It’s not just what you do ----- It’s how you do it!

Marc Sherry PT, DPT, LAT, CSCS, PES

Dan Cobian, PhD, PT

Disclosures

• Movement based rehabilitation • Dynamic Warm Up • Unanticipated movements • Movement skill acquisition

– Sources of feedback – External focus of attention vs. internal focus of attention – Blocked vs random practice – Imagery and AOI

• Patient adherence and engagement through communication and technology – Measurement

• Empathic listening and trust • Technology to improve assessment

Athletic Movement

Athletic Movement

Athletic Movement

Athletic Movement

Athletic Movement

Athletic Movement

Athletic Movement • Opposition of arms and legs • Multi-joint movement

– Triple flexion – Triple extension

• Multi-planar with emphasis on rotation • Quick changes of base of support • Unsupported • Unanticipated movement • Indirect contact

Physical Therapy

• Are we trying to developing athletic/functional movement or impress our patients with “stuff”?

No sense stuff

wall squat • function: closed chain multi-joint

movement with external support • theory: improves quad strength • critical review: strengthening quad in

isolation from glutes with decrease need for postural awareness – effective deceleration is triple flexion with significant contribution from glutes

Risk Factors Associated With Noncontact ACL Injury – “Neuromuscular”

• Altered movement pattern – Studies have repeatedly

shown that women land, cut, and pivot with dec hip/knee flexion and inc knee valgus/hip internal rotation/ tibial external rotation and increase quad to hamstring activity

Besier et al Med Sci Sports Exerc. 33 2001 Cappell et al AJSM 30 2002 Colby et al AJSM 28 2000 Decker et al Clin Biomech 18 2003 Hutson et al AM J Knee Surg 14 2001

High KAM during 3-D analysis of a drop-vertical jump task was the most accurate predictor of future ACL injury in a cohort of 205 adolescent female athletes – Hewett 2005

No sense stuff

• If evidence shows primary MOI for non-contact injuries of ACL deceleration with apparent knee valgus (femoral IR and hip adduction with tibial ER), then why

Really Stupid Stuff

• Is the exercise a means to an end or the end of meaning?

• Means to an end = something done to achieve something else

Movement Preparation / Dynamic Warm Up

What is “dynamic warm up”?

• A progression of active exercises designed to prepare athletes for the demands of their PHYSICAL THERAPY sport /activity

What is “dynamic stretching”? • Active and repeated elongation of a

specific MTU What is “static stretching”? • Passive and long duration elongation of a

specific MTU

WHY?

Dynamic Warm Up vs. Static Stretching

+1.4% -4.2%

Dynamic Warm Up BEFORE Static Stretching

Significant decrease in agility time with Dynamic warm up vs. Static stretching

Static Stretching

Club head speed -4.2%

Distance -5.6%

Accuracy -31%

Consistent ball contact -16.3%

5 Goals of Dynamic Warm-Up 1. Increase core temperature 2. Increase heart rate and prime the CV system and

the energy “delivery” systems utilized for a given sport, activity or training session.

3. Elongates MTU’s actively with the goal of preparing or improving dynamic flexibility

4. Improve timing, rhythm and coordination. 5. Increases neuromuscular reflex sensitivity and

promotes “psycho-motor” readiness.

Guidelines of Dynamic Warm-Up 1. After general warm up 2. Static stretching should be after practice or if needed

before practice then before dynamic warm up. Any static stretching should be less than 30 sec.

3. Should break a light sweat 4. Include lower / upper / core 5. Use multi-joint movement patterns --- age related 6. Progressive build up of speed

Fundamental Movement Strength Progression

Impact Progression

Agility Drills and Progression

Unanticipated Movement

• video

Movement Development

“Skill acquisition occurs when the skill is repeated correctly, frequently, in its entirety, and reflects the conditions under which the acquired skill will be ultimately performed or used”

-Gerald Lafon

Performance – Skill execution at a particular moment in time (not permanent) – Highly variable & sensitive to conditions that have no bearing on the assessment of skill (eg; fatigue, environmental conditions, instructions) Motor Learning – A permanent improvement in skill that is achieved as a function of practice – Suggests underlying mechanisms have been developed Motor learning is the basis for performance

Farrow, D.

Sources of Feedback Intrinsic • Information provided as a natural

consequence of making an action Extrinsic • Information external to the performer & adds

to or enhances intrinsic information – directed at helping them “feel it” (can be verbal or task oriented)

• Is either Knowledge of the Result or Performance

• Can be verbal or non-verbal

Feedback Modalities

KINESTHETIC • Allow the athlete to immediately practice the skill with minimal or no instruction • Provide verbal feedback describing the ‘feel’ of the movement

Farrow, D.

Manual Feedback • Aim to reduce errors & ensure correct

movement • Useful for low skilled performers • Powerful & effective when applied in

practice, but is not a strong learning variable because:

– Modifies feel of task – Decision making changes – Limited opportunity to experience errors or

correct errors – Specificity / Transfer

Visual Feedback • Allow observation of the skill by video, demo, or

watching others during ‘live’ action • Provide verbal descriptions utilizing visual terms • Calvo-Merino et al, 2005 (dancers) showed there is a

network of motor areas involved in preparation and execution of action that was also activated by observation

– Ballet vs. Capoeira – Activation was stronger in “experienced” dancers --- implication for rehab

Visual Feedback • AOT – Bellelli et al 2010

– Traditional PT + motor movies vs geographic movies – Post-surgical orthopedic pts – Significant improvement in both mobility and

locomotion in the motor movie group • http://www.youtube.com/watch?v=gPErSBmU-Gk

Verbal Feedback

• Effects Focus of Attention and Processing

Focus of Attention

• EFOA (Implicit learning) – Direct attention toward external effects of action or the

goal • IFOA (Explicit learning)

– Direct attention toward the body’s components during a task

Farrow, D.

ACL injury prevention, more effective with a different way of motor learning? -Benjaminse and Otten, 2011

• Direct instructions can have a detrimental effect on learning, thus disrupting the execution of automatic skills

• Less resilient under psychological and physiological fatigue

Prapavessis et al 2003

- Poor retention on skills learned through technical instruction >1 week

• Focus on the rungs of the Vertec that were to be touched (external focus)

• Focus on the finger with which the rungs were to be touched (internal focus)

• Focus on jumping as high as possible (control condition)

– Zachry et al, J Sport Exerc Psychol. 2005; 27:S162–3.

EFA vs IFA

• 36 grade 1 or 2 ankle sprains • Postural control

– EFA = board – IFA = body

• Biodex Stability Test Variables: • Overall stability • AP variance • ML variance

» Rotem-Lehrer JOSPT 2007

EFA + x 3

Lohse 2011

Plantarflexion isometric target • EFA = push platform

– TA 6% MVC – Less error – Higher median power frequency = increase

MU recruitment • IFA = contract calf muscles

– TA 20.7% MVC

Athletic Performance

• Putting • Golf – 9 iron pitch • Free Throws • Dart Throwing • Swim speed • Skiing • Soccer kicking accuracy • Tennis Strokes

• EFA > control – ?? Novel tasks are adopted by people as IFA

» Merchant 2006 » Wulf 2007

• “Choking” has been shown to be related to a shift to IFA

» Baumeister 1984 » Wan and Huon 2005

• PTs utilize “internal focus” 96% of the time – UE rehab – Durham et al, Physiother Res Int. 2009;14(2):77–90

• Ave of one verbal instruction or feedback statement every 14 seconds. 66%= internally focused, 22% = externally focused, 11% = mixed

– Gait retraining post-stroke

Don’t let your knees

kiss.

Keep your

knees over your toes.

Don’t leg your

knees touch.

Keep your toes forward

and push your

knees out.

External Focus of Attention

• video

Verbal Feedback - Processing • Use questioning

– Encourages problem solving, discovery and performance awareness

– "questioning“ leads to superior long-term athlete development and greater athletic self-competence (Chambers & Vickers, 2006)

– cognitive stimulation leads to improved self-awareness ultimately increasing autonomy and learning

• Delay feedback – allow time for reflection • Withhold instruction early in acquisition to

encourage variability

Motor Learning and Performance

• Delayed and reduced feedback translates to greater improvement in long term performance

– Constant feedback can create dependency – Less feedback mobilizes cognitive processes for

performance information (driving directions example) – “Bandwidth” feedback = outside certain limits – May incorporate self directed use of extrinsic feedback

» Chambers 2006

Chambers 2006

Goodwin and Meeuwsen 1995

• BW0(feeback every trial) • BW10 • Shrinking BW

(increasing feedback) • Expanding BW

(decreasing feedback)

Movement/Skill Acquisition

• Blocked practice vs. random practice

Random practice of a motor skill enhances long term learning more then blocked

Overdorf et al Perceptual and Motor Skills 99 2004

Creating random practice can occur by changing activities or by changing environments/

conditions

Farrow, D.

Imagery • Mental practice improves performance

compared to no practice • Mental practice =/= imagery

– mental practice = imagery, self-talk, relaxation, anxiety management, mental preparation

– imagery = picturing or seeing yourself perform a skill • Studies have correlated level of athlete with use

of imagery • Self-confidence is positively effected by imagery

Weinberg 2009

Skill Acquisition for Rehab and Athletic Movement

• Use more random rehab planning • Use less verbal feedback • Use more EFA and imagery • Have athletes observe ---- others,

practice, videos, etc • Try to create motor learning • Train a spectrum of movements

and conditions (replicate sport) • Integrate task and progress to

sports specific task • Train athletes to be adaptable not

just adapted (transfer ability)

PT Reimbursement

Patient Adherence – The Problem

Patient Adherence – The Solutions

• Empathetic listening • Support

Empathy

The ability to understand or share one’s feelings

“What’s the matter with you?”

vs.

“What matters to you?”

References Farrow, D. Current Directions in Skill Acquisition www.ausport.gov.au SCOTT G. MCLEAN1 and JULIA SAMOREZOV2. Fatigue-Induced ACL Injury Risk Stems from

a Degradation in Central Control. Med Sci Sport Exer 1661-1672, 2009 Weinberg. Does Imagery Work? Journal of Imagery Research in Sport and Physical Activity,

Vol. 3 [2008], Iss. 1, Art. 1 Chambers et al. Effects of Bandwidth Feedback and Questioning on the Performance of

Competitive Swimmers. Sports Pscy, 2006, 20:184-197 Wulf G, Shea C, Lewthwaite R. Motor skill learning and performance: a review of influential

factors. Med Educ. 2010; 44(1):75–84.