partially the explanation for why there is no “one response” of muscle function with pain or injury. Although common patterns may exist each person will ultimately have a unique pain experience, pain neurotag, and movement adaptations in response to injury. This supports why needing an individualized treatment program for their issue is so important.
- The nervous system may restrict range of motion subconsciously as a protection mechanism, creating generally mobile people to have sudden “tightness” or altered movement patterns. I can’t tell you how many times a congenitally lax gymnast has told me they get stretched more because their coach thought they were “tight”, when in reality it is likely a false positive for lost mobility to make up for an underlying motor control issue. There is a lot of different opinions of this kind of theory behind why generally hypermobile people may develop myofascial pain or trigger point pain (a separate beast of a topic).
- Following a return to gymnastics (or any sport) following injury a slow graded exposure back to volume, force, and loading is key in my mind to make sure the perception of threat does not sky rocket back up. Remember with an injury some has a lower pain and movement threshold, and you need to slowly restore that back to a acceptable level with graded exposure to ensure smooth return to sport. Second, if there has been significant tissue damage, the slow introduction based on objective force and volume helps to ensure proper adaptation to demands of the tissue. Third, if there were certain skills or movements that created the onset of a injury, that skill/movement needs to be retaught and corrected for so the same issues doesn’t return. Remember previous injury is the number one risk factor for another injury, and some gymnastics epidemiology research suggests up to 40% of injuries may be re-injury. I’ve heard about or seen far to many young gymnasts who rush back to gymnastics too early with no progressive return to sport program, only to lead to a re-injury or ongoing pain.
- I think teaching your nervous system to control the joints in full range of motion and with appropriate full range control is a very important key to this population (Big FRC concepts). I think younger athletes need a big focus on this so it hopefully becomes part of their “go to” patterning for skills. This goes for both mid range but more important end range control/proprioception. Not only do I think this is important to maximize neural control for such large ranges seen in gymnastics, I also think it is key in making sure small localized stabilizer function is optimized. Low threshold local stability is important to help maintain segmental stability and joint centration. However, the also important part to this is that by having ideal local stabilizer control, bigger more prime movers are able to function fully for power and larger movements (Gray Cook concepts). This is theorized to help increase performance as larger muscles can do their job more successfully in a prime mover situation. Another part to this theory is that it helps combat fatigue and increased endurance as larger muscle aren’t constantly overworking to create joint stability. All pieces of the puzzle and support in my mind to why you have to mix training up between both sides of the spectrum and teach the nervous system about movement variability.
- I think a combination of specific motor control training, gymnastics specific conditioning, and formal strength and conditioning/weightlifting is one of the best ways to help prepare a gymnast’s system against the high forces of gymnastics. This is in conjunction with the need for objective monitoring for training volume, proactive methods like screening/pre-hab, teaching about nutrition/recovery, and more attention being put to to objective data behind individual developmental profiles (think tracking peak height velocity). I absolutely think gymnasts need to be able to show control of their own body under all ranges, and train gymnastics specific conditioning. But, the use formal weightlifting/strength & conditioning to get develop tissue adaptations, increase power, and create individualized programs can’t be understated. I still feel the concept of formal weightlifting for gymnast is very misunderstood, and there are many myths about it. It takes a good coach, a formal program, and the right team to put it into place but when it gets rolling the benefits can be 10 fold.
Sorry if that was a longer post, but I think the concepts are interesting to bring up. I’m probably not right on the money and a lot of these are subject to various other thought processes. But, like I said just wanted to share some of my thoughts. Have a great weekend!
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