This past weekend I had the pleasure of attending a seminar at the Richmond Oval taught by Charlie Weingroff who is a Strength and Conditioning Coach and Physical Therapist out of New Jersey. His work is well known for bridging the gap that is often missed between the training world and rehab world, hence the name of his course training = rehab. One thing that some people may not know about Charlie is that he is actually the head Strength and Conditioning Coach for Canada basketball. I have no doubt that with him at the helm of athlete performance and the young crop of talent trickling their way into the NBA led by Andrew Wiggins, that we should definitely be a medal contender in the 2020 olympics in Tokyo.
A quick and honest review;
Pros: Great presenter and great information, that even though was new to a lot of people, he did a good job of showing why what he was saying is his believes. I liked how he always said you can not believe a single thing I’m saying, but I just showed you why I believe it’s that way and it’s your choice what you choose to do from there. I also personally loved his one comment about “my scientific research is I see a dysfunction, I do something to fix it, and if it works, it works, if not then it doesn’t. This is the practice of scientific method and research doesn’t always show the whole picture.” I share the same view point, and it’s not bashing anyone obsessed with research in their practice, as it is a piece of the puzzle that I do care about, but I agree with his sentiment that all our own practices are our own little research studies every day. He was highly entertaining and passionate as well!
Cons: Really not many. I heard some rumblings during the course from some attendees that it was almost in this awkward middle ground between training and rehab talk that it left the rehab professionals in the room not super involved in the strength and conditioning side of things and some of the coaches/trainers not quite knowing how to implement the rehab side of things into their training plans. Since I come from a training background and am a young rehab professional it was almost a perfect course for me because it confirmed many of my recent thoughts/transitions in my clinical practice as we will see below, and showed some insight into some training methodologies I was familiar and unfamiliar with. So I was extremely happy with the material, but could see why others may have found it hard to grasp or if they had been exposed to it, find it redundant.
Now onto some applicable information. Below I have 5 points I want to talk about. 4 of the points are actually things I have slowly been integrating into my clinical practice and definitely where I see myself heading over the next few months/years/life time. I was planning on writing a blog on these topics soon anyway, but after taking this course it has re-enforced my stand point that this is how rehab should be heading. Then the last point I will quickly touch on some views on mobility that were discussed in the course and have been bouncing around the physio/training social media world lately. Hope you enjoy the info!
1. High threshold and low threshold
After the first morning talk I went up to Charlie on the break and discussed this idea that’s been bouncing around my head the past few months and was happy to hear he said it was bang on. It’s really been how I have practiced from the get go, but just a different way of looking at the bigger picture. Really what it comes down to with injuries i whether the patient has a high-threshold strategy or low-threshold strategy. Often times the reason someone is likely in pain is because they may be using a high-threshold strategy for low level tasks. For example, if you don’t have the adequate mobility to squat, you may have to tension everything just to do the movement which may lead to knee/hip/low back pain. Another example might be a person with shoulder pain whose rotator cuff is on fire because the person has developed an aberrant movement pattern causing the rotator cuff to have to over-stabilize the shoulder because they may not be getting stability from the scap. Are band external rotations going to help this person? Probably not as the tissue is already high threshold. Or vice versa, what about the person whose upper back is toast because it has to create stability for the whole shoulder complex because their cuff is not stabilizing the GH appropriately? Tennis Elbow? Achilles tendonitis? Chronic low back muscular pain?
Most injuries probably stem from some sort of high threshold strategy to compensate for instability. Patients present to us typically with a pain/mobility problem, but there is almost ALWAYS an underlying stability problem. Why is that tissue tight? Why is it firing all the time in a high-threshold matter? Not often does someone present complaining about their stability problem, but that is what we need to find to explain the why their tissue is high-threshold. Sometimes these people may actually be fine under a given activity (depending on severity of tissue damage and the activity itself), but feel sore throughout the day and may have trouble sitting up and down from a chair or reaching for things in the kitchen. This is because during the activity they may be able to use their high-threshold strategy when it is needed, but during ADLs they continue to use it when it is not needed.
On the other hand, sometimes a patient may get injured due to a lack of ability to create a high-threshold strategy during movement. The person who can’t create tension in their leg sufficient enough to handle a cut in soccer leading to ankle/knee sprain. The person who can’t brace their spine appropriately during a deadlift. The person who can’t stabilize their scaps properly during pressing/pulling and their shoulder blows out. These can actually be more rare than high-threshold injuries and can actually be easier to fix in a preventive setting through coaching, movement training, and strength training. Their problem lies in their inability to switch from low-threshold to high threshold when needed. In ideal function, this transition should be smooth, easy and consistent amongst movement. A personal believe of mine, and a reason why strength training is so valuable to everyone, is that through strength training we can learn how to reach high-thresholds and this in turn teaches us how to be low-threshold when needed too (most of the day). There are also those people that are just in pain because they are weak as hell and have no control over their body whatsoever. This would fall under this realm as well.
2. Tonic muscles given Phasic exercises = probably not ideal
This was particularly funny because there has been an email thread at my work going around how glute band walks are an over-rated exercise and Charlie comes out and says that he thinks its completely ridiculous to train glute med this way when it is a tonic muscle. Tonic means the muscle fires at a lower grade level, consists of more type 1 muscle fibres, and is more important for stabilizing rather than movement production. So why then do we do side-lying hip abductions or glute band walks to create the movement of hip abduction, at a somewhat intense level of contraction in a manner typically used to activate type 2 fibres? I remember reading this in Gray Cook’s book Movement years ago and thinking it was excellent, but still implementing the above 2 exercises because the patient/athlete may “feel them”. Now I would still use the above 2 exercises for certain populations as I have seen their efficacy and I think they both lead to general glute activation which is nice to have anyways regardless of specific glute med function. However, maybe we should be performing exercises that allow the glute med to stabilize. Side plank from the knees is a great exercise that if done correctly will roast your glute med to stabilize your lateral line. Single leg balancing in different positions/different band assistance/resistance in ideal alignment may be all that is needed too (after mobility/centration is cleared).
In the shoulder, he used the example of band external rotations. Again an exercise that is creating movement, and aiming for strength gains when really the role of the rotator cuff is to stabilize the GH joint. After centration (more on this next) and mobility of the shoulder are full why not do some rhythmic stabilization to increase the stability effect of the muscle. Or isometric holds with your arm in certain positions we went over in the course that I won’t touch on here.
Sometimes doing the phasic exercises might actually make things worse. I have noticed a lot of glute meds and posterior cuffs in my practice so far that are both tight and weak at the same time. Note, not tight and strong, or weak and long, but both negatives at the same time. However, maybe weak is not the right word. Tight, from being used as a phasic muscle when it should be tonic, and dysfunctional, from being used as a phasic muscle when it should be stabilizing. Again, band external rotations and glute med phasic exercises could definitely still be useful, but I hope this opens some eyes as to the direction exercise prescription is heading. 10 years from now every PT will be laughing we did band external rotations all the time and the leaders in the field will probably be laughing at us for doing this new described way as they will have found something even better likely.
3. Joint Centration = Muscle activation
As I hinted at in my last point, the big word flying around my work place lately is joint centration. After going through my own knee injury the past few months I have started to make some major strides after focussing on my hip centration. Now this isn’t about cranking on the hip mobility to make it better or pushing it back to the centre. It is about doing the tissue work around the hip necessary and then allowing the head of the femur to properly reposition itself into the acetabulum through certain exercises and then developing proper movement patterns, stability patterns and tension to keep the hip moving properly throughout different activities.
Obviously we have thought about this with the shoulder as everyone with shoulder pain needs to reposition their Humerus posteriorly right? I am actually somewhat serious as this is often a huge factor in shoulder dysfunction and posterior glides can often be a very helpful technique for lots of different shoulder pains. However, if this isn’t corrected or the hip isn’t corrected are any amount of YTWs or hip bridges even going to do anything?
When the joint is not centrated it almost doesn’t even matter what exercises we throw at it (besides joint centrating exercises). The joint is not going to be in it’s ideal state to function and we are just going to continue to build dysfunction on top of poor alignment. However, when the joints do get centrated then the muscles we want to function are actually in an ideal state to do their job and can do so without necessarily being forced. This is done through communication of the nervous system between the joints/muscles and the brain. Through proper movement coaching, after centration is reached, it can be just about grooving the necessary pattern and creating stability where needed. Now I mentioned the hip and shoulder, but this can also be the case at any of the spinal levels, SIJ, knee/elbow, ankle/wrist or foot/hand.
I remember a Mike Reinold blog once discussed the topic of rearranging the common saying of mobility before stability into, “alignment before mobility before stability” and I couldn’t agree more with that thought process lately. Most of the stuff touched on about centration is taught in Dynamic Neuromuscular Stabilization courses, which I am looking forward to starting in April to expand my tool box.
One thing that was also frequently discussed at the course was the need to step away from scap retraction. People over retract their scapulae and the centrated position of the scaps are actually 10-20 degrees of protraction. Exercises that force scap retraction are likely to over jack up the rhomboids concentrically when really the rhomboids need to be strong eccentrically and isometrically when stabilizing the scap. A jacked up rhomboid can also lead to a downwardly rotated scap that can cause impingement problems down the road as well. Focussing on centrating the scaps during exercises was a key message and one of the more interesting brain scratchers of the weekend (in a good way because it got you thinking) was loading up a rowing movement so heavy that the person can’t actually go into scap retraction, but pulls as far as they need to go and then eccentrically control the scap coming forward.
4. Diaphragmatic breathing and core training
Now this could be a whole 10 page blog at shortest if I really wanted to get into details as there are textbooks and weekend courses on the topic alone. So I will just touch on some major ideas. Charlie very much was against the draw-in maneuver that a lot of therapists may use for TvA activation. If you want to know why, read Stu McGill’s books, or try to do anything powerful with a draw in, or realize from my previous point that the TvA is another tonic muscle so why train it in a phasic manner with draw ins. Also, you can stop beating your head into the wall with patients struggling to feel it because I know I friggin’ hated it when I was forced to implement it as a PT student and haven’t implemented it once since starting work.
So how should we go about training core then? McGill’s big 3? They can be helpful for sure, but often times these may be high threshold exercises when the person may need to work on something a bit lower level. This is where diaphragmatic breathing comes into play in relation to core function.
Again, I don’t want to get into too much detail here, but basically, often people come in hyper-extended through their TL junction, with ribs flared and often an anterior pelvic tilt as well. This position causes the barrel shape of the rib cage to actually open up a bit, which doesn’t allow for proper decent of the diaphragm. The diaphragm then can’t descend as well it should and thus doesn’t create optimal intra-abdominal pressure for the surrounding core musculature to activate properly. Thus, it may be ideal work on controlling their rib flare, working on diaphragmatic breathing, slowly introducing tension throughout the core musculature, and then slowly adding excursions of limbs, addition of bands, and addition of movement drills in more functional positions. A proper functioning diaphragm = proper functioning core at low threshold mechanisms and high-threshold mechanisms. Please don’t do TvA draw-ins if you still are and if you do McGill’s big 3, maybe realize that they may need some drills at a lower level of function depending on their compensations.
5. Random thoughts on mobility (some my own, some presented in course)
- Stretching after a workout can help the muscles at a cellular level uptake anabolic hormones better. Research was presented in his slides.
- Don’t stretch to increase performance, but if you do stretch before activity, follow it with a good dynamic warm-up. I think doing some mobility drills specifically before dynamic warm up is helpful
- If you do a stretch session separate from a workout, you can get more benefits when you are cold and not warm. Being warm will make it harder for plastic changes in the muscle tissue to stick. Sure it will seem like you can stretch better, but that is primarily a thermal effect. If you stretch when you are cold, you actually get more effect on the tissue and even greater effect when the thermal effect is added in later during activities.
- Foam rolling can be great for recovery, but if you continually need it on certain areas there may not be something ideal with your training program. Which is fine, there is nothing wrong with that and you can continue using the foam roller to recover, but searching for an adaptation you can make in your training to fix the recurring issues could help as well.
- Toes forward squatting for everybody…..not going to happen. I don’t even think people should necessarily strive for this, do whats comfortable unless you are extremely toed out maybe. Stance width is highly dependent on hip type/position as well. Also, the “Knees out cue” everyone seems to be ripping into Kelly Starrett of Mobility WOD for. Yes not everyone should squat knees out like they demonstrate in the book, but it is a good cue for most people learning how to squat so lets realize this, not throw the cue away, but make sure it’s not over stretched either
Thanks for taking the time to read my blog! I would love to hear everyone’s thoughts on anything discussed above! Looking forward to hearing from you!