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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
© Baseball Performance Group 2016www.baseballperformancegroup.com