Repetition without repetition

Repetition without RepetitionThe Role of Variability in Reducing Pitching Related Injury

Michael Chivers DC, FRCCSS(C).

Baseball Performance Group.

Jon Roegele @MLBPlayerAnalys

35% of the pitchers taken in the 2015 draft had previous TJS

It was not uncommon for pitchers to pitch 300-400 innings in a season.

https://docs.google.com/spreadsheets/d/1gQujXQQGOVNaiuwSN680Hq-FDVsCwvN-3AazykOBON0/edit

Surgeon # of Reconstructions

MLB Return %

Dr. James Andrews

124 82%

Dr. Lewis Yocum 69 80%

Dr. David Altchek 24 56%

Dr. Timothy Kremchek

21 79%

Dr. Neal ElAttrache

11 67%

Conte 2016

“The Epidemic”

Upper Extremity Injuries are Increasing!

Conte et al. 2016

Since the first Tommy John….

0

5

10

15

20

25

30

35

40

Number of UCL Reconstructions

2012 2013 2014 2015

There have been 400 “Tommy Johns” in MLB

30% have occurred in the last five years

Conte et al. 2016

What’s the Cost?Between the years of 1998-2015

$7, 614, 817, 407

“We have to stop pretending we know the answers, because whatever we’re doing doesn’t seem to be working”

Linear Thinking…

A B C D

A Reductionist View

Fleisig et al 1995, Dines et al 2009, Laudner et al 2014, Wright et al 2004.

Linear Thinking…

GHER

GHIR Trunk Tilt Pelvic Rotation

INJURY

SYSTEMSTHINKING

GHER

Pelvic Rotation

Trunk Tilt

GHIR

Stride Length

Unifying knowledge and information requires Systems Thinking

Need to see the relationships amongst elements.

A system…A set of things interconnected in such a way that they produce their own pattern of behaviour over time.

Interacting, Interrelated and Interdependent

Kim 2002.

EventsPatterns

System Structure

Kim 2002.

Events

(Injury)

Patterns(Lack of IR)

System Structure

Bittencourt et al. 2016, Philippe and Mansi. 1998

Emerging Injury Pattern

Many interacting factors referred to as a Web of Determinants

Bittencourt et al. 2016, Philippe and Mansi. 1998

Upper Extremity InjuryNo one element is causative in and of itself.

An injury will occur due to the relationships amongst elementsGERG

Recovery

Tissue capacity GIRDRestStrength

Hip IR

HRV

Fatigue

StressStiffness

Mobility

Capacity and Demand…

Capacity is the 3 P’s…

PhysicalPsychologicalPhysiological

Capacity is the 3 P’s…

Physical ability to tolerate a wide range of movement with strength and control.

PsychologicalPhysiological

System Equilibrium…

DEMAND = CAPACITY

The Injury Equation…

DEMAND > CAPACITY

The Injury Reduction Equation…

CAPACITY >> DEMAND

Capacity

Demand

Injury Mitigation

Performance Enhancement

Behaviour Over TimeCapacity Demand

Demand

Capacity

Complex Adaptive Systems…Every single interaction leads to new behaviour.

Continuously evolving in time.

Whole is greater than the sum of its parts.

Feedback

Complex Adaptive Systems…1. Are Non-Linear2. Are Self-Organizing3. Display Emergent Behaviour4. Behaviour based on Feedback Loops5. Are Continuously Evolving6. Have no Central Controller

Clarke and Crossland. 1985

“In a highly complex system like the human body all the parts affect each other in an intricate way and studying them individually often disrupts their usual interactions so much that an isolated unit may behave differently from the way it would behave in its normal context”

Dynamic Systems Theory

Esther Thelen:

Human movement dynamics can be thought of as a mountain stream

Physical Capacity is a Process

Newell. 1986

Skilled Movement Comes From…The interaction of:

constraints

Guide the process of self organization

Are limiters or amplifiers of movement capability

Constraints are…Physical

ROM, Strength, Tissue Status

ORGANISMIC

InformationalMound, Flat Ground, Trap

Bar vs Olympic Bar

ENVIRONMENTAL TASK

Constraints + Sensory Information…

SensoryPerception

& Reception

Organismic

EnvironmentTask

Reinold et al 2008. Sakurai et al 2000. Robb et al 2010

Ongoing Constraints…WORKLOAD

Starter-every 5 days 90-110 pitches Bullpens Training

Loss of glenohumeral joint ROM (particularly IR)

Loss of proximal radioulnar joint ROM (particularly supination) and elbow ROM (particularly extension)

Loss of lead hip joint ROM (particularly IR)

Variability Creates Options

Websters Dictionary 2016

“the power possessed by living organisms both animal and vegetable of adapting themselves to modifications or changes in their environment thus possibly giving rise to ultimate variation of structure or function”

Pattern 1

Pattern 2

Pattern 3

Skilled Performance…

Nikolai Bernstein…1930’s study on Blacksmiths

Discovered that variability isn’t negative but is necessary for normal function

Arutyunyan et al… Experts had greater variability in their joint interactions directed toward a target.

Biryukova et al…Experts characterized as having a “looser coupling” between segments involved

Websters Medical Dictionary 2010

Intelligence….A. The ability to learn or

understand or to deal with new or trying situations

B. The ability to apply knowledge to manipulate ones environment or to think abstractly as measured by objective criteria

C. Mental acuteness

Websters Medical Dictionary 2010

Motor Intelligence….A. The ability to learn or

understand or to deal with new or trying situations

B. The ability to apply knowledge to manipulate ones environment or to think abstractly as measured by objective criteria

C. Mental acuteness

A. The ability to adapt or vary patterns to deal with new or trying movement situations

B. The ability to apply feedback to manipulate ones internal environment or to coordinate movement intangibly as measured by performance outcomes

C. Physical dexterity

Repetition Without Repetition…Low variability at the “working point” is only achievable by having higher variability at the level of the coordinative relationships that underpin successful goal directed performance.

High Motor Intelligence System Resilience

Hamill et al. 2014

Injury States are Low Variability States…

HealthyHigh

Coordinative Variability

Injured Low

Coordinative Variability

Injured Too High

Coordinative Variability

Increasing Coordinative Variability Decreasing Coordinative Variability

Hamill et al. 2014

Injury States are Low Variability States…

HealthyHigh

Coordinative Variability

Injured Low

Coordinative Variability

Injured Too High

Coordinative Variability

Increasing Coordinative Variability Decreasing Coordinative Variability

“Loss of Complexity” “Loss of Complexity”

Lipsitz et al. 1994 Goldberger. 1994

Loss of Complexity… A) B)

Low Variability/Low Capacity/Low Motor Intelligence High Variability/High Capacity/High Motor Intelligence

Injury is a Systems Problem!…Impaired feedback loops:

Inefficient articular interactionInput OuputInability to adapt to constraints

Feedback

Collaborative Intervention…Therapist

Strength Coach

Pitching Coach

Sports Science

Staff

New Framework…Demand = Capacity

Demand > Capacity

Capacity > Demand

Task Dynamics = Coordination Dynamics

Task Dynamics > Coordination Dynamics

Coordination Dynamics > Task Dynamics

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