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- 1. The Role ofVariability in Reducing Pitching Related Injury Michael Chivers DC, FRCCSS(C). Baseball Performance Group.
- 3. Jon Roegele @MLBPlayerAnalys 35%of the pitchers taken in the 2015 draft had previous TJS
- 5. It was not uncommonfor pitchers to pitch 300- 400 innings in a season.
- 6. Surgeon # of Reconstructions MLBReturn % 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% https://docs.google.com/spreadsheets/d/1gQujXQQGOVNaiuwSN680Hq-FDVsCwvN- 3AazykOBON0/edit
- 7. Conte 2016 Upper ExtremityInjuries are Increasing!
- 8. 0 5 10 15 20 25 30 35 40 Number of UCLReconstructions 2012 2013 2014 2015 There have been 400 “Tommy Johns” in MLB 30% have occurred in the last five years Conte et al. 2016
- 9. Between the yearsof 1998-2015 $7, 614, 817, 407 Conte et al. 2016
- 10. “We have tostop pretending we know the answers, because whatever we’re doing doesn’t seem to be working”
- 11. A B CD A Reductionist View
- 12. GH ER GH IR Trunk TiltPelvic Rotation INJURY Fleisig et al 1995, Dines et al 2009, Laudner et al 2014, Wright et al 2004.
- 13. SYSTEMS THINKING GH ER Pelvic Rotation Trunk Tilt GH IR Stride Length Unifying knowledge and information requiresSystems Thinking Need to see the relationships amongst elements.
- 14. A set ofthings interconnected in such a way that they produce their own pattern of behaviour over time. Interacting, Interrelated and Interdependent
- 15.
- 16.
- 17. Bittencourt et al.2016, Philippe and Mansi. 1998 Many interacting factors referred to as a Web of Determinants
- 18. Bittencourt et al.2016, Philippe and Mansi. 1998 No 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 Stress Stiffness Mobility
- 20.
- 21. Physical ability totolerate a wide range of movement with strength and control. Psychological Physiological
- 22.
- 23.
- 24.
- 25.
- 26. Every single interaction leadsto new behaviour. Continuously evolving in time. Whole is greater than the sum of its parts. Feedback
- 27. 1. Are Non-Linear 2.Are Self-Organizing 3. Display Emergent Behaviour 4. Behaviour based on Feedback Loops 5. Are Continuously Evolving 6. Have no Central Controller
- 28.
- 30. Esther Thelen: Human movement dynamics canbe thought of as a mountain stream
- 32. The interaction of: constraints Guidethe process of self organization Are limiters or amplifiers of movement capability Newell. 1986
- 33. Physical ROM, Strength, Tissue Status ORGANISMIC Informational Mound,Flat Ground, Trap Bar vs Olympic Bar ENVIRONMENTAL TASK
- 34.
- 35. WORKLOAD Starter-every 5 days 90-110pitches 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) Reinold et al 2008. Sakurai et al 2000. Robb et al 2010
- 37. “the power possessedby 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” Websters Dictionary 2016
- 38.
- 39. 1930’s study on Blacksmiths Discoveredthat variability isn’t negative but is necessary for normal function
- 40. Experts had greater variabilityin their joint interactions directed toward a target. Biryukova et al… Experts characterized as having a “looser coupling” between segments involved
- 41. A. The abilityto 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
- 42. A. The abilityto 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 Websters Medical Dictionary 2010
- 43. Low variability atthe “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
- 44. Healthy High Coordinative Variability Injured Low Coordinative Variability Injured Too High Coordinative Variability Increasing CoordinativeVariability Decreasing Coordinative Variability Hamill et al. 2014
- 45. Healthy High Coordinative Variability Injured Low Coordinative Variability Injured Too High Coordinative Variability Increasing CoordinativeVariability Decreasing Coordinative Variability Hamill et al. 2014 “Loss of Complexity” “Loss of Complexity”
- 46. A) B) Lipsitz etal. 1994 Goldberger. 1994 Low Variability/Low Capacity/Low Motor Intelligence High Variability/High Capacity/High Motor Intelligence
- 47. Impaired feedback loops: Inefficient articular interaction InputOuput Inability to adapt to constraints Feedback
- 48.
- 49. Demand = Capacity Demand> Capacity Capacity > Demand Task Dynamics = Coordination Dynamics Task Dynamics > Coordination Dynamics Coordination Dynamics > Task Dynamics
- 50. © Baseball PerformanceGroup 2016www.baseballperformancegroup.com
Editor's Notes
- #2 Good Morning. Before I begin, I would like to thank my friend and colleague Dr. Scott Howitt for asking me to speak here today.
- #3 As a Fellow of the Royal College of Chiropractic Sports Sciences it gives me great pride in being able to present here at our annual conference, one that I have been attending since I was a third year chiropractic student, which for those of you who don’t know me was only a few years ago. I also look forward to hearing the rest of this great lineup of speakers share their knowledge and expertise with all of us.
- #4 I have been fortunate enough to work with high level baseball athletes. One in particular will stick out in my mind He was an ace, mid 90’s thrower, JNT, already signed to a top Division 1 program, which for a Canadian right hander is pretty significant, he was destined to be a Major League draft pick, until one day with one fastball just like that it was all gone. Following surgery, and a year and a half of rehabilitation, he never returned to his previous level of competition. Gone was playing for Canada and top level college baseball, the dreams of professional baseball dashed because of an elbow ligament tear. Why do these injuries keep happening? Why is it that this ligament of the elbow confounds us so much? It’s not even structurally that significant but injury to this tiny structure has had arguably the biggest impact on the game of baseball over the last decade.
- #5 We can all think of a big name player that has spent significant time away from the game due to elbow injury. Two of my favourites in the last few years have missed entire seasons due to having their UCL’s reconstructed.
- #6 You have to figure that pitching related injuries are nothing new. When pitchers were throwing 3-400 inning seasons you would have to expect that plenty of those pitchers got injured. The difference being that there was no such thing as sports medicine, no surgical intervention that could literally fix broken down and shredded arms, no training staff or sports scientist to deal with injury or monitor injury predicting trends. On top of that players were hardly making any money and the cost to the organization of losing a pitcher was probably fairly negligible.
- #7 Fast forward to today and everything has changed. We now have orthopedic surgeons who repair and reconstruct pitching arms at an alarming rate. Every team has a sports medicine department, on top of a thorough coaching and technical staff. However the biggest change being that the best arms in the game are now worth hundreds of millions of dollars, never mind the fact that franchises are now worth billions.
- #8 Let me frame our current injury problem in baseball, or as some like to call it, the “Epidemic” as was characterized by Jeff Passan in his insightful book The Arm. At the Major League level we are currently witnessing a very disturbing trend. Injuries are increasing! Particularly those involving the elbow which are skyrocketing.
- #9 It has been 42 years since Tommy John underwent the original Tommy John surgery and had his UCL reconstructed by Dr. Frank Jobe. Since that time there have been close to 400 “Tommy Johns” in the big leagues alone. Alarmingly, 30% of those have occurred in the last 5 years. The potential costs both to the athlete and the organization in time and money should an injury occur are enormous.
- #10 In attempting to put a figure to this Conte has documented that the total cost to all of the organizations in MLB for having players on the DL between the years of 1998-2015, is well over 7.5 billion dollars! To think that these trends and these numbers are viewed simply as the cost of doing business is frightening. No other major corporation would be comfortable with losing hundreds of millions of dollars yearly, and having their best performers not involved as a result of an aspect of the business that is theoretically controllable.
- #11 Asset management and security in professional baseball is absolutely essential. We can all believe that the science, the understanding, the knowledge is all there to allow for progress on this issue, it may just be that we need a different angle upon which to view the problem. As Billy Beane has said regarding our ability to deal with these trends “We have to stop pretending we know the answers, because whatever we’re doing doesn’t seem to be working”
- #12 In light of the continuing surge in arm injuries, injury prediction is one of the biggest challenges facing the sports medicine of baseball. The ability to identify potential risk factors is a key component of future injury prevention or reduction strategies. Traditionally scientific investigation has assumed a fairly reductionist view in the attempt to understand the mechanism of these injuries.
- #13 The literature has revealed some details surrounding potential predictors of injury. For example we have evidence to support the role of shoulder limitations, (loss of ER, loss of IR, shoulder abduction), trunk posture changes and hip/pelvis limitations (loss of IR) in being correlated to both shoulder and elbow injury.
- #14 However as we know the incidence of injuries is multifactorial and comes from a variety of factors. As such it may be necessary to start to apply a broader approach which comes from the application of systems based thinking. It allows us to step back from viewing the things themselves and start to see the relationships amongst things.
- #15 What is a system? A system is a group of interacting, interrelated or interdependent parts that form a unified whole that has a specific purpose and generates its own behaviour. It will be helpful to see how thinking in systems can fit into the wider injury context. To do so we can identify events, patterns and system structure.
- #16 Events- are the occurrences we encounter on a day to day basis. Patterns- are the accumulated “memories” of events. Over time the patterns can reveal recurring trends associated with the event.
- #17 Systemic Structures- are the ways in which the parts of the system are organized. These generate the patterns and the events we observe. When we do see patterns, particularly negative ones it should be a clue for us to dig slightly deeper and look at the interactions amongst things. Addressing underlying system structure is necessary. Once we see the relationship between system structure and behavior, we can begin to understand how the system works, what makes it produce poor results, and how to shift it into better behavior patterns.
- #18 Further still applying the model of Bittencourt and colleagues, the multifactorial nature of injuries arises from the interaction of what they called the web of determinants. These are linked together in a non-linear manner in the sense that small changes in one or a few of these determinants can lead to large and sometimes unexpected consequences. Therefore susceptibility to injury, the continued participation in pitching, and the risk factors and predictors can be thought of as a continual adaptation or maladaptation to the underlying system elements.
- #19 Think for a moment about how that fits into pitching injury. In pitchers, we often blame things such as training practices, innings pitched, number of pitches or mechanics for causing injury. But these things don’t and can’t cause injury in and of themselves. Injury occurrence is not based only on one risk factor. An injury will occur when a specific pattern of interaction happens amongst the web of determinants therefore we must look at all of them.
- #20 As you could see there are many different factors to consider when trying to maintain the health of any high level athlete. From the perspective of many of us in this room as performance professionals , the conceptualization of injury mitigation and performance enhancement comes down to the isolation of two particular elements: the capacity inherent within the system and the demand being asked of the system.
- #21 In dealing with a high performance population, capacity can be categorized according to the 3 P’s. In our athletes we must ask whether the physical, physiological and psychological systems are working in unison to create movement efficiency, to manage repetitive tissue stress to have physical and mental resiliency so that optimal performance is achieved?
- #22 Physical capacity can be thought of as the athlete’s ability to tolerate as wide a range of movements as possible with an adequate amount of strength and control and to do this over the course of a season. To understand physical capacity, and its interconnectedness to demand, we can break these two variables down into three fairly simple and deterministic equations.
- #23 If the demand of the system is equal to the capacity of the system we maintain system balance or homeostasis.
- #24 If the demand of the system is greater than the capacity of the system, then we have continual flow out of the system, which can set up the potential for injury.
- #25 If the capacity of the system is greater than the demand of the system then we have accumulation of stock, which mitigates against injury and more importantly allows for enhanced performance.
- #26 Capacity and demand are constantly and continuously having an effect on each other such that if we plot a very basic behaviour over time graph you will begin to see how these two variables have an effect on injury and performance outcomes.
- #27 What should be evident when we think about capacity, is that it is inherent to the individual athlete. As such we are relating capacity to the fact that athletes are systems themselves with many independent but interacting subsystems thus leading to complex and adaptive behaviour. They are complex in the sense that, the participating parts of the system are modified by every single interaction and as a result new behaviours may emerge, and they are adaptive in the sense that they are continuously evolving in time.
- #28 When the behaviour of a complex system is studied, it is observed that there are constant interactions and fluctuations, although ultimately there is order among the component parts as they are capable of linking together to move in and out of coherent patterns without the guidance of a central controller. Complex systems are classified as open due to the fact that their behaviour is continually driven by the environment and by receiving adequate feedback. This leads to the ability to spontaneously organize themselves to generate emergent behaviour that cannot be understood solely from the parts alone. This is a process called self organization that is inherent in all of us.
- #29 As Clarke and Crossland (1985) point out: ‘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”
- #30 A theoretical approach to the understanding of complex systems and how they can change over time comes from Dynamic Systems Theory. The principles of which are very straightforward, and deeply relevant to the study of human movement and easily applicable by performance specialists.
- #31 Esther Thelen provided us with a wonderful metaphor to understand the nature of a dynamic system. She compared human movement behaviour to that of a mountain stream. A stream is moving all the time in continuous flow and continuous change. Motor behaviour is continuous but constantly changing—whatever has happened in the past influences what happens in the future. The stream also has patterns. We can see whirlpools, waterfalls, places where the water is moving rapidly and places where it is still. Like the stream, motor behaviour also has recognizable patterns: in the throwing motion we see fairly succinct arm, hip and trunk ranges that often look repetitive and quite predictable. In the mountain stream, there are no programs or instructions making those patterns. There is just water and the streambed under it. The patterns arise from the water, the streambed and the environment and reflect the interaction amongst these things as the stream carves the streambed which then directs the flow of water. It is not possible to say what directly causes what, because the whole system is so mutually embedded and interdependent. Human motor behaviour also has these system properties. How a pitcher effortlessly throws a fastball at 95 mph depends not only on the immediate current situation but also on their continuous short- and longer-term history of moving. How much, how often? how purposeful and intentful? Movement history sculpts the athlete’s internal environment or physical capacity allowing them to interact with the external environment, creating new opportunities for better future movement behaviour.
- #32 Physical capacity then is a continual and ongoing process. It is not necessarily the grooving of motor patterns. It is continuously modifying and adapting and is the product of the exploration of new movement possibilities, or alternative patterns that might be more efficient when subsequently practiced in the realm of sport specific movement.
- #33 Now where does skilled athletic movement come from? Based on the work of Karl Newell (1986), in complex systems patterns come from the interaction of what we call constraints. Constraints are boundaries that dictate how the motion of all parts of the system are coordinated together to achieve a movement goal. They guide the process of self-organization and can be both limiters or amplifiers of appropriate movement dynamics. From a therapeutic or training perspective the type of constraint is what dictates whether it can inhibit or enhance movement capability.
- #34 Constraints are typically broken down into two categories, what are termed: physical and informational. Physical relating to the characteristics of the individual including such things as ROM, strength, tissue status etc, these being things that we would observe and assess on the treatment table. Informational relates primarily to the training environment and how that shapes movement, but also to the task itself in terms of what the goal of the task is.. This leads to three classes of constraints- organismic, environmental and task.
- #35 These classes of constraints coupled with how we perceive situations using our senses and our ability to use continual afferent feedback or sensory information coming to us from our body dictates the movement pattern that will emerge.
- #36 Now let’s take a brief look at how this may shape the motor behavior of a typical Major League pitcher based on a very simple explanation of their workload. They pitch every 5 days, which on a typical outing may end up being 90-110 pitches, on top of that there are warm up pens, an off day bullpen, and perhaps some long toss and other throwing between starts and maybe some form of flexibility training and training in the weight room. Now with all that repetition of throwing it is very easy for certain patterns of motor behavior to emerge depending on the interaction of all of the constraints on the movement. We know, as the evidence suggests that there will be a definite loss of ROM in the throwing shoulder, definite loss at the proximal radioulnar joint as well as elbow and definite loss at the hips also. From a very simple and logical perspective if we allow these changes to go unchecked and they continue to build, such that over time we get less and less ROM in the joints, therefore affecting the appropriate movement, and there is a build up some overlying increased nervous system tone in some of the muscles as a result of the high demand of the motion and due to the repetitive nature and large forces generated during the pitching motion, there will be some disorganized connective tissue leading to impaired relative motion and tissue breakdown, then all of these things will become organismic constraints to that pitcher, which will potentially impair that pitchers interaction with the environment and impair movement task goals. Because current movement is based on the history of previous movement (or lack thereof), the coordination patterns that emerge may not necessarily be the most optimal or efficient. As a result the potential for catastrophic injury increases.
- #37 How do we as performance professionals combat this so that we create a situation where the optimal pitching strategies can be expressed by the athlete? By using our interventions and aiming them at creating better options for movement or increasing variability for our athletes. Dynamic Systems Theory embraces variability as it is an important component in changing or optimizing motor behavior. The development of the most stable solution to produce a given movement pattern is based on exploration and the ability of the athlete to solve a motor problem.
- #38 Variability is inherent in all biological systems. And is defined as “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”
- #39 Rather than interpreting motor variability as being a negative feature of skilled performance, it should be thought of as a large contributing factor to stability of movement patterns, the dynamics of coordination and to a highly functioning movement system. This is characterized by the ability to accomplish a goal with rapid yet flexible solutions that can be recruited by the nervous system at any point in time.
- #40 The analysis of movement patterns shows us that it is fairly impossible for any athlete to perform two identical representations of the same task. This was originally demonstrated by Nikolai Bernstein back in the 1930’s in his historical study of professional blacksmiths where he discovered that over repeated trials there was high variability in the coordination of the joints involved which was associated with low variability of the hammer trajectory.
- #41 More recent evidence shows us the same. Arutyunyan et al. and Biryukova et al also found that expertise was highly correlated with increasing variability in the detailed patterning of the joints involved in the movement. They characterized this as a “looser coupling” between the segments involved. This contradicts the expected notion that those with more expertise in a particular movement task with an expected goal have less variability or tighter coupling.
- #42 When you look at the definition of intelligence it very nearly parallels the concept of motor variability.
- #43 Therefore we can conceptualize the ability to efficiently adapt and adequately vary the coordination of the joints involved in skilled performance as motor intelligence.
- #44 How does the concept of variability relate to baseball pitching? The traditional concept of variability is based on end point variability, which proposes that any deviation in the outcome of a movement should be less in a skilled or healthy individual. An expert would be able to replicate the same exact pattern every time. What is now evident is that to achieve a relatively stable end point in goal directed performance, like pitching a baseball, which we can call “low variability at the working point” is only achievable by having higher variability at the level of the coordinative relations that underpin that performance. What is important to notice is that he achieves a consistent release point by varying his overall pattern of getting to that release depending on the constraints of the task, such as his physical capacity at that point in time, the type of pitch he is throwing, and the competitive environment. This is an example of high motor intelligence as we see that the many interactions and interrelations between the components of the system are coordinated together into a whole on every repetition of the movement.
- #45 How might all of this relate to pitching injury? Injury states can be classified as low coordinative variability states. This loss of variability, or potential movement options is characterized by a loss of physical capacity and is termed a loss of Complexity.
- #46 What has been discovered in biological systems is that the path to frailty and subsequent injury is a loss of variability and has to do with a reduction in the adaptability of segments that underlie pattern formation.
- #47 You can see a loss of complexity from these very simple graphs. Diagram a) shows a situation of low coordinative variability because the pattern is repeated time and time and time again, as you can see by the small surface area at the bottom of the graph. This is a lowered physical capacity and a loss of motor intelligence. The means to the end are just not there. From a repetitive loading standpoint if forces are not able to be distributed appropriately and effectively by the variable coordination of the joints involved it gets absorbed repeatedly by the same tissues. In this case it would be fairly easy to see how this could easily lead to tissue break down over time. In diagram b) you have high coordinative variability, as the surface area at the bottom is wide and robust demonstrating adaptability on the part of the components of the system thus also showing high physical capacity for appropriate motor behaviour. Obviously with repetition the load on the body’s tissues gets distributed over a greater number of joints due to the effectiveness of their interaction. As a result the potential risk for injury decreases.
- #48 We must start thinking about injury states as a systems problem! Outwardly this will look like an injury event but the underlying system structure displays an information problem by having impaired feedback loops. This happens when we don’t have necessary and efficient joint interaction during motor performance. This creates a loss of adequate sensory feedback, within the ranges of motion that are limited or not controlled for. Therefore our CNS does not get a full picture of the movement task that we are asking it to process which leads to an inappropriate task command and leads to motor error and a reduction in the ability to adapt to constraints. Ultimately this impairs unconscious performance of the task.
- #49 As a result it is extremely important to focus on developing somatosensory feedback by improving joint function, joint mobility, tissue strength and nervous system function by continually assessing and treating and training those things. This is what ultimately allows for improved physical capacity of the athlete. This is where collaborative intervention becomes important in our athletes and there should be a seamless integration between the “on table” to “training” components. The on table interventions performed by the manual therapist are the beginning processes of creating better joint movement and the necessary tissue loading to create tissue adaptation and start to create and re establish that sensory feedback process. This creates the opportunity for the strength coaches to train with an improved physical structure and gives them the opportunity to manipulate the training environment and training goals to further the adaptive process of the athlete and deepen the stock of physical capacity. It should be our focus to take each element of the system, involved in the sport movement and make them function better and more efficiently so that on the field when a movement needs to be accomplished by the athlete we’ve made sure that all components are functioning as optimally as possible so that coordinatively they can function together. All of us working with baseball players have a huge role to play in setting this stage. From the therapy table to the gym to the field our main responsibility is to create the right conditions for our athletes and then get out of the way.
- #50 As a result of this let us revisit our capacity and demand equations and rephrase them based on the underpinnings of dynamic systems. Demand = Capacity => System Balance becomes Task Dynamics = Coordination Dynamics Demand > Capacity => Potential Injured State becomes Task Dynamics > Coordination Dynamics Capacity > Demand => Injury Mitigation (Enhanced Performance!) becomes Coordination Dynamics > Task Dynamics The bottom equation shows us our goal. Create a system that is highly adaptable, repeatedly over time. When most think that it is only a matter of time before pitchers will break down and when most are surprised when a high level pitcher hasn’t had elbow reconstruction, It is necessary for us as performance specialists to more than adequately prepare our athletes for the high demands of their task. In doing so, I feel that we can have a huge impact on the current rate of injury.
- #51 Thank you for listening