Friday, May 11, 2018

Thoughts on The Art of Programming

I think the art of programming --- the selection, order, dosing and progression of movements --- is becoming a lost art. It seems to be more of a "plug and play" kind of activity rather than a craft.

A good program, and the process of implementing that program, will be much more than the sum of its exercises.

The use of software makes it easy to copy and paste.  Software makes every workout look basically the same. We pick from the list put the "power" exercises here, the "strength" exercises here and the "plyo" exercises here.

Is this activity inherently different than writing --shaping--- a workout on a blank piece of paper or even white board? Are the relationships of the movements within a workout and among the various other days of the workout plan easily comprehended?

The use of phones and tablets to display exercises means they are more likely to be displayed one at a time, possibly losing context of how they are connected to other exercises. It's hard to zoom out and see the big picture of the structure of an entire session.

If there are videos next to the exercise name, athletes are not forced to remember the movement, to comprehend the text and process it's relationship to the movement. There is no need to remember and learn --- to develop the knowledge, skills and behaviors associated with learning to train.

We want athletes to learn and embrace the process, not just to do the stuff. Just as we want coaches and clinicians to learn the process.

In physical therapy, the art of programming is barely even taught. It is my observation that exercise prescription is no longer a valued skill for the therapist. It's more about evaluations, procedures and maybe manual therapy treatments. Delegate exercises to the extenders.

One of the recent student therapists at US Ski & Snowboard told me his therapeutic exercise class in school was online and the students were expected to complete it independently. His only formal experience with programming exercise was during his clinical experiences.


Terrifying.

I thought the whole point of being a physical therapist was to be an expert in human movement and to use movement to improve function. Isn't dosing exercise the very heart of physical therapy? Or has that changed now that all new therapists are doctors of physical therapy?

A few years ago I attended a continuing education course taught by two prominent orthopedic PTs. I was psyched to spend two days focusing on the athletic knee and shoulder. How did the best in the field program for their patients? I never really found out.

They spent the majority of the course describing, discussing and reviewing the various surgical procedures and gave a cursory overview of the actual therapy afterward.

Well, you know, we do focus on range of motion, then we do the strength work and then by week x we are back to plyos or throwing. There was no in-depth discussion of exercise selection and progression --- with a particularly glaring lack of focus on building basic strength.

Cue Mark Rippetoe.

I was devastated. Livid. The therapists were more interested in talking surgical procedures than they were about the details of the rehabilitation. No deep dive or reflection on programming and progressions. No concern about the how and why of what of the movements they prescribed.

I think it is a noble calling to use movement to create health and performance. 

We must do better, as coaches and as clinicians. Our athletes and patients deserve it. We must value the process of exercise selection, instruction and progression. We must value the process and act of programming.








Wednesday, May 09, 2018

Thoughts on the RDL: Risky Business or Essential Exercise?

I've been ruminating on this subject for the last four years. My goal with this post is to spark some thoughtful discussion on the use of the RDL in performance and rehab programming.

Some background. Prior to coming to US Ski & Snowboard in May of 2014, I'd been working in private practice for 10 years, primarily with high school basketball, volleyball and swimming athletes. In my world, the RDL was a highly advanced movement, reserved as an accessory training movement to prepare the body to efficiently move the bar from below the knee to the power position at mid-thigh in cleans and snatches.

Because we did full range of motion squats (bodyweight, front, back), full range of motion hexbar deadlifts, step ups and lunges in varying directions, amplitudes and speeds, skips and all kinds of other movements, I did not see any reason for this group of athletes to do RDLs, Good Mornings or any other resisted isolated hip-hinging movement. Hamstring work wasn't isolated, it was always integrated into a coordinated hip/knee/ankle movement.

For those who don't know the background of the RDL exercise, it came into existence when Nicu Vlad, a Romanian weightlifter, was observed doing the movement in the US. Different from the traditional "Stiff Leg Deadlift" it was given the term Romanian Deadlift. So, the RDL was never specifically intended to be an isolating eccentric hamstring strengthening exercise; it was an accessory movement for a very high-level weightlifting athlete -- still the heaviest athlete to ever do a double-bodyweight snatch in competition, if I'm not mistaken.

Since the late 2000s and onward, RDLs have become a staple in all of athletic preparation, in the name of hamstring-specific strengthening. This practice pattern has coincided with the use of the term "posterior chain" and specific emphasis on teaching the "hip-hinge" -- the ability to discriminate between hip and lumbar spine flexion/extension. This skill is an important part of body awareness for good lifting mechanics and maintaining good back health.

It is my observation that with regard to programming and terminology, there is now an emphasis on exercises and language to train the "posterior chain" vs a previous (maybe 2000 and before) emphasis on exercise to work "triple extension." Maybe I'm getting old and being an iron geek, but this shift in terminology and programming philosophy intrigues me. I do have an undergraduate degree in history & philosophy of science.

We are in a time where strength coaches, physical therapists and athletic trainers tend to emphasize all things hip extension, almost, in my observation, at the expense of knee extension altogether. Combined hip/knee/ankle coordinated movement has taken a back seat. Glutes and hams are the focus. Quad / knee extensor strength is almost summarily dismissed as unimportant or even being detrimental to function, despite everything we know about knee extensor inhibition in post-surgical and painful knees and our struggles to get good knee extensor strength back during rehab.

(Can you really ever have too much knee extensor strength? Is that really a thing?)

Single leg RDLs and hard-style RKC kettlebell swings now permeate rehab programming. Athletes of all sports and abilities are given heavy RDLs and no one blinks an eye. It's all about the "posterior chain" and the consensus is that we must isolate the hamstring to strengthen it and this movement is a superior method to do so.

Fast-forward to Summer 2014 and I enter the world of ski and snowboard. Heavy RDLs are common in programming. I am told they are an important part of ACL injury prevention. Back irritation or injury from doing RDLs in training does not seem to raise any significant red flags.

I get it, but do we really get it? We are locking the knee in a position of minimal flexion and working a two-joint muscle group only at the proximal end, in the sagittal plane. But aren't most ACL tears in ski and snowboard due to some type of torsion/rotation/flexion mechanism? Or during deep, backseat landings combined with catching an edge?

Are we really doing anything to help stop something that happens so fast and violently that no human, regardless of how strong s/he is, can physically stop the injury? If so, wouldn't working more combined hip/knee flexion/extension at varying speeds such as deep lunges with reaching or big step ups with some rotation be more specific to these injury mechanisms?

And a second important question: Is the risk of back injury/irritation during the RDL itself worth the perceived reward of isolated hamstring muscle strength? Is it worth it if athletes routinely report low back pain after doing this one exercise and it keeps them from consistently training in the weight room or puts them into rehab? Is it worth it if athletes are so sore from the eccentric work with this exercise that they cannot do their other leg work with full intensity and purpose?

Are we really getting the most bang for our buck?

It is my opinion that injuries in the weight room should be extremely rare. If athletes routinely complain of low back pain/soreness after any exercise, then I need to reflect on what I am programming and why. 

Is is appropriate for an athlete to do heavy RDLs? With weight they cannot clean, squat or regularly deadlift with ease?  If you take the stance that and RDL is an accessory lift to support performance of cleans and snatches from the floor, I don't think it is. As a weightlifter, the RDL has a very specific context within set of movements.

If an athlete doesn't clean or snatch from the floor or low hang/blocks on a regular basis, are heavy RDLs a necessary part of comprehensive lower extremity preparation?

Does this movement, as a stand-alone, isolated muscle exercise, do what we really think it is doing? Or is it just cool-looking busy work? Does back or hamstring soreness equal productive / protective work?

When I observe athletes doing RDLs with weights they cannot clean, snatch, squat or deadlift with full range of motion, I am concerned. Especially when athlete cannot even lower the weight with control on the final rep; they drop the bar. In my mind, this is a red flag and the athlete has not earned the right to use that weight. If you cannot lower the bar with good form and control, you have no business picking it up in the first place.

(Side note: The presence of platforms and bumper plates doesn't mean you / your athletes should drop the bar on every lift. If your athletes do, you might rethink how you are teaching and progressing them. Every opportunity to lower the bar to floor well is a rep of solid coordinated torso/lower extremity eccentric strength. If we value eccentric work so much, why are so many athletes dropping the barbell on every kind of rep/lift imaginable?)

In my mind, the risk of back irritation is not worth the reward with RDLs. And I'm not sure we really know how functional the hamstring strength is, with regard to truly supporting performance or reducing risk of injury.

We just know they make your hamstrings as sore as shit. And most young people think it's pretty cool to put more than one plate on the bar and pick it up and drop it for 4 sets of 5. Low back pain may just be part of deal.

I think we can do better.

No amount of low back pain, or the high risk of back irritation, should be a normal part of regular training. And yes, I've squatted and deadlifted heavy, as have many of my athletes.

Is it wrong to think full range of motion squats, hexbar deadlifts, step ups and lunges don't work the hamstrings in a fully functional and supportive manner? 

Do we really know the value of heavy double-leg RDLs or single-leg RDLs for that matter, in rehab or performance? Are there appropriate alternatives that do the job as well or even better?

Have there been any comparisons of programming in non-weightlifting athletes with these exercises vs programs without these exercises? Or is it currently just accepted as the thing to do because people are focused on that thing called the posterior chain vs the coordinated strength of the entire lower extremity?

I caused my rehabbing and snowboard team athletes a bit of confusion and concern over the last four years, as their programming had no isolated hamstring work. I had to convince them to trust me they weren't missing out.  No RDLs (single or double leg), no glute-ham apparatus exercises, no Nordics, very little to no bridging. We learned to squat and hexbar deadlift with full range. Pause squats, speed squats, partial squats. Hexbar jump shrugs. Push presses, power jerks. Lunge and reach in all shapes, sizes, speeds and directions. Step ups and alternating single leg box jumps. Bounds, hops, jumps. Leg circuits, Spectrum Squats, Tabata-style interval squats.

Their leg work was comprehensive and extensive, but simple. It was challenging. We did it consistently. It supported their successful return to World Cup level and even Olympic competition in the ski and snowboard world.

So with these particular athletes, I have real-world examples of non-sprinting/running athletes competing at a high level without isolated hamstring work. Not proof of anything, but maybe a cause for reflection on current practices in rehab and performance.

I'm genuinely interested in other professional opinions on and real-world use of heavy RDLs. Does anyone else see the risk greater than the reward? Were my athletes missing out by not doing RDLs and other hamstring-specific work? Are light RDLs effective and less risky?

What does the research out there say with regard to the use of heavy RDLs in running and non-running athletes? 

With RTS for ACL and other knee injuries, is the RDL really creating protective hamstring strength and stability about the knee? Is is an essential exercise for hamstring graft patients or can we get the same or better benefits from other exercises that emphasize full range of motion, coordinated hip/knee/ankle flexion and extension?

And so this is one of the things that has been swirling in my head the last four years. I look forward to hearing everyone's thoughts.