Injuries are an unfortunate part of sport.  No matter how hard we try to prepare athletes prior to competition, sometimes injuries happen.

It is commonly thought that pain and injury have a one-to-one relationship – IE, I twist my ankle and I get pain.  While this may be so in some situations (especially acute situations like an ankle sprain), it is important to remember that pain is a lot more complex than that.  Pain doesn’t exist in your muscles, joints, or ligaments.  Rather, pain exists in your brain (and like Arnold says, “it’s not a tumor”….well, sometimes it might be a tumor!).

Pain is an important aspect for our survival.  It tells us something is wrong.  In fact, if you did have a brain tumor, those intense headaches that are the source of your pain would force you to go to the doctor, get a thorough evaluation, and then get appropriately treated.  However, sometimes the signals of pain can get crossed.

What about those people that for whatever reason aren’t having pain when faced with a life threatening condition?  For example, the people who have cancer eating away their stomach, yet experience no pain at all, until it is to late, only to find out about the problem a week or two before they pass away.  Where was their pain?  Where was their warning sign?

What about the people that are always in pain yet there doesn’t appear to be anything medically wrong?  What gives?!  Why are they so prone to feeling pain?

Pain is a multi-factorial process and takes into account several of the bodies systems collectively feeding information, in the form of signals, to the brain.  These signals are bombarding the brain with information and the brain is basically filtering things out and deciding what to react too based on everything else going on – which signals present a potential threat?  (Think about the soldier who gets shot but doesn’t realize it because there is the chaos of war going on aruond him.)  I liken this to those in charge of investigating every single terrorist threat that the USA receives daily.  They have to filter out all those threats and decide what is not worth reacting upon and what is really important.  They can’t react to everything, right?

This collection of inputs and outputs from various systems has been termed the neuromatrix by pain researcher Ronald Melzack.  This information can be better understood by spending sometime studying the below diagram.

As you can see, many factors/systems affect pain – visual, sensory, endocrine, vestibular, past experience, anxiety, depression, etc.

Based on what we know of the neuromatrix model it is important that we appreciate and respect the fact that the body consists of many systems that are all dependant on each other and work together to support healthy function.  Whenever we try and distill things down to one single system as the “problem” we end up missing a lot of other stuff going on.

Unfortunately, this is how anatomy and physiology is taught.  You go through chapters devoted to one single system – circulatory, lymphatic, nervous, integumentary, musculoskeletal, etc – but no one seems to teach you how to put it all together and how to address or manage these systems collectively, especially when there is something wrong.

Because pain is created by the brain as a result of information received from these systems, when dealing with athletes in pain, it would be appropriate to keep all of this in mind and not just focus on one element in the equation, but rather try and see the big picture (the full human).

Just some things to ponder.

References

Melzack R. From the Gate to the Neuromatrix. Pain 1999; Supplment 6: S121-S126.

Melzack R. Pain and the Neuromatrix in the Brain. J Dental Education 2001; 65(12): 1378-1382.

The debate about whether or not to do lumbar flexion exercises (sit ups, knee ins, bicycles, v-ups, etc) is a heated one.  To tell you the truth, it probably wont ever end as professionals will always reside on one side of the fence (lumbar flexion isn’t that bad!) or the other (stabilize, stabilize, stabilize!).

Dr. Stuart McGill has done a great job conducting research on the topic and lecturing around the world regarding appropriate training strategies for strength coaches, fitness professionals, and rehabilitation specialists.  However, one of the common debates that often comes up is, “Competitive fighting athletes go through lumbar flexion (sometimes very aggressive lumbar flexion) in their sport and thus we must train that movement to ensure that they are adequately prepared for competition.”

Sounds good, right?  After all, the role of the strength coach is to prepare the athlete for their competitive endeavors!

The only problem I see with this argument is that as the strength coach, we need to ensure that the athletes are healthy and injury free.  If we know that the mechanism of disc injury is repeated flexion, and we know that the athletes go through this movement in their sports training and competition, is this a movement that we really need to do more of in the gym?  To me, that sounds like the same as doing a high volume plyometric program for an inseason basketball or volleyball athlete.  They are already getting a lot of contacts in practice and games, why do we need to load that up more?  In fact, we should unload that and do something with less impact that sufficiently addresses the strength needs of those athletes.  Speaking of basketball, when taking a jump shot, athletes will typically go into knee valgus.  With this same mentality, shouldn’t we train that movement it so that they are prepared for it when it happens in a dynamic environment like competition?  Obviously I don’t expect anyone to answer“yes” to that question.

The next point that is always brought up is “Athletes who fight competitively all over the world train using lumbar flexion exercises and then go and practice and compete and do more lumbar flexion and don’t seem to have problems.  Maybe it isn’t such a big deal.”

One of the things science does is helps us to remove our assumptions of what we think is going on based on our observations.  Our assumptions are brought about by several factors including the sample size of people we are working with and our own personal bias towards what we are doing.  Basically, we put it in the hands of a neutral third party who tests these assumptions and then comes back to us an either says, “Yep, you were right!  It looks like that is happening”, or “Actually, we tested your assumption and we found the opposite to be true.”  This of course leads to more research and more questions and eventually theories are developed to help give us a larger explanation of what is taking place.

While the idea that, “Training these movements is essential because they happen in sport” may sound good on paper, are the programs being created really helping these athletes compete without incident?

A 2007 study conducted by Okada et al, looked at the prevalence of nonspecific low back pain and lumbar radicular abnormalities in 82 male judo athletes in three different weight classes – light, middle, and heavyweight.

Back pain:

• 10 out of 29 lightweight athletes had nonspecfic low back pain (34.5%)
• 10 out of 31 middleweight athletes had nonspecific low back pain (32.3%)
• 9 out of 22 heavyweight athletes had nonspecific low back pain (40.9%)

Lumbar radicular abnormalities:

• 19 out of 29 lightweight athletes exhibited lumbar radicular abnormalities (65.5%)
• 28 out 31 middleweight athletes exhibited lumbar radicular abnormalities (90.3%)
• 20 out of 22 heavyweight athletes exhibited lumbar radicular abnormalities (90.9%)

With lumbar radicular abnormalities and WITH low back pain:

• 50% in the lightweight group
• 100% in the middle weight group
• 88.9% in the heavy weight group

With lumbar radicular abnormalities and WITHOUT low back pain:

• 73.7% in the lightweight group
• 85.7% in the middleweight group
• 92.3% in the heavyweight group

The researchers concluded that the prevalence of low back pain in this group ranged from 30-40% and that the prevalence of lumbar radicular abnormalities with nonspecific low back pain (79.3%) and without nonspecific low back pain (83%) suggest a lack of association between back pain and imaging (this should come as no surprise since it has been indicated in previous research). While medical imaging didn’t give us the full picture as some athletes had pain without positive imaging and others with positive imaging did not have pain, low back pain appears to be a problem in this group of athletes and Okada et al state, “Because nonspecific low back pain is a common complaint among athletes, it is important that the athletes and their coaches work towards prevention so that athletes can continue their sports activities.”

In the wrestling community, reports of low back pain have been shown to be as high as 69%.  Wrestlers are a group who spend a lot of time on the mat getting into and (hopefully) out of a variety of positions. Iwai and colleagues (2004) evaluated trunk muscle strength and functional disability of chronic low back pain in 53 college wrestlers.  The wrestlers were evaluated for radiological abnormalities and isokinetic trunk muscle strength.  They found that 14 of the subjects with radiological abnormalities had low back pain (40%) and 8 of the subjects without radiological abnormalities had low back pain (44%).  Similar to the study by Okada et al, we see that the percentage of those with low back pain and with or without radiological findings is relatively close.  Iwai et al, concluded that low trunk extensor strength may be a potential factor in chronic nonspecific low back pain in this population of athletes.  Which would be in contrast to those supporting more lumbar flexion training for these types of athletes.

Just looking at these two studies, we see that maybe the assumptions being made regarding lumbar flexion training and competitive fighting athletes is not a good one.  Perhaps the anecdotal information that we get from other coaches is not valid?  In other parts of the world, how much pain/injury goes undocumented or maybe the athletes don’t even bring it to the coach’s attention?  How well is the record keeping of these coaches?  Everyone seems to remember the “hits”, “This is how we’ve have always done it and we have had 10 world champions.”  However, they failed to remember the 30 other athletes that were sidelined with injury.  Are we missing people?

Conclusions

Low back pain is common in sports and the training program should be comprehensive and well thought out in a manner that helps to prevent or reduce the incidence of injury.  While some potentially injurious movements happen in sport that doesn’t necessarily mean that we need to further train those movements in the gym.  Rather, it may be more advantageous to prepare athletes to handle the loads and forces placed upon them in competition with a strength and conditioning program that teaches healthy movement and does not seek to overtrain/overuse patterns that are commonly performed in both sports preparation and competition.

References

Okada T., Nakazato K. Iwai K., Tanabe M., Irie K., Nakajima H. Body Mass, Nonspecific Low Back Pain, and Anatomical Changes in the Lumbar Spine in Judo Athletes. JSOPT 2007;37(11):688-693.

Iwai K., Nakazato K., Irie K., Fujimoto H., Nakajima H., Trunk muscle strength and disability level of low back pain in collegiate wrestlers. Med Sci Sport Exer 2004;36(8):1296-1300.

Buchheit M, Bishop D, Haydar B, et al. Physiological Responses To Shuttle Repeated-sprint Running. Int J Sports Med. Apr 2010. 402-409.

Repeated sprint ability, cutting and changing direction are crucial skills in many sports.  Traditional training normally involves straight-ahead running. This study sought to evaluate differences in running performance, cardiorespiratory variables, muscle deoxygenation, and post exercise blood lactate levels between straight ahead, maximum effort sprints or change of direction, maximum effort sprints (shuttle-runs) in team sport athletes.

Key Findings

• Running times during the shuttle runs were slower than running times during the repeated sprints without change of direction by approximately 30%.

• Fatigue development was lower in the shuttle runs.

• Oxygen uptake and blood lactate were higher in the repeat shuttle runs compared to the repeated sprints without change of direction.

• Neither protocol showed a difference in muscle deoxygenation measured at the vastus lateralis using near-infrared spectroscopy measurements.

To read the rest of my review as well as practical applications of this study please visit fitness.researchreview.com

“What gets measured, gets managed” was a quote that Jon Torine, Head Strength Coach for the Colts, used during his lecture at the NSCA National Conference to emphasize the importance of using objective testing in the training process.

Basically, if something is important, you need to measure it.  Determine what is important to you – deadlifts, squats, cleans, bench press, movement tests, 10yrd dash, vertical jump, etc.  If you measure it, you will attempt to manage and improve upon it.  If something goes unmeasured, you have less chance of knowing if you are making progress or not.  Making it difficult to sustain a well developed training system.

I thought about this quote today as I rolled into the facility to do some soft tissue work on my first client.  I was thinking to myself how most massage therapists are in a rush to get people on the table and “do work”. 

If we aren’t measuring anything, how do we know if we are being effective?  How do we know that we are getting what we want from our treatment?  Are we only relying on subjective information provided from our clients, “Yes, that feels a little bit better.”  Or are we actually making some improvements in how things work – Do they function better?  Move better? Walk better?  Has joint mobility and end feel improved?  Was there a change in the soft tissue texture and pliability?

“What gets measured, gets managed.”

Take some time out of your treatment session to assess things and see what you can improve on.  If you measure something, it will help you put together a treatment plan and hopefully yield favorable results when the session comes to an end.  Additionally, if the results were less than favorable you at least have somethings to think about for next time and you will be sure not to repeat the same approach.

Don’t think of your soft tissue/massage work as 60min. of just rubbing lotion on people.  Rather, consider it a dance between some manual work, re-test/evaluate, work again, and repeat.  Each time, trying to manage that which has been measured.

I recently did a research review on the topic of concurrent activation potentiation for Fitness Research Review Service:

The concept of concurrent activation potentiation (CAP) is centered on the idea of improving power and strength via contraction of muscles remote from the prime movers (ex. jaw or fist clenching during jumping exercises).  This study utilizes EMG to evaluated the effects of CAP on isokinetic knee flexion…the results are interesting and provide insight into techniques we could use to improve client/athlete performance.

If you would like to read the rest of my review on this topic, please check out Fitness Research Review Service where you can read this and other great research reviews by top professionals in our industry.