Ep 24: The blurred line between performance and rehab training

Voiceover (00:02):

Welcome to The Confident Body, where experienced health professionals discuss how to get the most out of your body for the lifestyle you choose. We believe everyone can exercise and get the most out of life regardless of your injuries or health issues. Now here’s your host, senior physiotherapist, Michael Dermansky.

Michael Dermansky (00:23):

Hi everyone, and welcome to the show that helps you become more confident in your body so you keep doing the things that you love. My name is Michael Dermansky, I’m the senior physiotherapist at MD Health, and I’m here today again with David Smith, who is a fantastic resource and knows exactly what he’s doing in this field as well. Thanks for coming on board again, David.

David Smith (00:42):

It’s a pleasure. And thanks for the invite again. It’s always a good chat.

Michael Dermansky (00:45):

Well, this is a passionate topic of mine, the blurred line between performance training and rehabilitation. And over the years it’s become a much more blurry line because they do fit into each other so much. Some of the time it’s hard to tell what’s performance training, what rehab is. And there was a fantastic quote I heard in a podcast is rehab is performance training in the presence of injury. And I would love to hear your take on this topic today. The first question being today is what do you see as the difference between rehab and performance training?

David Smith (01:20):

I think it’s a great way to describe just even with the title, it is truly a very blurred line and I think it’s a good thing. Just as a caveat to start. So I’m an exercise scientist, strength condition coach and trainer. I’m fortunate to work with a team of great Allied Health practitioners, physios and EPs that help people write through their journey from injury to performance. And we’ll talk more about that. So just wanted to clarify that this is from my perspective as a coach side of things and I have a great team that will kind of really help manage the real acute type issues.

(01:50):

But starting I think the evolution of rehab and performance, it comes down to the practitioners themselves. So most physios and osteos are becoming more skilled at strength and conditioning principles. Most coaches, like myself, EPs, exercise scientists are becoming more skilled in the understanding of injury, pathology, and disease.

(02:09):

And this is really good. So I think it’s kind of removing this gap that once existed between when you leave the treatment table to when you’re on the field or on the training floor. And this gap was a massive detriment to our clients who somehow have to find their way. Once they left the bed, they’d then engage with a gym or a PT or a coach, and the coach would then try to apply performance principles to someone who just wasn’t ready and they would end up re-injuring themselves.

(02:34):

So the blurred lines is as a benefits to us as practitioners and our learning skill sets and really beneficial for the clients. So I think the difference really, for me it’s minimal. The best approaches should have very little difference in principle, it’s just a dosing or a scaling based on individual circumstances. The best rehabilitation plan should look like a strength and conditioning program, and the best S&C programs should have the variability and flexibility to manage people in states of injury.

(03:05):

I think the major differences for me, the way I view it at a high level is more the client’s mindset around it. And that sort of will dictate the language you use, the approach you take. Are they simply driven to get out of pain in this current episode or this current experience that they’re having or are they wanting to get past this and kind of see what is possible on the other side of it. And that to me, I think is the major difference between rehab and performance or the approaches that you take as opposed to anything movement, sets, reps related.

(03:38):

On a more technical base in general rehabilitation processes will probably involve lighter loads, lower velocities, reduced or changed range of motion, potential reduction in volume, but also potential increases in volume in certain patterns and higher frequencies. And this I guess is all in respect to sort of knowing soft tissue healing times and things we have to respect at any more acute based or musculoskeletal based injuries.

(04:04):

But of course this is, and same thing in anything of sports medicine, this is not an always kind of situation case. And then particularly if you’re dealing with chronic pain or disease states, it really kind of murkies the water and blurs things even further. Technically, rehabilitation could involve high velocity plyometrics, performance could involve isometric training and various long slow steady state cardio training. But very often it’s been dichotomized as either one being injury or one being performance. So I guess sort of as a summary standard sports medicine response, it depends, but I really do think it comes a little bit more down to the individual case and the client’s mindset as opposed to anything too technical.

Michael Dermansky (04:46):

I couldn’t agree with you more, David. I think you’ve summed it up beautifully because that’s the whole thing. It depends on what the client wants out of the program as well. And often you know when you want to get someone to a certain outcome, whether they’re training for performance, training for injury, that what you have to do with them is identical. The only difference is, as you said, the parameters you put in place when they do have an injury. So if there’s coming off a state of injury, there might be certain things you adjust at the start or through the program where you limit the range of movement, you limit the load at a certain stage, but the outcome you’re trying to achieve, absolutely identical.

(05:24):

Because if someone has weak quadriceps, glutes, whatever it is at the start, whether they’re training for performance or they’re training for injury, they should have worked on that in the first place or they need to work on that anyway. So none of that changes. It’s still the same game you’re playing, it’s just having that extra knowledge and that little bit of tweaking to adjust to people’s needs, and it doesn’t matter whether you’re training someone for performance or for injury as well, when they come through the door that day, they are what they are like that day. And so you may need to change things anyway.

The client comes in, you’ve got this beautifully perfect designed plan and then they come through the door and that goes out the window because of something else.

David Smith (06:01):

Life happens.

Michael Dermansky (06:03):

Life happens, has happened between the last time you saw them and your next time you saw them as well. So you have to adjust it based on what their needs are still with their long-term goal in mind.

David Smith (06:11):

Yeah, absolutely. Yeah, I think even just the use of the term rehab and performance, if you will use that term right from the start you’ve almost changed the way the client’s going to approach it, the patient will approach the next thing you say, the next thing you do. I think even using the term rehab versus let’s just get moving, let’s just get training, puts a sense of fragility around it in the individual anyway.

Michael Dermansky (06:33):

Yeah, absolutely. And I mean the crazy thing is as well, I mean I noticed this years ago as well that we waited for people that injure themselves to work on these things that they needed to get strong anyway. And then you waited for someone to hurt themselves and say, oh, you should have worked on this and you should have worked on that. Well, why don’t we work on this and why don’t we work on that too? We know what’s coming.

David Smith (06:54):

Be proactive.

Michael Dermansky (06:55):

Be proactive, you know what’s coming, you know what they need to work on. So start from day one rather than wait till they injure themselves when you work on the things they should have worked on in the first place. What are the principles that you keep in mind when you are dealing with someone with an injury? So you keep trying to get them from A to B, what are you have in your head?

David Smith (07:12):

Again, I get great communication and handover from my Allied Health teams. So I get to really, I guess focus on the performance end of the scale. But number one principle is you focus on the individual first. The person before the injury, understanding how do they perceive their current injury and limitations, what has happened, what narratives they have around it, how much Googling they’ve done, what did Uncle Kevin with the bad back tell them has happened to them. But most importantly, how is it limiting the things they currently really want to do? And then principally it’s just about building back their confidence physically and mentally.

Understanding the bigger picture elements, stress, environments around them, their barriers, their limitations, their physical literacy, their competencies, their understanding and always the question I like to ask of anyone when they’ve come to me through a rehabilitation is what comes next?

(07:59):

You’ve started to talk about that already, and I think it’s a good question to ask anyone in rehab principles is when someone’s in pain or injury it can really sort of cloud what they want to achieve. Their only view is about getting out of pain, which is completely understandable. But I think we really want to make sure, we want them thinking at all stages through the rehabilitation journey.

They’re thinking, yeah, okay, but what comes next? What comes next? And I think if we ask that, it changes the mindset to a more positive scope right from the start. And if we stop short of just going, let’s get past this pain point, you get to that situation where you end up having those recurrence of injuries because they’re not really preparing for life, they’re just getting past pain.

(08:40):

So technically I guess the service of rehab like any training approach, it should be incredibly simple. It’s often overcomplicated and it’s normally overcomplicated by someone who’s selling a method. And all of this does is creates a sense of fragility and uncertainty for our clients. We’re trying to pick on these tiny little things that are happening. We need to find key patterns of movement that are currently limited, something that’s irritable or something that’s critical to achieving the goals that they want to achieve. And then it’s about finding an entry point for that particular movement for that particular pattern and slowly build back their confidence, tolerance and capacity over time with smart loading strategies.

(09:18):

The nuances, of course there are some smaller technical elements that’ll come along with it, but that’s an individual case where you focusing on smaller movements or smaller deficiencies, it may be relevant before you reintroduce some of those bigger patterns. Those squat, hinge, lunge, push, pull, that will really impact people over the long term, not just on their current injury trajectory but their overall health side of things. But again, I’m really fortunate that I’ve got a great team at Allied Health of osteos and EPs and stuff. So by the time that they get to see me and my coaching team, we really just get to play with all the fun stuff for the performance element side of things.

Michael Dermansky (09:57):

I couldn’t agree with you more. What you said is make sure they know where they are, where their goals are. The pain is one element of it, but it’s not the element as well. It just gives you an idea of where the injury’s happening and what the limitation around their program are. But they’re not the long-term things they’re the short-term things to work on with the long-term goal of where do they want to be, what do they want to do. And that’s really why they’re coming to see you.

(10:24):

And we’re in the same boat where people come in and they have a short term focus like, “Oh, I want to get rid of pain.” “Okay, great. Well what next? What do you want after that?” Because that’ll be the first part. And then afterwards, why are you doing this? What do you want your life to look like after this? Because that’s all achievable. It’s just step by step planned process with a few limitations at a period of time where an injury is present. Sometimes the limitations are in the long-term and sometimes the limitations are short-term, but that’s not the goal. The goal is to get them to the life, the one that they actually want to achieve.

David Smith (10:58):

Yeah. But obviously you can completely understand. I’ve had injuries myself and when you’re in that level of pain or discomfort or challenges or limitations, the only thing you can focus on is not having that sort of sensation anymore. So you understand why it gets hard at that point.

Michael Dermansky (11:14):

Oh absolutely. And that has to be respected. Absolutely. And you have to listen to the client’s story too. Someone tells you that they’re in pain, they’re in pain, but whether you think it’s a big thing or a small thing, it’s irrelevant. That’s what they’re feeling. You have to be respectful for that too. But also guide them through where they need to be in the long term because you don’t want that to live their life, because people deserve a better life than that. It’s an element of what they work on, not the only thing.

So it’s very, very important. We keep that in mind and then slowly work on this element they don’t have, as you said, the control part, the strength part, and then adding on those functional movements hinge, pinch, pull, push. They’re all super important because that’s where you want people to take their lives so they can perform the things they want to do.

David Smith (12:00):

More importantly, it’ll stop them from having to be back in those pain cycles. I think the move to focus on the performance shift will break the recurrence cycle.

Michael Dermansky (12:11):

What do you think the biggest aspects are that hold people back from performing at their peak whatever their goals are?

David Smith (12:19):

Yeah, I would start with the peak physically. The winner by this is a long way, particularly when you’re working with general population, is consistency. I’m not saying this in a way that you kind of just need to just make it happen. Pull yourself up by the bootstraps, just do it kind of thing. But unless you’re a full-time athlete where you’re sole focus, the only thing you have to worry about is your physical performance, then your peak physicality will be limited.

(12:45):

There’s going to be almost certain other priorities in life that will impact consistency, work, kids, family, illness. So by far and away, the biggest aspects that stop people performing at the peak is their consistency, which is unfortunately very often out of their control. In regards to people performing at their peak in life, which is kind of where I guess we focus on as opposed to if you’re working in elite sport, whether that be emotional health, performance at work, providing for the family and having a meaningful and engaging family and social life, they’re the things that truly mean performing at their peak and meeting your exceeding life goals.

(13:18):

And I don’t think enough emphasis is put on or a enough is understood about how immensely beneficial, prioritizing your strength training, prioritizing your regular cardiovascular needs will actually start to impact all those other key aspects of life. So then you prioritize and that consistency builds. Time is our most precious resource. So anytime we do one thing, it takes time away from doing another thing. So once you have responsibilities in life, your peak performance, whatever that means to you, will be reduced if you’re unable to see the value in how physical activity will improve everything else around you.

Michael Dermansky (13:56):

That’s a really good point that I think you’re spot on right there David, in terms of consistency being that number one barrier. And we’ve seen this over the years as well, is that when people are consistent, the outcomes happen. They may not see the journey they’re going to go to in the long term, but if they just put one foot in front of the other and you look back at where they were, it’s amazing where they go going forward. I had a case of a lady I saw a few months ago, I did her initial assessment and her major aim was the rehabilitation of her lower back after a fall off a horse. And people do that.

David Smith (14:30):

Happens, it does happen.

Michael Dermansky (14:31):

And I saw her [inaudible 00:14:31] weeks ago, and she didn’t realize where her life could be and what she was putting up with as normal wasn’t enough and like, “Oh, I can do this easily now, I can go for this walk. Or I go for this run, I can go on the horse as well now and it’s no longer a hard work. It’s easier. I enjoy it and I can get through it and I’m not wiped out at the end of it too.”

(15:04):

And one of the biggest aspects when you look back at that program is the program itself is nothing magical. There’s nothing special about it too. It’s just slow progressive load over time. It’s nothing magical about that. That’s just basic strength [inaudible 00:15:19] are its principles, but the consistency has been the winner and because she was consistent, you see this really quite dramatic effect from day one to today, a few months later where she didn’t expect her life to be there.

(15:34):

She was just focused initially on this injury. Now it’s “Oh well I can actually enjoy my horse riding better. I can actually enjoy my time with my friends better.” That’s the real role that peak performance has in people’s life. They actually get more out of life and have that life they imagined or often didn’t even think it was going to possible, as opposed to just getting rid of the injury. It’s a huge deal. And I’ve seen this over the years. One foot in front of the other, don’t try to get there yesterday, it ain’t going to happen. But just consistency. And it’s been a real winner and I know it’s a different time now too, but now that all that covid period of time is over, mostly over-

David Smith (16:17):

Thank God.

Michael Dermansky (16:19):

-we’ve seen consistency happen with people’s programs again, and the outcomes are there. The slow steady step between where they want to be and where their life can be starts to happen. Yeah, I can’t emphasize that enough. It’s been the theme of so many of these podcasts. Consistency, consistency, consistency. It’s just amazing how that’s probably the most important conversation we ever talked to them about with clients. If you’re consistent, it’ll work. If you’re not consistent, I don’t know where you’re going to go, but you’re not going to get the outcome you want.

David Smith (16:49):

I think then we are looking at even the purest S&C principles are in elite sport, which I’ve spent some time in. There’s an over assumption that things we do have this magical effect. The number one thing we can do for whether it be an athlete or an individual is to keep them in the game and time itself and consistency is what’s going to change that physical performance, that psychological performance, that reduction in pain.

So to think anything that we magically do with our programs, with our rehabilitation processes is what creates change, it’s good for our egos, but it’s really not the case. So the number one thing we can do is just help people find that consistency and just let time, the natural course of time, do its thing.

Michael Dermansky (17:32):

Yep. I mean that’s part of the game. We underestimate what your body will do. The growth occurs when you rest, not when you exercise. So taking time to rest, taking time to stop, taking time to not exercise every day is part of the process. It is an active part of the process. It is not you taking a day off or slacking off. It’s actually has to be there otherwise you don’t have time to adapt. You change when you rest, you don’t change when you exercise, you load up, give the body a stimulus, give it a reason to adapt and let it do its job.

David Smith (18:06):

Yeah. Often the best coaches are the ones that know how to stay out of the way most of the time.

Michael Dermansky (18:10):

So can you give me a case example? Give me me a case example where you start off someone with an injury finishing with peak performance. What is that journey?

David Smith (18:21):

Well, everyone’s journey is of course completely different, but a chronic condition could be very murky and we could be another several hours on this, but maybe we’ll just use a random, acute case example, whether it be a short term lower back discomfort, non-specific. And generally it will begin with an Allied Health practitioner.

(18:40):

It’ll involve a physio like yourself or one of our osteos to first and foremost understand the pain, the injury, and how it’s currently limiting them. This practitioner then of course has to work with the individual to calm down the agitated or painful elements and often that can be rest, but a very short term approach, but should also involve some movement. Because until you get past that initial pain point is that it really can cloud people’s views of what is possible, what comes next. Once that sensitivity is settled, it becomes a very simple approach of greater reintroductions to activities depending on what they wanted to get back to.

(19:12):

The quicker they’re off the table, out of the clinic room, out into the gym, onto the sporting field, out doing their runs, their rides, the better it is. So the quicker we can get someone back to that. As the pain levels are starting to reduce the way we’d work and everyone should be working with a multidisciplinary team of people to help them out, it takes a village. As the pain reduces, the Allied Health practitioner would start to engage with the coach.

(19:38):

So there’s always going to be from a very early on in the process there should be a handover period where you’re starting to work with two people together. And this is where over time as the pain element starts to go down, there’s less emphasis on the rehab component, there’s more focus on the performance component. The time requirements of the practitioner where the individual will spend their time, will just slowly transition more to the coach and the performance elements.

(20:06):

Timelines here, I’m not going to put timelines on it because everyone’s completely different. This could be a day for some people, this can be six months to two years for some people. Allied Health will then always remain in focus, but becomes more of a monthly check-in. We tend to not use Allied Health and our osteos and our soft tissue therapists as a really reactive element. Let’s wait till people are in pain or things are broken, so to speak. Well, it’s a poor term broken, but I think hopefully that makes sense. Rather than waiting for pain to return, the Allied Health member just becomes a monthly, so then the sole focus from there moving forward is performance.

Every time they achieve the goal, reset the goal, keep progressing until the things that led to that initial injury, they’re just no longer relevant or no longer a concern for the individual.

Michael Dermansky (20:53):

That’s a great example, David. And interestingly enough as well with our practice as well I’m really big on the fact that if someone has an injury as well often, and it’s really, really not this case, that you may be dealing with the pain and the acute injury at the time too, but you want to even be introducing elements of what they can do from day one. I mean, I love having people in the gym area from the first day.

They say, “Oh, I’ve got an injury, I won’t exercise today.” “We’re doing it today.” “What do you mean we’re doing today?” “We are doing it today. There is no good reason.” Well, there is something you can’t actively do and it’s almost never the case that you can’t do something where you start to start a journey of getting better as well and moving on the performance journey.

(21:38):

And it’s a massive mental mind shift to the client as well that, “Oh, I can do something. I’ve got an injury, but I could still do something.” Yes you can. There is no good reason why we can’t go there and then start you on that next journey of getting you to that to long-term goal. There’s a massive psychological benefit of saying, “I’m okay, I can do this. I might have an injury, there are the things I can’t do, but there is definitely something I can do.” And that empowering element that you can do something is huge. It’s a really big deal.

David Smith (22:12):

And I think there is never a situation in our world where bedrest is the best mechanism is required. The only situations where bedrest is actually a potential, it’s normally an emergency situation, they’re probably having to go into ER for surgery. But we should never, there’s no approach in any of our worlds that we should be focusing on, okay, this is purely bedrest. I think the way you put it is getting him out onto the floor in those initial sessions.

So even the very first one, even if it means they’re actually just almost lying on the floor, if it’s a really acute, painful episode to do some gentle movements, some mobs that you would take them through, them being in that performance environment at least has them sort of looking around and going, “Oh, okay, I can get back to that.” As opposed to the second you’re lying someone on a treatment table, they’re in that rehab mindset.

Michael Dermansky (23:00):

That is exactly the switch you want to change as well. And sorry, there is a second case if they’re actually sick, if they’ve got an infection, you can be exercising like that.

David Smith (23:09):

Yes, but not, that’s not a musculoskeletal issue though.

Michael Dermansky (23:13):

No, not a musculoskeletal issue at all. Sometimes we need to tell people it’s time today to not exercise. It’s okay.

David Smith (23:15):

Yeah.

Michael Dermansky (23:18):

But yeah, otherwise from a musculoskeletal perspective, super rare. Super, super rare. Last question I have as well. Where do you step into your role, I guess as when we’re doing performance or we’re doing rehab training and then hand them over to their coach, their sports coach, their basketball coach, their football coach who’s going to take them, that’s part of their team? Where does that fit into it?

David Smith (23:43):

Yeah, well, so my role as the coach, I mean I’m normally on the receiving end of that situation of the client being moved on, passed over. But I don’t think the situation really changes here, no matter which direction you as the practitioner or the patient is going, but it needs to be continual communication levels between the practitioner, between the coach and the patient. It needs to be smooth, it needs to be regular and it needs to be succinct and then it needs to be led and driven by the patient.

(24:14):

They want to make sure that they’re really engaged and feeling like they’re in control of the process as opposed to just the passenger. A at no point in any of these situations does it become a stop start situation. So you stop with your Allied Health, you start with the coach, you stop with your performance coach, you start with your skills coach. There’s always a transition, there’s always a crossover. Everyone should be involved at all times to take care of the client, to take care of the patient, take care of their performance outcomes. And it’s just, as I said, more of a dosing on which individual practitioner is more heavily involved at the time.

Michael Dermansky (24:47):

Yeah, I couldn’t agree with you more, and that’s interesting. It’s not either or, it’s both. The communication is such a big deal. And if you have a communication with the person’s coach, it’s such a big deal. And when it’s a barrier and it’s not there, the only person that suffers is the athlete or the person in rehabilitation because there’s two different messages and they’re not coming through one into the other. But that communication, if you can make it open, it’s not always easy, but if you can make it open as well, it makes a massive difference to the overall outcome for that client.

David Smith (25:18):

Absolutely.

Michael Dermansky (25:20):

Well David, thank you very much for your time today. It’s been a great conversation as well. This has been a passionate topic of mine as well for the last few years, because I want to say people get their best performance not just being limited in a box. And it sounds like you’ve really looked at this space quite a lot as well.

David Smith (25:36):

Yeah, absolutely. It’s been lovely to be involved and I think as you said, with this rehab to performance view, it should not be viewed as these completely separate departments and dichotomized, it’s all part of the same thing. We’re just helping the individual perform better at life depending on what they’re presenting with at the moment.

Michael Dermansky (25:54):

Very good. Well, enjoy your morning. Thanks again for your time and we’ll talk to you soon, David.

David Smith (25:58):

Pleasure. Thank you for today, Michael. I’ll speak to you again soon.

Voiceover (26:02):

Thank you for listening to The Confident Body. For practical articles to help you build a confident body, go to mdhealth.com.au/articles.