Compex doesn’t have to be complex

compex

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).

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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).

musing
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

Case Study: Myositis Ossificans – Deadlegs aren’t just for the playground

Whether you call them a “dead leg” or a “Charlie horse” or a “cork thigh” chances are we have all had one. Mostly from the playground days where the bigger kids want to take pleasure in seeing you limp for 5 minutes. However when they happen in sport, with fully grown athletes running at full pace, a collision to the thigh can result in an injury much more serious than the one we associate with from childhood.

The reason I wanted to write this blog was that I worry  that thigh contusions are underplayed in the treatment room, potentially because we associate them with those school sports injuries that can be “run off”. This is a case study that I became involved with after initial management of the “dead leg” failed, and to this day is one I reflect on about how important initial management can be in saving severe stress in the long run. This is a case of a “routine” dead leg that is commonly seen in contact sports that resulted in 9-months of rehab to manage a secondary case of myositis ossificans.

What are we dealing with?

There are two types of “dead legs”

  1. Intramuscular: blunt force trauma to the muscle that results in a haematoma, in this scenario the epimysium remains in tact and the bleeding is contained within the muscle compartment.
  2. Intermuscular: the epimysium surrounding the muscle is broken along with the damage to the muscle tissue, the resulting haematoma spreads outside of the damaged muscle.

The intermuscular hematoma by far looks the worst, it’s the one where the whole thigh goes black and blue and looks pretty nasty. However, clinically these ones tend to heal quicker and they look a lot worse than they feel. The problem with the intramuscular haematoma is that because it is contained, the pressure can build up and become more painful. It is generally more debilitating as a result, with larger loss of range and more pain. It also doesn’t provide that visible diagnosis as very often you just get a small sign of bruise on the skin from the impact – this is where it can get dangerous as we like to be able to see injuries (hmmm something about invisible injuries and under diagnosis.. concussion?). We have discussed acute management before (here) but with dead legs, it is always worth monitoring for a few days and hoping that the leg goes black and blue.

fig2

In the first few days, range is a good indicator. On day 1 after the injury, if they are unable to achieve >90 degrees knee flexion, the prognosis is generally longer. For a bad intramuscular contusion, you could be looking around 6 weeks. This is where the coaches tell you it’s just a dead leg and they’ve had worse. But, it is structural damage to the tissue resulting in bleeding and should be given the same respect you would give to a tear. (Muscle injury classification via the Munich Consensus here).

Myositis Ossificans (MO):

MO is the formation of heterotrophic bone within the muscle following trauma (here) essentially following failed healing the body begins to lay down bone in an attempt to add stability and structure.

Case study:

The following case study is an example of an academy player, where an initial intramuscular trauma to the muscle was accelerated back to activity resulting in a 17cm tear of vastus lateralis (VL), consequently being diagnosed with MO that was estimated to be 3cm thick and of equal length to the tear.

Timeline:

  • Day 0 – initial impact to right VL via collision in training, had to be removed.
  • Day 1 – “able to squat and lunge but pain on a stretch”. Player expressed determination to train and so was allowed to.
  • Day 2-3 – continued training
  • Day 5 – Removed from training with “cramp / DOMS” in right leg.
  • Day 8 – Sudden loss of power with running and kicking, removed from training.
  • Day 30 – returned to training
  • Day 31 – played in a competitive game but substituted by manager after 25 minutes due to inability to run. Assessed by doctor and head physio. Visible contained swelling in VL, palpable solid mass, loss of range and pain on contraction of quads. MRI scan demonstrates a 17cm longitudinal tear of VL. Suspicion of MO so sent for ultra sound scan which was confirmed, absent from full team training for 9 months.
Intramuscular haematoma Contained haematoma within the vastus lateralis muscle after 30 days of continued training post-initial injury

Management:

Surgical excision of MO is only really reserved for persistent cases that don’t respond to conservative treatment (here). A collective decision was made that we should try to reduce any form of load that may stimulate further bone growth. As a result, the player was removed from all activity of the lower limbs, no soft tissue therapy to the quads and at this stage no stretching of the affected tissues.

It is neither healthy nor beneficial (or fun!) to completely rest when you are used to training 6 days a week. Credit should go to Will Abbott (@WillAbbott__) for his contribution to the maintenance of the athletic profile for this player. A periodised program was designed to maintain metabolic and cardiovascular systems, strengthen the upper body and completely unload the lower body.

Screen Shot 2016-06-19 at 9.02.28 AM A periodised model to demonstrate maintenance of unaffected systems with complete lower body unload (designed by Will Abbott)

The program included swimming, with multiple floats between the legs to reduce the temptation to kick. All gym based activities were performed seated or with legs supported when lying to reduce axial load through the legs during upper body lifts. Upper body metabolic sessions were implemented via high intensity interval training, with small rest periods to help maintain specific anaerobic demands relating to the sport. This was done using medicine balls, ropes, boxing pads.. anything to reduce the monotony of daily upper body training.

Each month was broken down further (as shown below), with follow-up ultra sound scans every 4 weeks. After the first 4 weeks, we observed a 2.5cm reduction in length which consolidated our thought process to continue de-loading. With limited exercise potential and treatment for the leg, we ran half days and 5 day weeks to help maintain a positive psychological presence.

Screen Shot 2016-06-19 at 9.02.58 AM

This was an opportunity to increase muscle mass in the upper body, an opportunity that would not have been possible during season if the player continued to play and train. This allowed a clear progressive pathway for increased lean mass with the following phases:

Hypertrophy –> Max strength –> Strength / power conversion –> Power

While the conditioning phases were as followed:

Aerobic base –> Max aerobic –> Supra max aerobic

There was a decrease in calcicific mass every month, although the rate of this varied each time. By the end of month-4, the mass had completely reabsorbed which meant the reintroduction of load to the lower libs.  By this point, the end of the season was 6 weeks away and therefore no realistic opportunity to play again this season, so the decision was made to start physical preparation for the following season.

Screen Shot 2016-06-19 at 9.03.30 AM An example of the lower body periodisation

The lower body gym program was tailored as followed:

Strength endurance* –> Strength –> Max strength –> Strength & power complex training

(* This was probably more “re-introduction to the gym” rather than true strength-endurance. But this phase would have served as a gentle hypertrophy phase given the 4 months of atrophy)

Before undergoing a linear outdoor session progressing from general preparation to sport specific drills with Tom Barnden (@barnden_tom). The player completed a full pre-season and no recurrent symptoms to date.

Conclusion:

Hopefully the lengthy timeline of this case study demonstrates the importance of giving each individual injury the respect it deserves. While I hope the management is interesting, the key discussion point is how do we approach “dead legs”? Should there be better education to athletes and coaches about the magnitude of injury? Essentially given the tissue damage, are they a tear? If an A4 piece of paper represented a muscle, and we tear down the middle (strain) or poke a hole through the centre of the page (blunt force trauma), that page is still affected and unable to serve as an A4 piece of paper. Why does the mechanism of damage change the management of injury? Given any loss of range or function following a blunt force trauma, always consider the magnitude of potential damage; monitor swelling, bruising and pain and have adequate timelines in the back of your mind – don’t rush to a diagnosis / prognosis on day 1. There will be times where there is impact and initial pain but full range and full strength – this is where our pitch-side assessment and reasoning comes in (here).

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:

imageCompletely 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.”

opinions
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

Rehabbing teenagers can be awkward! – sensorimotor function during adolescence

There is a bit of a buzz phrase in rehab about “individualising programs” and while it is something we wholeheartedly agree with, it is a phrase that is very easy to say and yet very difficult to implement. Especially when you work with a population where said individual changes rapidly through time, like a teenager! It is a common sight on a training pitch to see a star player in their age group suddenly tripping over cones or developing a heavy touch where there was previously effortless control. Side effects of the adolescent growth spurt, where the brain is now controlling a much longer lever. It’s like giving a champion gardener a new set of garden sheers when for the past year they have used little hand-held scissors and asking to them maintain their award-winning standards. (My garden embarrassingly needs some attention and it’s affecting my analogies).

Master-Gardener-Pruner-Secateurs-Shears-Garden-Hand-plants-Shears-trim-cutter-easy-carry-Garden-Tool
The control and precision between these two instruments is influenced by the lever length of the handles…
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…Similar to a rapidly growing femur and tibia which is still being operated by muscles that have length and strength suitable for shorter levers.

 

 

 

 

 

 

 

 

Alongside the performance related issues, there is suggestion that this period of growth may coincide with increased risk of injury (Caine et al 2008). We believe that bone grows quicker than soft tissue, so we are asking a neuromuscular system to control a new, longer lever using prior proprioceptive wiring. Imagine our gardener again, for a long time he has been able to keep his pair of scissors close and controlled, now with his extra long shears the load is further away from his body, his back and shoulders are starting to ache. Not sure what I mean? With one hand hold a pencil to the tip of your nose. Now, with one hand hold a broom handle to your nose. The longer lever is harder to control. **I promise it gets a bit more sciencey than gardening and broom handles. **

Managing these growth spurts is something we have talked about before and recently contributed to a BJSM podcast on the topic (Part 1 & Part 2) and a complimentary BJSM blog about “biobanding” during periods of growth and development (here). This particular blog was inspired by a recent (2015) systematic review looking into exactly which sensorimotor mechanisms are mature or immature at the time of adolescence by Catherine Quatman-Yates and colleagues over in Cincinnati (here). The following is a combination of their summary and our examples of how these findings can influence our rehab programs.

Tailoring the program:

We have so many options for exercise programs, that’s what makes the task of designing them so fun. It challenges our creativity. When working with a teenager with sensorimotor function deficits, let’s call them “Motor Morons” for short, we don’t have to totally re-think our exercise list, just perhaps the way we deliver them. We previously spoke about motor control and motor learning (here) and how our instructions can progress just as our exercises do, but the following relates to children and adolescents in particular.

Consider the stimuli.

Children aged between 14-16 have well-developed visual perception of static objects however their perception of moving objects and visual cues for postural control continue to mature through adolescence. When very young children learn new skills such as standing and walking, they become heavily reliant on visual cues. Quatman-Yates et al suggest that puberty and growth spurts (think gardener with new shears) brings new postural challenges that causes adolescents to regress proprioceptive feedback and increase reliance on visual cues again. From a rehab perspective, we need to consider this as part of our balance and proprioception program. How many of us default to a single leg stand and throwing a tennis ball back & forth from therapist to athlete? For our Motor Moron, this may not be an optimal form of treatment in early stages, where it is commonly used, however it may incredibly beneficial to that athlete in the later stages or as part of ongoing rehab as we try to develop that dynamic perception.

Consider the amount of stimuli involved in an exercise versus what your goal of that exercise is

We should also consider the amount of stimuli we add to an exercise. Postural stability in children is believed to be affected by multiple sensory cues. If we consider that children are more dependent on visual cues than adults are, perhaps our delivery of external stimuli should be tailored also. With a multi directional running drill for example, there is sometimes an element where the athlete is given a decision making task (a red cone in one direction and a yellow cone in another) and they have to react quickly to instructions from the therapist or coach. Rather than shouting instructions like “red cone”, “yellow cone” etc, hold up the coloured cone for the corresponding drill. This way we are utilising this developed visual perception, minimising the number of stimuli and also encouraging the athlete to get their head up and look around rather than looking at their feet.

When to include unilateral exercises:

Within adult populations, it is often considered gold standard to make exercises unilateral as soon as tolerable. If they can deep squat pain free and fully weight bear through the affected side, progress them to pistol squats ASAP, or single leg knee drives. However, young children (pre-pubescent) may struggle with this for a couple of reasons.

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Difficult enough even for an adult to perform, but uncoupling the actions of the each leg & fine muscle movements to maintain balance are extra challenging for children

Firstly, we need to consider postural adjustments. Where as adults and young adults can adjust their balance with smooth control and multiple, small oscillations, children rely on larger ballistic adjustments. There is also reduced anterior-posterior control in younger athletes which suggests reduced intrinsic ankle control. Put this alongside immature structures and (if working a physio, most probably) an injury then single leg exercise become a progression that may be further down the line than an adult counterpart with the same injury. Instead, consider semi-stable exercises. Support the contralateral leg with a football or a bosu ball – something that is difficult to fixate through but provides enough stability to support the standing leg.

Secondly, we understand that coupled movements are mastered earlier in adolescence, around 12-15 years old but uncoupled movement patterns take longer to develop, 15-18 years old (Largo et al). A good example is watching a young child reach for a full cup of water at the dinner table. It is much easier and more natural for them to reach with both hands than it is with one, as coupled movements are unintended. Rarely do you see a child taking a drink with one hand filling their fork with the other – yet this is something commonly seen with adults as they are able to uncouple and segmentalise. Another example is watching a child dynamically turn, watch how the head, trunk and limbs all turn as a “block”, it is not until further down the line where dynamic movements become more fluid. The argument here is that surely running is an uncoupled movement? Or kicking a football, swinging a tennis racket, pirouetting in ballet – they are all uncoupled, segmental movement patterns that we expect kids to do, and in all they cope with. Correct, but it is usually in rehab programs for kids that we begin to introduce unfamiliar tasks and exercises that they may not have encountered before. Also, we should respect the impact of the injury on proprioception and control. So these are all considerations for starting points in exercise & if a regression is ever required.

For this reason, it is important that exercises are monitored and reviewed regularly. There is no need to hold an athlete back because of their age and making assumptions on motor function because of their age. If they can cope, then progress them. But be mindful of “over-control” where speed and variability of movement are sacrificed in place of accuracy and control (Quatman-Yates et al 2015).

Become a Motor Moron hunter

It is worth spending some time watching training, watching warm ups, watching gym sessions and talking with coaches and S&C’s trying to identify a Motor Moron as soon as possible. It’s important to minimise the chances of an immature sensorimotor mechanism ever meeting a growth spurt. It is when these two things combine that we see kids doing immaculate Mr Bean impressions and therefore increase their risk of injury.Safari-kids

Regularly re-assess your exercise programs. If things arent quite progressing as quickly as they should, it may not be failed healing of an injury, but it may be that we are providing the sensorimotor mechanism with too much information!

 

Yours in sport,

Sam

 

“The Young Athlete” conference 9-10th Oct, Brighton. Here

Hamstring Injury – What are we missing? by Jonny King

We are delighted to introduce a guest blog from Jonny King (@Jonny_King_PT), a sports physiotherapist based at Aspetar, Qatar. Jonny has experience working in professional football in the UK with both Norwich City FC and AFC Bournemouth before he made the big move East to Doha. A prevalent voice on twitter and definetely worth a follow, he provkes some intriguing questions regarding our current understanding of hamstring injuries. We hope you enjoy… P&P

 

Hamstring strain injury (HSI) continues to present as a huge challenge for those of us working within the sport and exercise medicine field – whether that be in a research or clinical setting. Disappointing figures have recently shown that despite an increasing body of publications over recent years and a perceived improvement in understanding of underlying causes, the epidemiology for HSI in elite sport has not changed over the past 10 years (Ekstrand, Hagglund & Walden, 2009) A worrying reality.

Some will argue that WE HAVE improved our understanding and management of hamstring injuries but the evidence base is not being applied effectively into clinical practice. (Bahr, Thornborg, EKstrand, 2015). Others will state that our ability to influence epidemiological data at elite level, has been affected by the evolution of sporting competition including increased physical application. Take professional football for example, both sprint distance (35%) and high intensity running distance (30%) have significantly increased over the past 7 years, alongside a reduction in recovery times as a result of increased fixture congestion (Barnes et al, 2014) These can all be seen as restraints to our drive for better data around HSI.

These are all factors we should appreciate, however are we missing something else?

In brief, we know those at highest risk are those with history of previous strain, weak eccentric strength and those in a fatigued state (Opar, Williams and Shield, 2012). Flexibility, neuromuscular inhibition, biomechanics and H:Q ratios have all been flirted with, but with no real hard conclusion as to their influence on HSI. Identifying those at risk is relatively straight forward these days, given increased accessibility to advanced monitoring technology, helping to identify fatigue or strength reduction. We can thank systems such as GPS and The Nordboard for this. These are for sure all very important considerations as we take a multifactorial approach to injury management and prevention. But, Is there anything else we need to consider?

One area that I feel needs further investigation with regards to HSI is the psychological harmony of the athlete. It may be difficult to account for the primary injury, but are negative beliefs, anxiety and apprehension contributing factors to high rates of re-injury?

jonny blog
More brain training before RTP?

Cognitive functioning and therapy has been discussed at length in the treatment and management of many other musculoskeletal conditions, notably chronic LBP (O’Sullivan 2012) and ACL Reconstruction , with methods such as CBT proving an effective intervention in many cases. I wonder therefore if this needs more consideration when it comes to hamstring injury treatment? Poor psychological readiness has been associated with hamstring strain re-injury (Glazer, 2009) and this would also provide a feasible explanation as to why completion of Carl Askling’s H-Test appears a strong indicator for RTP. Maybe it’s something we are missing, or not considering enough? By more thorough monitoring of anxiety and apprehension can we mitigate ‘previous HSI’ as a risk factor? Food for thought..

What about fatigue and eccentric weakness?

  • We know HSI is more likely to occur towards end of 1st half & throughout the 2nd half (Ekstrand 2011) and that optimal time for full physiological recovery is 72 hours (Dellal et al 2013).

We also know..

  • The widely documented success of the Nordic Curl programme and other eccentric lengthening programmes in reducing HSI in some populations (Arnason, 2008 and Askling 2013).

Throughout the competitive season, the clinical challenge is to address both fatigue and eccentric strength, because for me, the 2 are counterintuitive to one another. You cannot perform regular, effective eccentric strength training without inducing fatigue, therefore it becomes very difficult to address both variables during a season of heavy fixture congestion.

I do wonder if we spend too much time in-season, prescribing injury prevention programmes and exercises. I feel there is a strong argument that we are only exposing our athletes to a greater risk of injury by adding to the overall accumulative training load and fatigue.

jonny blog 2
Are we doing too much?

Why are we not reducing hamstring strain injuries?

Are we trying too hard in search for that holy grail of HSI prevention? Do we just need to ease off these guys?

Ultimately, and realistically I think there has to be a fine balance between the 2 . Windows of opportunity, such as the international breaks and pre-season, should be fully utilized for specific strength training and the remainder of the season used to ensure players have adequate time to recover and prepare physiologically for upcoming competition.

 

No answers here, just some food for thought. Enjoy your sport =)

 

Jonny

Motor learning theories – why should progression stop at physical?

imagesMRH79NZM

As a younger physiotherapist, I don’t think I ever consciously paid attention to the psychological aspect or power of my job. By that I mean, I didn’t read any research around it – it all seemed a bit wishy-washy and non-tangible. But quickly you realise that a verbal cue that just clicks with one patient turns into a complex dance choreography with another.. “No, I just wanted you to bend you knee.. why are you doing the worm?”

I’ve talked before about the clinical reasoning behind exercise progression and regression and in doing so, I skimmed the surface of the addition of intrinsic & extrinsic stimuli.  So now I want to build on the concepts of motor learning to underpin that exercise progression.

My inspiration for this blog came from a couple of podcasts by the PT Inquest gang, Erik Meira (@erikmeira) & JW Matheson (@EIPConsult). Well actually, first I bought a chinchilla, then I wrote this blog. If that doesn’t make sense, don’t worry. It doesn’t. But listen here (PTInquest).

Funny chinchilla1

The gents speak in detail on two particular podcasts about non-linear pedagogy and how this teaching concept & theory of motor learning ties in with implicit learning. I will break down the idea and definitions shortly, but the reason I wanted to blog about this rather than just direct listeners to the podcast, is I feel the motor learning concepts need to be progressed just as much as the physical demands of an exercise are considered.

explicit

What are we talking about?

Ok so breaking down some of the terms. Because from first hand experience, these terms can be confusing. Cap in hand moment but, I Published a model to explain exercise progression (here). You will see I have described implicit & explicit learning – where in fact I mean intrinsic and extrinsic. Very different things, here’s why:

Intrinsic exercises – relies on internal feedback mechanisms, such as capsuloligamentous structures – Pancian & Ruffini receptors within joint capsules providing proprioceptive feedback that the athlete is acutely tuned into. A good example is a single leg stand where the athlete is consciously thinking about balance, aware of every movement in the foot & knee, the upper body and arm position etc – those exercises where nothing else in the room matters apart from the mark on the floor you are concentrating on to keep your balance.

The opposite to this are Extrinsic exercises – these revolve around the athlete and their environment. A snowboarder reacting to a sheet of ice after carving through powder, or a downhill biker absorbing the changes in terrain – their thought process is very external. Its about the factors they can’t control. At no point (or at least for an extremely limited time) are they consciously aware of their scapular position or degree of knee valgus, for example.

Explicit teaching – This is probably something that is easy for us to relate to. It’s a teaching technique that most of us are comfortable with because we can achieve quicker short term goals. “I want you to put your feet shoulder width apart” or “keep your knees in line with your second toe during the squat” – very clear instructions that require the athlete internalise their thoughts, suddenly their actions become intrinsic. But we get quick results in line with our (not necessarily their) goals.

Implicit teaching – this is a bit more tricky. It is giving the athlete non-directive instructions with the aim of externalising their thoughts. “When you jump onto that box, I want you to land as quietly as you can” or as the PT Inquest lads say “Land like batman” (in the batman voice). If you are encouraging effective change of direction, Conor always says “Push the ground away with your foot.” We are still giving instructions, but the athlete is thinking about external environment; noise, surface contact etc.

And this is where non-linear pedagogy comes in. Creating learning environments for athletes to explore movement variability. After all, that perfect text-book single leg squat we spent weeks mastering isn’t going to look so perfect on a skier trying to regain their balance. Chang Yi Lee et al (2014) use the example or learning a tennis stroke – comparing linear pedagogy of prescriptive, repetitive drills versus non-linear pedagogy of more open instructions like “make the ball arc like a rainbow.”

Think shoe lace tying - easier to learn with the rabbit going round the tree etc
Think shoe lace tying – easier to learn with the rabbit going round the tree etc

 

How does this fit into progression?

The ideal scenario is for the athlete to have as little reliance on us as therapists or coaches as possible. We wont be following them around the track, or on the pitch reminding them of their pelvic tilt.

I think the concepts of non-linear pedagogy are brilliant to explore with coaching. Working with young athletes for example that are still developing their motor control and have some fantastic imaginations to tap into.

However with a rehabilitative role, I think we need to be more inclusive of all concepts. Learning of a new task is initially rapid but without the addition of further stimuli it can quickly plateau (Gentile 1998). A rehab program should always be low risk, high demand (Mendiguchia & Brughelli 2011).Consider the pathophysiology and the structures injured. No injuries happen in isolation, if muscle is injured we will have some neural limitations also. The presence of swelling and inflammation decreases cell metabolism along with a decrease in the presence of oxygen; so we can assume that proprioception is reduced and risk of secondary injury is high.

Therefore, following injury, it is always a good concept to assume that skill level has regressed to novice, regardless of the level of athlete pre-injury.

th8HKBHUZC
“So whats the knee brace for?”                                             “Well you only had your surgery 2 weeks ago – just being safe”

What if we were to encourage intrinsic, explicit, linear pedagogy exercises in the early stages? We don’t need to be adding external stimuli at this stage. It’s important to internalise in order to rehabilitate proprioception. You can’t safely expect someone to externalise while proprioceptively deficient – as soon as someone can weight bear, we don’t start throwing them a tennis ball whilst stood on a Bosu (I hope!)

As the injury improves and skill levels progress, it is then important to move our instructions towards non-linear pedagogy methods, encouraging extrinsic thinking via implicit instructions. By end stage rehab, our instructions should be “start – stop” and hopefully not much more.

Just as we would progress the demand of physical activity following injury, we should really progress the cognitive demand also – but we need to start from a safe, effective position in acute stages.

Yours in sport,

Sam

Walking the “Plank” with core stability prescription

My colleagues are currently taking great pleasure in including “clams” in their exercise programs just to wind me up, so thought it was about time I gave them some new material. (See my thoughts on clams here).

Like “Clams” I have similar opinions on the rational behind including “planks” as part of an exercise prescription for athletes. I will start, and re-iterate later on, that there are times when they are appropriate, providing they have been clinically reasoned. But this is my point, do we throw them into rehab plans / injury prevention plans out of habit or have we individualised the exercise for an athlete?

 

walkingplank

 

What are the benefits?

Performed properly, the Plank is an isometric exercise that crudely speaking, activates the “core”. In doing so, it should encourage a sustained hold of a posterior pelvic tilt and neutral spine for a set duration of time, also working the shoulders and lower limbs to support the torso. Stability provided by the trunk muscles allows for whole body dynamic balance (Anderson & Behm 2005) and as such, these muscles require both strength and endurance.  The deep stabilisers of the lumbar spine display a small cross-sectional area, as such their ability to generate any torque is limited, so their function is to provide local stability and require this endurance component we talked about – perfectly targeted by a well performed plank. In patients with chronic low back pain, isometric exercises had positive effects on increasing the cross-sectional area of the multifidis muscles (Danneels et al 2001).

If we apply the principle of Optimal Loading, then there may be examples of injury where a static exercise is the only way of applying load to an individual. It may be that they are limited with any rotational components of exercise and are pain free in a neutral position. We also understand that isometric contractions can have an analgesic effect on patients (Bernent et al; Huber et al), hence the popularity of adductor squeezes for adductor tendinopathies.

 

..So what is wrong with Planks?

There are undoubtably examples and case studies where the use of a Plank is appropriate for an exercise program. However, un-supervised, there are many compensation patterns that patients can adopt when performing this exercise.

If prescribed as a home exercise, you should have great confidence in the athletes proprioception and ability to self correct. Otherwise you will likely re-enforce the exact reasons why you are treating the athlete in the first place. My biggest gripe with Planks, or Side Planks, or any isometric core exercise is that most people will fixate instead of stabilise. Locking the back into extension (plank) or into side flexion (side plank), or tilting the pelvis anteriorly, or flexing through the thoracic spine are examples of relying on passive structures like ligaments and joint capsules rather than stimulating active structures that should stabilise these joints.

“Don’t replace STABILITY with FIXATION”

Core stability is “the product of motor control and muscular capacity of the lumbo-pelvic-hip complex” (Click here for an excellent core stability review by Paul Gamble). The clue in this quote are the the words “stability” and “motor control”. There are very few examples in sport or even in daily living where we need to hold a whole-body isometric contraction for 1 minute or more. Essentially movements in sports occur in multiple directions. Even in events like Skeleton or Luge, the athletes are reacting to perturbations from the track or adjusting their course via small shoulder or lower limb movements, so I’m struggling to think of the cross-over benefits of a plank into sport. The benefits of a strong lumbopelvic region help transfer ground reaction forces to produce movement and integrate the function of the kinetic chain. Weakness or dysfunction of any link in the chain can increase risk of damage to another structure and as such, any one muscle should not be views a more important to another in terms of lumbopelvic stability (Brown 2006).

 

Note the increased Lumbar lordosis due to extension at the head end of the tiger
Note the increased Lumbar lordosis. Also, the stripy athlete underneath is rotated slightly.

 

“Don’t give me problems, give me solutions”

As I said, in principle there are he benefits to core stability, especially in terms of proprioception and limbo-pelvic dissociation. But for me, the trick is to stimulate the core during movement.

Some simple modifications of the Plank can greatly enhance its suitability for athletes.

 

1) Plank with Wall Taps:

Assume the traditional Plank position, you can regress this with bent knees, similar to a press up regression. Position the athlete about 2ft from a wall, facing the wall. Ask them to reach forwards and tap the wall with alternating arms but maintain stability of the pelvis and trunk.

Although a sagital plane movement, the athlete will be working against a transverse plane to stop the pelvis and lower trunk from rotating to the side of the moving arm.

photo 1[4] photo 2[4]

 

2) Plank with Stacking

Again, in a traditional Plank position, but this time set up a stack of 3 x 2.5kg weight discs on one side of the athlete. Ask them to reach over with their opposite hand, pick up a weight and start stacking on the opposite side. Repeat until all weights have transferred sides, then begin with the other arm. In doing so, instruct the athlete to stay as still and controlled in the hips and lumbar spine as possible, the movement should come from the shoulders only.

By reaching across with one hand, you are de-stabilising the torso. Moving the weight from one side to the other adds a transverse element to the exercises, as well as the challenge of moving with and without a weight.

 

photo 3[3] photo 4[1] photo 5[2]

 

 

3) The Side Plank with arm tucks:

Add an element of upper body rotation whilst stabilising the pelvis. Instruct the athlete to keep their hips up (relative hip abduction of the lower leg), tuck their extended top arm underneath themselves (like putting on a seatbelt) but in doing so, don’t let the pelvic twist. Encouraging dissociation of the pelvis and spine to stop them moving as one column.

 

photo 1[3] photo 2[3]

 

There are so many variations that I haven’t included; you can add cables or theraband and ask the athlete to pull  in different directions maintaining the plank position, you can add movements of the lower limb or think of various ways to de-stabilise the more advanced athletes. For those athletes that just “get it”, there are brilliant variations of the Bear Crawl which may be appropriate – for me, a perfect example of “core stability” (averagely demonstrated below)

– Bear crawl core stability exercise

 

Conclusion

Activities during sport require both static and dynamic strength – however in rehabilitation, these should be dynamic exercise with a pause rather than prolonged holds. At times, we may have to regress back to its most simple form in order to educate the athlete on correct positioning or increase proprioception but there should always be a plan to progress into dynamic core stability, rather than progressing the time holding a plank.

When designing rehab programs, we should always consider the individual – what do they need to cope with for their sport / daily life? What physical capabilities do they have at this moment of their program? Am I challenging them appropriately?

I hope this provokes some thought and discussion, please let us know your experiences and opinions

 

Yours in sport,

 

Sam

 

Exercise Progression & Rehab Programs

A year or so ago, I put on a CPD evening for our part time staff at the football club discussing exercises and the clinical reasoning behind developing a program (needless to say I got talking about the use of clams for a quite a while – clam blog). In this presentation, I started drawing my reasoning process onto powerpoint using some coloured blocks to help visualise the theory that I was trying to describe.

The theoretical model was recently published in Physical Therapy in Sport and I thought I would use this blog to try and discuss it in a less formal way than the writing style allowed in publication.

 

The model (here) is designed to be fluid and adapted to any individual by any level of clinician. Let me quickly introduce the components:

Model
A theoretical model to describe progressions and regressions for exercise rehabilitation (Blanchard & Glasgow 2014)

 

  • The triangular blocks (1) represent the fundamental exercise, the core ingredient that will remain throughout the progression. The arrows running up the side of the triangles represent an ongoing progression throughout the rehab process such as speed, duration, repetition etc. So basically, something that can’t be affected by the stimuli that are added or removed. If you add an unstable surface to an exercise, you can still progress by increasing the duration.
  • The coloured blocks represent a stimulus that will help the exercise progress. This can be one of two things;
  1. Internal – something that the patient has to focus on intrinsically. A decreased base of support for example, where the patient must focus on the balance element of an exercise.
  2. External – the addition of something to the exercise that takes the patients focus away from the movement or action they are performing – adding a ball to a running drill, or a verbal command that initiates a change in direction.

The blocks are interchangeable and can be added / removed at the clinicians discretion.

  • Adding a new block, which will progress the exercise, is accompanied by a regression of the “gradient” on the blue triangle. Creating a step-like progression across the model. As you progress with an internal or external stimulus, its important to bring the difficulty levels back down, so reducing repetitions or speed or duration. This allows the pateints to adjust to the new stimuli without fear of re-injury or task failure. When teaching a child to ride a bike with stabilisers, you don’t take them off and ask them to cycle at the same speed you did with them on. For that reason, you wouldn’t get someone going from 30 reps of a hamstring bridge straight into 30 reps on a single leg bridge as a progression. You would decrease base support and reduce reps to allow adaptation.
  • Adding a “block” doesn’t mean you have to add something to the exercise. The block represents a step up in their progression. So progressing from two legs to single legs is technically “taking away base of support” but is an addition to the ongoing progression.

 

Lets use an example, recently I started designing a program for a teenage footballer with a proximal adductor strain. New to professional football with no history of conditioning.

In the sub-acute stage, once intial pain had settled, we began looking at his movement patterns and stability and noticed a huge imbalance with his left sided control through sagittal and transverse planes compared to his right. He is left footed, so his plant leg (right) is used to supporting his body weight.

His body awareness and “physical literacy” was so poor we had to regress him right back to basics. The following represents a small proportion of a larger exercise program. I’m not usually an advocate of planks in a multidirectional sport like football, but in this case, his single plane control was so poor that I swallowed my pride and began with basic planks.

imagesCA39QJMI

When I say basic, we reverted to short lever planks with the knees on the floor – this was the only was we could get him to control the relationship between his trunk and pelvis. Looking at the model, this short lever plank would be the singular blue triangle at the start (1). We built up the duration of the hold from 30 seconds to 90 seconds over time. This would be the arrow running up the gradient of the triangle.

 

The addition of the first block (2) was to increase the length of the lever so that he now has to hold a traditional plank. In doing so, we dropped from 90s hold back down to 30 seconds and over time, built up to 90s. (These are just arbitrary times, based on no real evidence).

 

The next block we added was a rotational element (3), but to ensure the progression wasn’t too sharp, I removed the long lever and returned to a short lever position. I then asked the player to move a light 1.25kg weight from his left side, with his right hand and place it on his right side. Then with his left hand etc etc. The purpose of this was to introduce a transverse task to a sagittal plane activity – as the arm moves from the ground and across the body, the player has to control the rotation through his trunk and avoid rotation at the pelvis. Instead of duration, we built up repetitions over time.

 

Now that we were confident he could hold a plank, and control rotation in a short lever plank, we could combine the two blocks as the next progression. Now in a long lever plank with a rotational element.

 

The next progression was to add an unstable surface (4). To do this, the player performed a plank with his thighs on a gym ball. This in itself was quite easy so we instantly added a rotational component with an unstable surface, gym ball pelvic rotations (see video here). So now on the model, we have the basic “plank” triangle at the top, a block underneath to symbolise the long lever, another block to symbolise rotational control and a third block to symbolise an unstable surface.

 

“The length of time required by an individual to master a task has

been described as a linear function that begins quite rapidly with

the introduction of a new task and then plateaus or slows over time

as practice continues (Gentile, 1998).”

 

 

This is a very simplistic example of how the model works, but hopefully it demonstrates the fluidity that is intended with it and how the blocks are interchangeable and can work independently or as part of a more complex progression. Every program you write will be individual and the progressions will be different, therefor every model will look different. Some will continue longer than others, some may be shorter than the one I’ve described here. Some will end up with taller columns due to the number of progressions. The width of one column compared to its neighbour may be different size due to the length of time it takes for the patient to master. And so on and so on. If I continued, hopefully I could have ended up with the player doing this:

imagesCANGK06X
But whats the use of that defending a counter attack?

 

Like many conversations I begin or poor jokes I tell, this may be one of those things that only makes sense in my head, but I would love to hear if it makes sense to others – if you think it works and examples of doing so.

 

Yours in Sport

 

Sam

 

 

S&C – Can you ever be too young?

Strength and Conditioning in youth sport is more popular than ever.  Many independent gyms operate “academy” sessions to help the future rugby, football and olympic hopefuls to reach the top of their disciplines.  Initiatives such as the Premier League’s Elite Player Performance Pathway (EPPP) has lead to increased investment in the football academy’s throughout England while Rugby’s academy system has been established for a number of years, with increased specialist support being made available i.e. S&C/Sports Science/Physio support.

Not all exercises are appropriate for young athletes
Not all exercises are appropriate for young athletes

There are many stigma’s attached to Strength and Conditioning training in youth sports.  We have all heard remarks like… “Weights training stunts growth…damages the growth plates” or “Strength training will make you injury prone”.

Is this the truth?

The most commonly reported injuries sustained in youth Strength and Conditioning training are a result of incorrect technique, attempting to lift too much weight, incorrect use of equipment and the absence of a properly qualified supervision – ALL of which are easily avoided with properly programmed and coached sessions (Faigenhaum et al., 2009). The reality is that there are many peer reviewed papers available that prove the effectiveness of S&C programs and injury reduction across a wide variety of sports from Aussie rules football to rugby. While there have been numerous position statements from leading organisations such as the ASCM, NSCA and UKSCA regarding the benefits of a well designed S&C program in aiding the development of young athletes, yet the publics perception has yet to change.  The fact remains there are many benefits in youth athletes undertaking S&C training programs (when carried out properly!).

 

Benefits of  Strength and Conditioning for youth athletes

There are various benefits to Strength and Conditioning in youth athletes, so many in-fact it is beyond the scope of the current blog to cover them all.  Firstly consider that the World Health Organisation recognises physical inactivity as the fourth leading risk factor for global mortality for non-communicable diseases any additional physical activity that is undertaken will help combat the ill effects of modern living.  Appropriate strength training combined with aerobic and anaerobic training, along with a balanced diet, will lead to an increased amount of lean muscle mass which would be especially useful for young athletes in contact sports such as rugby and football.

“Significant gains can be seen as youth elites reach peak height velocity”

From a purely sporting and performance perspective pre-adolescent children show considerable potential for motor learning, therefore there is an opportunity to effectively develop skills such as squat and lunge patterns, running mechanics, deceleration and change of direction prior to the onset of puberty (Barber-Westin et al., 2006).  This should be achieved using exercises that are whole body in nature (no bicep curls…sorry) and aim to develop coordination and overall athleticism, which could also act as a protective mechanism against injury risks later in their sporting career.

kids bicepcurl

Puberty triggers the release of masses of hormones which are of massive benefit when trying to gain muscle mass and strength (if only I knew that 15 years ago).  This also results in changes to the muscular system and cardiovascular systems, mostly in the responses and changes noted to aerobic and anaerobic training stimuli.  While these qualities can be improved pre-puberty, significant gains can be seen as youth elites reach peak height velocity (period of quickest rate of growth, roughly 14 years old in boys/12 years old in girls, Naughton et al., 2000), while the mechanical loading undertaken during youth Strength and Conditioning will also positively influence the development of bones and connective tissues in the body.  Exercises such as sprinting, jumping, plyometrics as well as gym based work all have positive effects on the osteogenic processes.

What should young athletes do in S&C sessions?

Pre-puberty – At this stage of physical development the emphasis should be placed on neuromuscular training and consist of coaching the young athlete through various patterns and movements i.e. coaching a player not to perform a lunge pattern with a knee valgus.  Other movements to master at this stage of development are jumping, landing and change of direction skills.  Skill or game based activities are best for conditioning the aerobic system by manipulating the tasks, number of players or even the size of the area being used for the sessions.  Strength training should consist of exercises, both unilateral and bilateral, and loads appropriate for the age of the athlete.  Body weight exercises would be more than appropriate for this stage of development with a rep range of between 6-15 and 2-3 sets.

Puberty – Neuromuscular training at this stage should show a level of progression in comparison to the previously undertaken tasks e.g. progression from a bilateral to a unilateral exercise  or from basic balance exercise progressing to dynamic stabilisation exercises.  Conditioning exercises should be mostly interval based and consist of more games/skills orientated.  Strength training should show an increased complexity with more unilateral exercises and the introduction of Olympic lifts for appropriate individuals.

Adolescents – Neuromuscular training should consist of increased speed work, unilateral and dynamic stabilisation work.  Conditioning work should feature anaerobic based intervals and progressively more strenuous game/skill based work.  Strength training should progressively load the athlete unilaterally, bilaterally and in the olympic lifts (Gamble, P., 2009).

Summary

What’s not to like?  Starting a S&C program from a young age, provided it is supervised, structured correctly with appropriate progressions will enhance performance on the field and track while concurrently producing many lifestyle and health benefits.  A appropriate program will develop neuromuscular control and athleticism and gradually develop more specialised components of performance.  Ensuring this will help the young athlete reach their maximum potential and encourage physical activity throughout their lifetime.

Yours in Sport,

Conor