These boots are made for walking… sometimes

Image is everything in sport these days, like it or loathe it. And Aircast boots aren’t exactly en vogue. Unless you are David Beckham, who has become synonymous with the “Beckham Boot”, there aren’t many that can pull off the grey, dull, clunky boot look well.

Aircast boots / walking boots / Controlled Ankle Movement (CAM) boots… or just Beckham Boots.

This is becoming a problem, as perception of the walking boot amongst athletes, coaches and even other medical staff (unfortunately) is that the provision of a boot must equal a severe injury. Wearing one is a badge that not many people want. This worries me for a number of reasons…

Do no harm:

Whether you use POLICE or PRICE, our first thought in acute injury management is “Protect”. I’ve written about acute assessment before (here) but if you have just witnessed the injury and don’t have any immediate concerns about preservation of life or limb, then often we don’t want to rush into a diagnosis. Things can always look worse immediately after injury, so our plan is to offload, reduce risk of secondary injury or worsening of the initial injury (AKA.. “Protect”).

So, with lower limb injuries around the foot and ankle, quite often we will provide a walking boot. Cue the groans.. “I can’t be seen in this”, “Its not that bad”, “Don’t let the coach see me wearing one”.

But here are our options; walking boot, below knee cast, tubular bandage… or nothing.

Immobilise

If we are talking about doing no harm, then evidence suggests that long term immobilisation (greater than 4-6 weeks) of acute ankle sprains is detrimental when compared to “functional treatment” (to avoid an argument of what is functional, lets just call this “Optimal Load” and leave it to clinical discretion) (Here). But also no intervention could be seen as negligent. If we have enough suspicion to be weighing up “should I offload this?” then when compared to a control (wearing a normal shoe), a walking boot limits sagittal plane range around the ankle to around 4 degrees and reduces body weight in peak plantar plane surface forces (154% vs 195% BW) (Here). So if we face an option of boot vs no boot, where we know we can limit range and peak forces in an acute injury, the answer is “yes, offload it” even for a day until you can re-assess. Why wouldn’t you?

A brief period of immobilisation, “around 10 days in a below knee cast or removable boot”, along with treatment to reduce pain and inflammation is recommended (Here). In a study of fifth metatarsal fractures, those that we provided with a walking boot had better outcomes of pain and return to activity vs those immobilised in a cast (Here). This is an advantage of the boot. We can protect the foot and ankle in a boot but remove it to utilise other treatments and rehab. We can keep unaffected joints mobile – perhaps another blog but I like to use ankle injuries as an opportunity to work on detailed foot control, like great toe flexion, abduction, tibialis posterior control and so on. We can do all of this whilst limiting inversion and staying in plantar-grade if necessary. Or if its a 5th metatarsal stress, we can keep the ankle mobile. You get the point, we couldn’t do that in a cast.

Our other option was tubular bandage. In a world where we can download apps to make us look like cartoon dogs for free, we still have plain grey boots and boring beige tubigrips, I say this as an academy physio trying to make acute injury management appealing to young kids. When compared to those provided with a below knee cast & removable boot, severe ankle sprains had better clinical ankle function measures, quality of life, levels of pain and levels of activity at 3 months vs those provided with a tubigrip (Here). Perhaps a little bit unfair on the tubigrip, whose role in dealing with a severe ankle sprain is “compression” – a bit like saying an elastic band is worthless because its unable to hold sand together. But ultimately, in an acute injury, tubular bandage isn’t going to provide much protection at all.

Long term use:

Now the point of this blog is to de-sensitise reactions to using a boot for the short term, but it would be remiss not to mention their use in long term injuries. Following surgery or a fracture, the use of a walking boot is associated with a quicker return to normal gait and function (Here).

But does it come at a cost? Fixing the foot and ankle is obviously not conducive to “normal” walking, so it will change gait temporarily. In doing so, it can also create problems elsewhere. 84% of people using a boot developed or increased a secondary site of pain in the first two weeks of using the boot (Here). Now, 68% of those reported this pain made no difference to their life, but if you have someone with existing problems, especially in the low back, you might want to consider this stat as part of your clinical reasoning. Remember, part of our job is to prevent secondary injury.

If the boot fits..

There’s one option and aid we haven’t talked about and thats crutches. The reason I haven’t mentioned them is they come with the same stigma as a boot. They are obvious, they demonstrate you are “injured” so if someone doesn’t want to wear a boot, they probably aren’t going to want crutches either. But hopefully this brief blog gives you a bit more of an argument behind your reasoning to help reduce the association that wearing a boot equals a severe injury. So when we hear that a player has left the stadium in a boot, for the first couple of days, so what? It might be nothing. Something I have trialled before in a key first team player, which I admit is divisive, is to manage an athlete across 24 hours. So.. There are some injuries that can continue to train, like an inflamed sesamoid or plantar-fascia pain, but to give them the best chance of training and competing it would help to offload the structures through the rest of the day. So, instead of trying to control 1-2 hours of the day and reduce training / matches, why not try a boot to offload for the other 22 hours in a day? As the evidence above suggests, this is certainly not a long term solution. But across a couple of days, maybe? Limited evidence, but its worked twice for me.

The key to this working, was education. Ensuring that other players and staff understood that the boot didn’t mean a serious injury. But was an adjunct to help offload… or “protect”. There’s a theme here.

This is the message we need to get across, protecting an acute injury is not the same as us diagnosing or offering a prognosis. “You might only be in the boot overnight, but its a safe way of transporting you home.” We just need to help give them some good PR and make them seem less daunting, less serious…

 

Yours in sport

-Sam

 

 

 

A vision of high performance sport

 

I recently embarked on a professional development tour of North America, sparked by the inevitable malaise that comes from years and years of working in pro sports. I love my job and my profession and am incredibly lucky and grateful to have worked where I have, but the long hours and short recovery time don’t always allow for that enthusiasm to be re-ignited, to go out and learn from others and see what the world looks like. So, when Oliver Finlay, the concierge of sport, offered me the opportunity of a lifetime to visit Vancouver, Seattle, Las Vegas and LA to see some of the best high performance operators in the world, I jumped at the chance. 

(Top row, left to right): Jeremy Sheppard & Elliot Canton; Andrew Small. (Middle row, left to right): Amy Arundale; Graham Betchart; Nick Pituk. (Bottom row, left to right): Scott Savor; Teena Murray; Per Lundstam.

 

This is a reflection of four key themes that I took from the meetings; Strategy, impact of change, ego and mental performance.

(Top row, left to right): Marc Cleary & Brian Moore; Nicole Surdyka. (Middle row, left to right): Lindsay Shaffer; Sean Muldoon. (Bottom row, left to right): Amber Rowel & Damian Roden; Patrick Ward.

Out of respect for those that provided their time, I would like to acknowledge each and every one of those that met with us but also provide some anonymity & confidentiality to how they operate and what they are working towards. So, for most parts this is a general reflection and synthesis of information. With the odd tip of the cap where appropriate to the exceptional individual work that is being done. So, my thanks go to:

• Jeremy Sheppard (Canadian Sports Institute)
• Elliot Canton (Canadian Sports Institute)
• Andrew Small (Milwaukee Bucks)
• Per Lundstam (Redbull)
• Teena Murray (Sacramento Kings)
• Graham Betchart (NBA mental skills coach)
• Scott Savor (NBA mental skills coach)
• Duncan French (UFC)
• Amy Arundale (Brooklyn Nets)
• Nick Pituck (Cirque du Soleil)
• Katie Perlsweig (Cirque du Soleil)
• Brian Moore (Orreco bioanalytics)
• Marc Cleary (Orreco bioanalytics)
• Nicole Surdyka
• Lindsay Shaffer (Headspace)
• Sean Muldoon (Seattle Sounders)
• Amber Rowell (Seattle Sounders
• Damian Roden (Seattle Sounders)
• Patrick Ward (Seattle Seahawks)
• Sam Ramsden (Seattle Seahawks) 
  

STRATEGY 

We met with a range of disciplines with a range of experience in their current roles; athletic trainers, strength coaches, physio’s, performance directors, mental skills coaches; Ranging from 1 year on the job to entering their 10th year. But we didn’t meet one person that wasn’t aware of their process, where they were going and what challenges they faced. 

The environments that had a tangible feeling of sustainability all had clear and concise visions. Strategies of where they are now and where they need to be. Sounds obvious right? But it’s an easy thing to say and a different thing to do. 

“Build it and they will come”

Graham gave a great analogy that serves this thought well; who will be more successful, the person who tries to chase after the rabbit or the person who plants a field of carrots and sits quietly? The standout environments for me that planted fields upon fields of carrots were the Canadian Sports Institute and Redbull. Because their population within extreme sports have lived a life ungoverned by rules, they are the rule breakers that don’t conform to structure. So applying a regiment schedule that you may see in American Football just wouldn’t work. In very different ways, both organisations planted the carrots and waited. And there was a comfort in this superficial lack of structure because underpinning it were clear objectives and a vision that sat on a level that was detached from the athletes. 

Away from working with the athletes, there were processes about building, developing and sustaining a performance team that again was underpinned by clear strategy and purposeful recruitment. Seattle Seahawks, under the wisdom of Sam Ramsden, stood out as one of the departments that had perhaps been on the longest journey and was now at a point that he was truly comfortable but still had a 3 year progression plan ahead of them. Consistently, performance directors spoke of the time that this took, between 5-7 years was the consensus to establish a harmonious and collaborative performance team. 

At the other end of the journey were practitioners finishing their first year in the job, reflecting on the change around them, the change they wanted to create and how their environment was coping with the change that came with their employment.

CHANGE

Nobody likes change. Unless you are Oliver Finlay and you are studying change management as your PhD. Whether you are trying to implement change or you are a product of the change, it comes with uncertainty and requires an ability to balance and gradually influence. It was interesting to see that everyone had a different approach to this. 

Some people were energised by the positive approach to change at their organisation, whereas others clearly demonstrated signs of “change fatigue” where year on year something operational or structural had occurred and was creating a demotivated approach to change

“what’s the point in getting on board with this when it will probably change again next year” (paraphrased quote amalgamated from a few different conversations). 

The introduction of new staff was a major component of this association with change. And it was interesting to hear how new staff are integrated at different organisations. Take Cirque du Soleil, an environment where every single person has a very different personality and background, from dance, gymnastics, trampoline to military, NFL or academia. As part of the circus family, each individual was celebrated for who they are, no one had to conform. Equally, we were told that a new member of staff is almost expected to know nothing, with a robust and consistent induction period to each show. 

At one end of the scale, we met people who agreed that their philosophy in year one of a new role was to sit and be quiet, to observe and speak when spoken to. To essentially use the year to “be accepted”. At the other end we met people with vast depths of experience that could identify early on where changes needed to occur and how to improve, picking that “low hanging fruit” but on reflection, felt that perhaps too much change at once had been detrimental. 

And this made me reflect on my experiences, having been a contractor that “fills in” or on a 1 year fixed term contract and how that compares to being part of a project on a permanent contract. Going into any role now, I would know what questions to ask of those above me. What are the expectations? Knowing it’s a short term contract means you know to do the quick fixes, but if its permanent, what do year one expectations look like compared to year 3? What changes are necessary and what can be a longer term project. I am forever grateful to a conversation I once had with Dr Ben Rosenblatt who outlined a matrix for change, looking to “traffic light” interventions and opportunities that:

1) would be immediately important

2) would be easy to implement 

3) had greatest magnitude of effect?

Outlining these things and revisiting them regularly helps you to gauge the need for change. Herein lies a thin line, and what side of that line you fall depends on ego.

EGO

An overriding message from the trip was “there is no room in performance departments for ego”.

What you implement, what you decide to change, who you decide to invest your energies in, can not be driven by ego. And here was the deepest level of reflection for me. I would like to think I am not known as having a massive ego, but when I spoke to people much wiser than I, I realised I did have one that perhaps was enough to influence my practice over the years. 

Another gem from Graham, as soon as you feel you have to justify your job, you are onto a loss. The athlete has reached this level without you and, more often than not, will remain there in spite of you. Supporting them doesn’t come from enforcing your beliefs on them, it also doesn’t come from running monitoring systems that serve a purpose to publish your data. The best organisations we visited again had a structure in place to safeguard this. Whether it was a layered approach to implementing a new monitoring system, robustly scrutinised at each level to ask “does this serve the athlete?” Or whether it was an end of season audit to review practice and ask “what have we done and why did we do it?” Both approaches served the purpose to ask, “Am I satisfying myself and my ego or does it benefit the program & the athlete.”

Now, this is a two sided relationship. To have that ability to sit and be patient, to not feel the need to prove your worth, to know where the low hanging fruit is with immediate impact whilst planning the longer term vision, it all requires support from above and around you. Again, those organisations stood out. The Seahawks, UFC under Duncan French, Canadian Sports Institute among many others, all had people at the helm who knew the happiness and development of their staff was crucial to the long term success of the organisation and their athletes. 

MENTAL PERFORMANCE

We all know sport is tough, rarely does it come with the glamour or success that we dreamed before entering the profession. Instead it is long hours, time away from family, missed weddings, flying visits to hotels and long delays in airport waiting rooms. It also has a lot more adversity than it has championship medals. I personally took great motivation from Pep Guardiola’s advice to John Stones: “In football, there are more mistakes than success and you lose more than you win” 

From a medical perspective, I think this can sometimes be overlooked. Its is easy to chase success; a successful rehab, a low re-injury rate, a correct diagnosis after initial assessment, even thinking outside of your department and focusing on team selection and competition results. But focusing on chasing success can mean you aren’t learning from the mistakes.

If the staff are feeling the pinch from the characteristics of sport listed above, or perhaps an injury that doesn’t go to plan, it can be compounded by the fact that the majority of interactions through the day have negative connotations; “I am in pain” “I can’t do this” “why does this hurt”…. no one sticks their head in the treatment room to tell how amazing they feel. 

If you don’t like hearing these questions then you shouldn’t be a health professional. But my point is, if the staff are looking after the players and absorbing or buffering their negativity, who is looking after the staff? 

This was a recurring question we asked of performance directors and of the mental skills coaches we met with. Headspace, in a move that just oozed with everything Headspace stands for, blocks out two 15 minute spaces in the day to ensure staff get some alone time. No meetings can be booked in these times, they are free to meditate and group meditations are encouraged, but equally they can just sit in a quiet room and breath for a small period of time in a busy day. This made me think about its application in sport. Why not? 15 minutes should be achievable, right?

Without having a rigid meditation structure like Headspace, there was acknowledgement of the need to decompress at UFC, where work can intensify over a period of weeks. Duncan made it clear that when the opportunity comes, he encourages staff to go down a gear, take more time and be sensible about energy expenditure. Knowing that they can ramp it up again when the next time comes.  

If you have the opportunity to employ a mental skills coach, or perhaps you are one and you are part of a new team, how are you going to integrate and operate? Oliver himself was able to draw on reflections from a previous role where a proactive approach to build mental skills actually highlighted an unforeseen problem; if you have one mental skills coach, or sports psychologist, and they look after both staff and players, what does the player think when they open up about how they feel and then watch as the sports psych walks straight into the coaching office? One of the mental skills coaches we met actually withdrew themselves from a full time position and intentionally became part time, so that they didn’t become too familiar or part of the furniture, giving themselves some distance become a more intermittent but effective presence. 

Conclusion

I guess the overriding message through this reflection is the importance of a clear vision. Something that is easily articulated, frequently visible and actually lived. This then provides the foundation for who you employ, how they integrate into the team, what’s expected of individuals and the department and ultimately feeds performance of staff and athletes. 

I would be interested to hear people’s opinions or reflections on experiences of change, how you coped, how you were managed and supported. What will you do given the opportunity to influence a department?

Yours in sport,

Sam

 

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Viewing balance exercises with eyes closed

For a long time, I have questioned prescribing balance exercises with eyes closed to athletes in sport. Regular readers of the blog will know that I continuously explore the clinical reasoning behind treatments and interventions but have a particular interest in exercise prescription. I have to admit that single leg balance with eyes closed is an example of exercise prescription that just doesn’t make sense to me, how many athletes close their eyes to perform a sport related task? I’m regularly seeing discussions online about “what is functional?” and most of the debates are based around semantics without much weight behind them but provide a good opportunity for people to have a little disagreement about something. To avoid getting into a debate about “functional” I thought it best to better understand the concepts and demands behind “balance” to see if I can answer the “why” behind balance exercise progressions.

Now stay like that for 1 minute or until another player throws a ball at your face

One argument for closing eyes during balance exercises is to remove the visual stimulus and encourage the athlete to challenge vestibular and proprioceptive senses. Remove one thing and make others compensate for this deficit. In a study of track athletes, sway velocity (cm/s) increased two-fold when athletes closed their eyes during a static balance test (here) but the only significant finding in the study was the difference in centre of pressure displacement (cm) between non-dominant and dominant limb across the medial-lateral plane. So, no difference between male and female athletes and no difference between “eyes open” and “eyes closed”.

So how does this explain the increase in sway velocity? The sway velocity is the area covered in both the anterior-posterior and medial-lateral planes of the centre of pressure per second, indicating speed of correction. The fact that the displacement between “eyes open” and “eyes closed” was not meaningful suggests that the demand on the fine motor correction increases. A decent argument to include “eyes closed” in a balance program, if that is the aim.

Static balance in dynamic sports

Compared to dynamic balance tests, static tests do not allow re-positioning of the centre of mass within the base of support, so the athlete becomes more reliant on smaller corrections. Different sporting populations have demonstrated varying abilities in static and dynamic balance skills, with gymnasts outperforming in static balance but soccer players demonstrating better dynamic balance (here).

This may seem obvious given the control on the balance beam vs changing direction to avoid an opponent. But actually, perhaps where the argument becomes more broad and complex.

As with any exercise selection, it needs to be appropriate to the aims of the rehabilitation program and the demands of the sport, taking into consideration open and closed skills and linking these to fixed gaze drills vs dynamic gaze drills.

Have we gazed over “skill”?

In a given skill, experts can recognise which cues are relevant and avoid information overload (Martell & Vickers 2004). Below is a slide from my presentation “3 sets of when?” It explains the concept that following any injury, the athletes ability to perform a given skill returns (temporarily) to novice level.

Take a skill like walking. Immediately after an ankle sprain, your ability to perform that skill at an expert level is decreased. A skill that has taken years to perfect, to become automatic, now becomes a task which requires concentration. Thankfully, the return to expert level doesnt take years (hopefully!) and this is where our exercise selection becomes crucial to optimally load and sufficiently challenge. We can’t presume that the pre-injury skill level is the same post-injury. We should also consider experience of the balance task specifically. I can think of experiences where athletes are standing on one leg on a Bosu throwing a reaction ball at a 45 degree trampoline. “Oh you’re no good at that are you… we need to address your balance”

I’ve digressed slightly from single leg balance with eyes closed… and actually I still haven’t discussed “gaze control”.

Gaze control links specifically to experience of a task. Comparing those skilled at orienteering to non-skilled (here) demonstrated an increased ability of the orienteering folk (what do you call people that go/do orienteering?!) to employ a wide focus of attention and to shift efficiently within a peripheral field. The test very cleverly measured gaze control to flashing images with varying degrees of relevant and irrelevant information. What is interesting from this study was that the control group where physically active and proficient in other sports, but the “skill” advantage lay with the orienteering-iers. [shrugs and thinks “sounds right”].

I did not know that about balance!…

Elite athletes have heightened spatial awareness and processing capabilities vs their non-elite counterparts, where gaze control is cool and calm, with long duration of fixation of specific locations. This results in better body positioning end efficient limb actions (here). What better example than ballet. When comparing professional dancers to controls walking along a thin taped line, it was observed that experienced dancers focus far into space, delivering effortless and accurate movements where as controls looked down and focused on the line, moving with greater speed and less control (here). Dancers shift their neural control from somatosensory inputs and to an increased use of visual feedback, via peripheral fields and focused gaze control. Interestingly, sub-maximal exercise has been shown to increase visual attentional performance (posh words for reaction time) and a decreased time need to zoom focus of attention (here). This is useful for prescription considerations.

This efficiency has been demonstrated in other studies also, where the addition of a 4-week balance training program to Physical Education classes in school resulted in increased CMJ, Squat Jump and Leg Extension Strength (here). A time period that can’t be associated with physiological adaptations to muscles (regardless of time, they did balance exercises!) and even when a balance training program has been compared to a plyometric strength program (here). It is thought that improved centre of pressure is linked to spinal and supraspinal adaptations, due to high inter-muscular activation and co-ordination.

My question for any budding researchers out there… if there is a spinal level involvement here, can we utilise the contralateral limb at the very early stages of injury to improve balance on the injured side?

Finally, I get to my argument… balance is the output. Balance and proprioception are different entities, as are gaze strategies and balance. But they may all be interlinked via “skill.”

In researching this blog, I’ve certainly become more accepting of “eyes closed” as an addition to balance programs. But also think I’ve gained more clarity on appropriate prescriptions and the suitable progressions for individuals.

Perhaps “eyes closed” is not a progression, but a starting point!

Immediately post injury, we are looking to internalise feedback (intrinsic) and focus on local, fine movements. There are plenty of regressions within “eyes closed” balance that we can make the athlete safe from secondary injury. Graded progressions from static to dynamic, trying to keep the demands appropriate to the skill required to return the athlete to “expert”.

From here, our progressions should not be the removal of a visual stimulus, but instead optimising and enhancing gaze control:

• Focus on a stationary target –> moving target
• Head still –> head moving (repeat stationary and moving target progressions within this)
• Static balance –> dynamic balance (repeat progressions above)

Essentially, we progress through from intrinsic cues to extrinsic cues, where gradually the athlete is thinking less and less about the mechanics of balance and more about skill execution and performance. We know that gaze control components improve with sub-maximal exercise, so our ordering of our program can reflect this. It is commonplace for balance exercises to be at the beginning of the program, but if balance is our primary aim for rehabilitation, perhaps it should be later in the schedule.

I don’t think this is too dissimilar to how most people prescribe exercises, but for me at least it has given me a better thought process into the “why” which ultimately should make rehabilitation programming more effective and efficient and therefore more elite.

Yours in sport,

Sam

Compex doesn’t have to be complex

I should probably start by acknowledging that there are other muscle stimulation devices available… but I’m not employed by Compex, I just have some very good experiences using their product. This blog was borne out of frustration of seeing Compex machines gathering dust in treatment rooms or being used ineffectively as passive, plinth based modalities. I think a lot of people are missing the trick, you need movement!

While I am an advocate of its use clinically, I  want to disclose that using a Compex will not make a bad exercise good. It is a bolt-on to a rehab program and is something that can make a good exercise great. That is key. The clinical reasoning, exercise selection and placement of the stimulation all underpins an effective application, so before rolling it out to all athletes or patients make sure you can reason why it has a place in your practice.

Its all about progress

Like with any intervention, the clinical reasoning behind the application of muscle stimulation can influence its use at different stages of injury and rehabilitation. In the acute stages, it is believed that muscle stimulation may modulate pain. For an interesting read on the use of electricity and pain throughout the centuries, click here. However, as we understand more about optimal loading and mechanotherapy, we probably need to limit the time an athlete sits on the plinth watching the latest Mannequin Challenge on their smart phone while their quad twitches. It is worth considering that a Compex placed on a dead body would still cause it to twitch. The key is to get them moving and use the Compex to either facilitate movement or provide an external load. Interesting that we can use the same machine and the same settings to either regress or progress an exercise… the key is in the exercise selection.

Consider the tissues

Muscle injury: It should be pretty obvious that placing a muscle stimulation device, designed to promote contraction of muscle, on a contractile tissue with a tear or micro-damage could have negative consequences. For a second, lets forget the Compex. Respect the pathology and consider if you really need to lengthen or contract that muscle to load it. Is there a way you can work that tissue as a synergist perhaps? If the hamstring was injured in the sagital plane, can we move through coronal (frontal) planes and still load the hamstring? This could possibly be a slight progression on an isometric exercise and shouldn’t change the length of the muscle that may cause pain or further damage. Certainly more beneficial than sitting on the treatment bed though. So now consider how muscle stim may benefit this stage of injury. It could possibly help with any inhibition due to swelling or pain, perhaps be used to add an increased load to unaffected tissues that you may not be able to load otherwise.

As the healing progresses and the level of activity increases, it is quite common that we see some deficits in muscle function, especially after a long acute phase (if that isn’t a paradox?! Think post surgery or fixation). A good example is post ankle reconstruction, where you have worked on regaining plantar / dorsi flexion but when you ask the athlete to do a heel raise, it’s quite an effort. It may be appropriate to use the Compex here as a little crutch to facilitate movement and contraction. But the key thing here is it is not our cadaver that we causing a contraction in, the athlete is consciously initiating the movement. (Previous blog on internal and external cues here).

Now promise me if the Compex hurts, you will turn it down. OK?

Progressions by all definition, progress. So after working through isometric and concentric exercises, the program may require some eccentric load. This is worth trying yourself before asking a patient to do it, because a very simple exercise like a TRX squat that may have been cleared earlier in the program can dramatically increase in work with the addition of Compex. Consider a quad injury. The Compex has two phases of a cycle, a fasciculation phase that causes visible twitch and a long contraction phase (depending on the setting, the length and intensity of the contraction change). After one or two cycles for familiarisation, instruct the athlete to work against the contraction – so when the Compex wants to promote knee extension via a quad contraction, sit back and encourage knee flexion. Try this yourself for 6-8 reps and feel the fatigue induced, it usually surprises people. Again, make sure you can reason WHY you are doing this. This is usually a good bridge for someone who needs to step up their program but maybe can’t tolerate external load (confounding injuries, instability of joints, lack of technique etc etc.)

Joint Injuries: In comparison to a muscle injury, your application of Compex may be more aggressive. Because you are unlikely to affect a non-contractile tissue with the stimulation, you may use the eccentric reasoning to help reduce atrophy rates following a intracapsular injury like an ACL. Ensure you know the available range first of course.

With these injuries, the external stimulation may help with inhibition, improve proprioception lost by the ligament or capsule or it may provide stability to the joint by increasing the available contraction. Again, there will be a time and a place and it requires the clinician to reason through the application, but this may be a great addition to a program that is becoming stale.

Tendon injuries: The use of the Compex to enhance an isometric contraction or to create an eccentric contraction may be a great addition for an in-season tendinopathy as a way of managing load. The timed contraction allows clinicians to monitor Time Under Tension (TUT) which is essential for tendon management. If considering a High-Medium-Low frequency through the week, a pain free exercise that is used on a Medium day can become a High load exercise with the addition of an externally generated contraction. But consider the two things that aggravate a tendon, compression and shear. Appropriate exercise selection and range is going to be crucial, that being said, it may be that the addition of stimulation to the quads actually reduces shear through the patella tendon by changing the fulcrum of the patella (no research to back this up, just my musings).

I really like Geckos. I found this Gecko a musing

Conclusion:

I think there are many options out there to enhance rehabilitation by considering the diversity of muscle stimulation. But I want to repeat for the hundredth time, it is the exercise selection that is key. The addition of a Compex will only amplify that choice.  For the patient, it adds a bit of variety to a rehabilitation program and for the clinician it is another tool to help with optimal loading of a healing tissue or structure. I am a big fan of weight training (don’t let my chicken legs fool you) but there are injuries or athletes that for one reason or another are unable to tolerate weights. This is one tool in a very large and overused metaphorical tool-box that may bridge that gap between body weight exercises and weighted exercises. I also believe there is great benefit when complimenting this with Blood-Flow Restriction Exercise or Occlusion training… but that’s another blog.

As always, thoughts and opinions are welcome.

 

Yours in sport,

Sam

“I’ve come here for an arguement”

I’ve recently made the move from the clinical environment into academia (despite the occasional clinical fix to satisfy my itchy feet). Part of this move was to set up some new MSc modules at the University of Brighton. The way I wanted this to run was based on me facilitating discussion rather than standing up and banging on about what I would do in different situations – no-one is going to enroll for that! But for this to work, it relies on people feeling comfortable talking about their own practice, something I’ve been surprised by the reluctance in doing so. People seem very uncomfortable disclosing what they do and how they do it.

A while back I read a blog re-tweeted by IFL Sciences (@IFLScience) about how a disagreement is different to an argument. Now rather than me eloquently blurring these definitions and confusing you more, why not allow the genius of  Monty Python to explain.. please watch this brief 3 min video (here).

The original clip goes on a bit longer and in true python fashion, gets stupider. But this clip can translate into our practice. It is perfectly reasonable and healthy to argue. We are not going to learn from each other by accepting that the other guy sat in the room, who has more experience than me, treated his ankle sprain using those exercises, so that’s what I should do.

No! Why? Why those exercises for that individual?

 

There are many roads to Derby:

Completely random destination (just so happened to be one of the cities I can spell). But this image sums up what I think about clinical reasoning. It also demonstrates what I encourage our students, more so post-grad students with clinical experience, to accept when questioned about their practice.

Most of us have at some point ignored the sat-nav, right? Intentionally or not. But it simply re-routes and will eventually lead you to your destination. The same with rehab & treatment. We may all have the same goal & end point, but how we get there is different. The route we chose depends on many factors.

Letting the sat-nav make the decision:

For a relatively less experienced clinician, the situation may be this:

“I’ve only ever been to Derby once, but when I did go, that route worked pretty well for me, so I’m going for it again. Why risk otherwise?”

This is the equivalent of following a protocol or being led by a more experienced clinician. Perfectly legitimate but after a time the question will become, “have you tried other ways?” Yes that’s a pretty direct route, but sometimes it’s not about the speed you get there. An example I can think of was a player with a partial ACL injury that occurred just before christmas. We made the decision to prolong his rehab until the pre-season, despite realistically being able to get him fit for the last 2 games of the season. But there was no advantage to that, instead we were able to focus more on smaller details, enhance his “robustness” and ultimately, we had no re-injuries with him the following season. We decided to take the more scenic route and enjoy the drive. Sometimes, it shouldnt be other people asking why you have done something, but yourself. (Do this internally, arguing with yourself in a cubicle at work could have very different consequences to the intended career development).

Thanks Sat-Nav, but no thanks:

This option comes after you have driven to & from Derby a few times. Or if you insist on keeping it relevant to practice, an exposure to a certain injury with a set population. Experience may tell you that the route suggested by Sat-Nav has an average-speed check for 25 miles, so you may choose one of the alternate routes. This is the same as saying, “I wanted to use squats for his knee rehab, but it aggravates his hip so instead I used dead-lifts.” Someone has asked you why you went that route, the answer is reasoned and justified and neither party needs to be offended. But you have argued your point.

 

An argument is different to a disagreement:

An example of this not being constructive may be:

“I prefer this route because the services have Costa and not Starbucks. I hate Starbucks.” This opinion, without any justification may turn into a disagreement. “I don’t ever use a wobble cushion in my rehab, just don’t believe in them.” A genuine statement that I heard years back when I was studying myself. There was no rationale, every counter argument was met with “Nope. Dont buy it.”

This is a disagreement. Something I disagree with… Oh, balls.

Conclusion:

An argument doesn’t have to be raised voices or expletives (although people who swear more are shown to be more trustworthy and honest. If you belive that bullshit). It can be someone wanting to develop their own thinking and reasoning, therefore probing your experience – “But WHY did you chose that? (subtext = help me learn!)”

Equally it can be someone pushing you to develop. “You use that exercise for all of your patients.. why?”

I’ve started to do a little presentation at the start of our modules to explain this thinking, I will be asking “why?” A lot, but I don’t want people retreating or getting defensive. Asking Why is not a sign that I disagree with you. arguing is not a sign that I disagree with you. If you feel comfortable with those concepts, you have either done an MSc already, or you are ready to do one! For those not on twitter, firstly – how are you reading this blog? Secondly, get on there. Prime examples of arguments about clinical practice everyday and very quickly, normal jovial exchanges are resumed (I would highly commend Tom Goom (@tomgoom) for this attribute). But also, it is a good place to observe some people misunderstanding an argument and presuming it is a disagreement (I wont name people, don’t want to get in a disagreement).

 

Yours in sport,

Sam

Trying to simplify “Critiquing literature “

In order to effectively clinically reason, we need to be able to critique the evidence. I want to be clear from the start – I’m not here to sledge any authors or specific papers, so I’ll just use hypothetical examples throughout. But what I want to try and do is simplify the ability to critique research for those people who maybe aren’t comfortable doing so.

A few recent discussions with colleagues and MSc students at University prompted me to write this blog. I’m not a researcher and I’m certainly not a statistician. My wife just throws more than 3 sums at me to convince me I owe her money. Numbers fry my brain. But, that shouldn’t put me off being able to critique a paper in a constructive way.

Critical Comment #1: Can I understand why they’ve used this Methodology?

For an author to create a robust methodology, there has to be the existing literature available in the first place to support their design. We place a great deal of trust in authors that they have researched their methodology appropriately -the tests they use are validated, there’s evidence behind their outcomes, a clear rationale for their intervention. But have they made all of these clear? You can see already how we can create a peeled onion effect, whereby we could (if social lives weren’t an issue) trace back all of the references for outcomes measures and tests.

We can easily end up chasing references. Which like an onion, will probably make you cry.

I feel a great deal of sympathy for authors here, because in some cases they cant win. Authors are torn due to previously limited research, to which they need to reference their proposed methodology in order to be considered robust.

Lets use something that’s not contentious, I don’t know…? Massage. No one has established an appropriate and valid duration. Neither have they determined best technique, and so on – so a great deal of literature these days will standardise their methodology to an arbitrary figure, often 2 minutes per technique. Where has this come from? For those who do use massage as part of their practice – when do you time a duration for techniques? Surely its individual, dependent on the therapist, the treatment outcomes and goals etc – but any paper that justified their methodology on something that is extremely subjective like clinicians experience would get slated!

Why did you bring up massage again?!

I’m sure this will get shot down monumentally, but personally I would commend a study brave enough to use an experienced clinician and trust their clinical knowledge & autonomy. Let them use an intervention they use routinely and daily and allow for creative freedom and individual needs. We constantly bang on about treatments being individual, so lets put our money where our mouth is. I’ve used massage here, but the same could be applied for a lot of interventions – types, techniques, durations. If they haven’t been validated historically, how can we be assured about results from this current paper we’re critiquing?

It’s another argument for another time – but do we need to go back to basics with some interventions and learn more about them before we critique and dismiss them? Rather than compare intervention vs no intervention, should we compare the same intervention but with different goal posts first?

I’ve used massage here but that’s not my point, its the methodology I’m trying to emphasise.

• Is it a fair comparison between interventions?
• Does it even need a control?

 

Critical comment #2: Is there an appropriate population used for the research question?

We have to remember that any outcome or clinical relevance from a study can only be applied to the population that they used within that study. Can we assume that a new training program implemented with recreational athletes will have the same benefits with elite athletes? It’s impossible for authors to give us huge details about population because of their limited word count – but we need to make some educated guesses regarding the outcomes. The benefits of an eccentric intervention for an elite group of footballers doesn’t mean we can start Sunday league players or even semi-pro players on the same intervention at the same intensity or volume.

Take the findings and apply them to your clinical practice & patient exposure. Would this intervention fit with your athletes current schedule or level of conditioning?

Flip that around and consider that a study using a lay population may find huge benefits from an intervention – but is it just an accelerated learning curve that wouldn’t impact an elite athlete in the same way? Exposure to something completely new will have bigger consequences and effects.

 

Critical comment #3: The dreaded stats! Or am I just being Mean? Probably (<0.05)

I’ve already said, I’m no statistician. The critique that can be applied with some understanding of these stats processes is incredible and I am in awe of people that can do this. But there are some simple points to consider when looking through analysis and results of papers. The first thing to consider, does the presented data tell you what you need to know? Go back to secondary school maths with Mean, Median (and Mode):

We want to investigate how many hops a subject can manage after ankle mobilisations (assuming we had no other variables like fatigue etc). Their pre-test scores are around 50. During assessment they record the following scores (40, 51, 45, 52, 100), one time they have blinder, recording 100 hops. A mean score would suggest that the effect of mobilisations increased their pre-intervention scores from 50 to 57.6, this sounds quite impressive. A median score used in this example would tell us that aside from one outlier, their post-intervention scores didn’t change too much (51). In this case, we want to know for definite whether or not our mobilisations have allowed this subject to hop better – they have a world championships in hopping coming up. If the data is clearly presented, we may be able to work this out ourselves. But I’m lazy – I’ve got 30minutes over coffee to read an article, I want to read their results and discussions and hope that this leg work has been done for me.

Now an author wanting to get a publication is always going to present the data with greatest impact – in this case the mean. That’s fine, but its worth checking the number of scores recorded. The greater the amount of data, the more accurate a mean will be. But less subjects or less tests would always be worth double checking the data.

 

“If you can’t explain it simply, you don’t understand it” Albert Einstein

This brings us nicely onto probability. After writing this blog draft, I was shown this brilliant lecture by Rod Whiteley (Here) who understands this much more than me! (See above quote). It must be en vogue because the editorial in Physical Therapy in Sport this month disucsses P-Value also (Here). But what I do understand about P-Values is to always ask.. “So what?” So its statistically significant, but is it clinically relevant?

Again, another hypothetical study. We investigate the use of weighted squats to increase knee flexion. We find that by squat 1.5x body weight can significantly increase knee flexion (P<0.001). That significant difference is 3 degrees. Is that going to make your practice better?  In some cases it may do! Achieving a few degrees in smaller joints with less room to play with, or perhaps post-op TKR and we just need a few more degrees to allow this patient to safely negotiate stairs – if they cant do stairs I’m not sure I would get them doing 1.5x BW squats though, which takes us back to our population critique.

Hopefully you have watched the Rod Whiteley lecture by now, so you can see where non-significant data can be very clinically relevant. It does make me wonder how much we have thrown out or dismissed that could be very beneficial.

 

Critical Comment #4: The Conclusion

So we have 30 minutes to quickly search for a paper, read the abstract and decide to read the article. I’ll hold my hands up to skimming the vast majority of a paper just to get to the conclusion. Not good practice though. Its worth checking who the author is, have they published on this topic before? What is their motivation? Most people will publish something that they either strongly believe in, or don’t believe at all. We’ve already discussed how its easy to manipulate stats, so if I strongly want to prove something works, given enough data & appropriate stats I could probably could. This sounds incredibly synical, but it should be a question you ask. If the conclusion is strong despite some variable results, bear it in mind.

Our Conclusion:

“Its actually quite exciting, what you know now will probably change”

So can we believe anything that’s published? Yes. We can & We need to. Otherwise we stand still. Being critical is not the same as disagreeing or dismissing something. It just shows us where there are gaps and where can start investigating next. It’s actually quite exciting, what you know now will probably change. Something you don’t understand now, we will probably find out in the future. But taking a single paper and changing our practice based on that is a bit drastic. We need to consider the body of literature, read articles that challenge accepted beliefs and make our own decision. The beauty of sports medicine is there are no recipes. Where possible the literature should challenge our thinking and keep us evolving, but it doesn’t always restrict us to guidelines and protocols. We are lucky enough to be autonomous in our treatment and our exercise prescription and we should celebrate that. Ask 3 respected conditioning coaches to create a program for one athlete with a specific goal and see how diverse they are. Thats what sets us apart from each other and makes us individual therapists and coaches.

Take home points:

1. Check the methodology – are you happy with what they are investigating & how they do so? It is perfectly acceptable to disagree!
2. Does the population used apply to what you’re looking to take from the paper? You are reading this paper for some reason – hopefully to re-inforce / change your practice. Do the female college basketball players used in this study apply to your clinical caseload?
3. Don’t accept or dismiss a paper purely on its P-Value.
4. Has the author based their opinion purely on the P-Value? Check! Don’t just accept their conclusion. This is their entitlement but its their interpretation of the stats.

#PrayForAuthors: They do face a fight between getting something published, and in doing so making their study conform to previously accepted literature but perhaps deviating away from what the masses actually practice in clinic. The lasting question I will leave you with; considering the points made in this blog and the discussion by Rod Whiteley – where does that leave systematic reviews? I have my own thoughts 😉 Let us know yours.

 

Yours in Sport

Sam