Applied Technology in Training and Rehab

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Note from MR: Adam Loiacono is one of my favorite guys to talk shop with.

He first came and hung out at our facility over Christmas break, and we immediately hit it off because or our mutual love of soccer (and John Cone’s hair).

As a physical preparation coach and sports scientist for the MLS’ New England Revolution, he obviously knows what he’s talking about.

But I think this article really helps bring a lot of the pieces together.

If you’re interest in technology and monitoring, and how to make it really work for you, then take 15 minutes out of your day to read this article.

Enjoy!

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The Growing Interest from Teams, the Public Audience, and Private Gyms

The integration of technology in sport has been a growing interest amongst athletes, medical professionals, rehabilitation specialists, and physical preparation coaches.

Akin to any growing public interest, the accompanying business market has capitalized.

The sports technology market is booming with the likes of several tech-savvy companies emerging that promote their product’s ability to optimize performance. Many products now exist on two markets – the private (military, university, or professional sports) and public (retail).

When considering the implementation of technology, the question that the curious individuals should ask themself is:

  • “What is the purpose for including technology within my current __________ (insert ‘training’, ‘clinical practice’, ‘team’, etc…)?

Many sports science professionals much smarter than myself may respond differently when asked the purpose behind technology – but I do believe we all could agree on two resounding concepts:

  1. What question is the technology attempting to answer?
  2. Education

What Question is the Technology Attempting To Answer?

First, we need to establish a question to find purpose behind why we are implementing technology, which implies collecting data.

If the professional has a good question, then that question tends to lead to other good questions (thank you Dave Tenney). I will also offer this – once we have that question, and are able to find an answer, can the answer fulfill these three checkboxes:

  • Will that answer be meaningful to the professional?
  • Will it be meaningful to the client?
  • Will it be actionable and help improve what we do?

…If not I suggest we go back to the white board.

Below are examples of practical questions that may be interesting to ask:

  1. Team or private setting: What level of strength is related to decreased injury occurrence?
  2. General or rehab setting: How is the client’s body responding to the current training program or intervention?

Each of the above questions has the potential to be meaningful to both the professional and client and can appropriately influence the training program or intervention. Each question also has the potential to have follow-up questions…

  1. Lower body or upper body lift? Does that strength need to be maintained all season or just in pre-season? What is the physiological cost to achieve the required strength?
  2. What’s the client’s level of soreness? How is their sleep quality and quantity? Are they often fatigued throughout the day at their job?

Collecting data and using technology should make the professional more efficient – not create more work. If implementing technology is not answering meaningful questions, then the implementation of technology is meaningless.

The Ability to Educate

One application of technology is education – both to the professional and to the client.

Technology educates the professional about numerous topics about their training program or intervention including the type of external stimulus provided, the volume of stimulus, and the quality of the stimulus.

Consider the implementation of GPS player tracking systems in team sports. GPS is able to determine total distance (volume), change of directions (hip and groin intensity marker), and sprint distance (posterior chain intensity marker).

Also consider the implementation of heart rate monitoring in group exercise classes. The use of these examples helps the professional refine their methods and truly understand if what was planned in theory is being applied in practice.

Objective and subjective data from technology can also offer valuable information to the client or athlete. The data has the ability to provide knowledge of results, knowledge of performance, and more opportunities for success (read on to learn more).

The data can then offer a line of communication from the professional to the client. Many professionals develop valuable, meaningful relationships with clients.

The implementation of technology can help the professional strengthen those relationships by directing specific questions during conversation, directing attention to certain clients on certain days, or utilizing data to educate the client to better achieve buy-in.

Technology is to Training as Supplement is to Diet

A simple and introductory perspective on technology is to treat the application of technology like a diet.

Chances are if the client starts eating whole foods, appropriately consumes the micros and macros necessary to meet energy expenditure, then most likely that will clear up any diet concerns. THEN maybe the client needs a supplement or two to compliment the diet to optimize results.

Within the context of training, replace the following words in the above scenario:

  • ‘Whole foods, micros, and macros’ with ‘training, rehab, and coaching.’
  • ‘Diet’ with ‘performance’
  • ‘Supplements’ with ‘technology.’

As sexy as some of this technology may become, stay rooted in the fundamental, basic sciences that have withstood the test of time. Implementing technology because the professional hit a roadblock may not be the solution.

Become a great coach, a great clinician, and an even better person before attempting the implementation of technology.

Creating More Opportunities For Success

Training clients or rehab patients often set goals that commonly consist of increasing performance on certain lifts, losing weight, decreasing pain, or returning to some sort of activity level.

Patients or clients often take a myopic viewpoint as to how to achieve that goal (ex: losing weight means eating less). Research in the area of rehabilitation and performance offers consideration that everything matters and that everything can have an influence on that individual achieving their goal.

So how does the professional utilize technology to educate the client to have a more global rather than myopic perspective when developing strategies to achieve their goal?

Consider viewing the client or patient through a lens influenced by Dynamic Systems Theory.

The Theory considers how the individual, the task, and the environment influence human development. Furthermore, each of the three components can each be viewed as a system and the many sub-systems that have potential to influence that system in the context of achieving the goal.

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The above figure to the left is an example of how the professional can view the client as a system compromised of many sub-systems. The figure to the right is how the professional can transfer that thought process to practical opportunities to assess each sub-system.

Many technologies, apps, and clinical tests afford the professional the ability to assess each sub-system.

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The implementation of technology can help assess each sub-system and create more opportunities for success.

Clients often hit a plateau during a training plan and patients may run into a roadblock when returning to function. Plateaus and roadblocks are common and are part of a normal process, but often have a negative influence on the individual. Professionals can create more opportunities for success by assessing each sub-system to help mitigate that negative influence.

Consider a common goal of many clients – improved lifting scores. The client has been continually improving their 5RM consistently over the last 6 months, but recently has not been able to make improvements.

If technology is implemented to assess other sub-systems, then the professional now has the capability to educate the client on other success they have been having. Perhaps despite plateauing on external output (deadlift 5RM) over the last 4 weeks, the client has increased hours slept per night from 6.5 to 8, reported feeling less stressed during the day, and reduced their resting heart rate.

The professional has now educated the client on how they still have been succeeding and as a result achieved greater buy-in from the client because the professional viewed the client from a global perspective.

The concept of more opportunities for success can help educate a patient or client why they may be having a decline in function or performance.

Consider a patient in pain. The patient’s pain perception on a visual analog scale increased from 2/10 to 7/10 over the last two weeks and their range of motion measures influencing their posture have decreased. The patient begins to question the intervention and plan of care.

If assessments of other sub-systems have been consistently monitored, then perhaps the patient’s sleep hours and HRV scores have been decreasing simultaneously. Now the professional has the power to educate the patient that perhaps the decline in sleep and HRV are what may be contributing to increased pain, not the interventions.

Directly or Indirectly, Everything Matters

The field of rehabilitation and performance continues to evolve evident by research and experiences shared by professionals.

A caveat to all of the information that continues to advance the field is that the more we learn, the more we realize what we do not know. As we continue to ask more questions to better learn the influence of the many sub-systems on the human system, some valuable answers have been provided.

  • The Effect of Physical and Academic Stress On Illness and Injury in Division 1 College Football Players. Mann et al.
  • Chronic Lack of Sleep is Associated With Increased Sports Injuries In Adolescent Athletes. Mileweski et al.
  • Behaviorally Assessed Sleep and Susceptibility to the Common Cold. Prather et al.

The progressive literature can help develop an appreciation that directly, or indirectly, everything matters. Professionals cannot possibly assess and manage everything, but can certainly strive to be better by implementing technology efficiently to help assess the individual. In the context that everything matters, I offer this advice:

Keeping things simple is necessary for the sake of practicality, but not at the expense of undermining the complexity of the human system.

The professional needs to find a practical way to help achieve the client’s goals. Technology is a way to help find some practicality and create more opportunities for success.

Finding Meaning of Sports Data – The Big 3

When selecting technology to assess the individual’s system and implementing meaningful questions, there are three fundamental areas the professional ought to consider:

  1. Objective internal load (ex: HRV or Polar HR monitoring) ==> understanding how the body is responding.
  2. Subjective internal load (ex: daily questionnaires) ==> understanding how the client is feeling relative to sleep, fatigue, soreness, stress, mood, etc.
  3. External load monitoring (ex: periodization, GPS tracking systems) ==> understand how much of a stimulus the professional is providing

A Simple Start to Analysis

Once time has allowed for volume of data to be collected, a simple starting point to the analysis is to understand the influence of the external load on the internal load.

What is the physiological cost for the amount of work produced? Consider these examples:

Client #1: 38 year old business woman participating in group exercise class

External load: 3 rounds of 10 exercises of 20 seconds on, 40 seconds off

Internal load: HRV score next day via Omegawave – 70 (red)

Client #2: 58 year old male with upper cervicothoracic tension

External load: Dry needling to upper trapezius and levator scapula

Internal load: Self-reported soreness 8/10 one day after intervention

A major benefit to considering the physiological cost of external loads is to educate both the client and professional on timing of the stimulus.

If throughout a training program the client and professional notice that Day 3 of a 4-day program or a certain intervention (i.e. dry needling) causes a low HRV score and increased soreness, then appropriate measures can be made to plan that stimulus at a time when recovery can be optimized.

From the above Example B, maybe it is not in the best interest to provide dry needling the day before that client has to baby-sit his grandson. Or maybe the training program for Example A should be implemented on a Friday when the ensuing 24 hours will not have a day full of stressful meetings.

It behooves the professional to consider the client as a whole person and the impact a particular external stimulus will have on their overall well-being.

Longitudinal Analysis

Longitudinal analysis is a way to examine changes over periods of time.

Physiological cost can be considered an acute assessment, while longitudinal analysis can be considered a chronic assessment.

Longitudinal analysis examines if the training or intervention has created any positive or negative impacts on the client’s well being. Simple examples include:

  • Daily HRV trend since initiation of a hypertrophy phase of training.
  • Levels of self-reported soreness 24 hours post manual therapy interventions.
  • Number of sleep hours following implementation of a sleep hygiene routine

Consider longitudinal analysis and physiological cost in the context of utilizing a GPS when driving to an unknown location. The driver has a goal of getting from point A to point B, similar to how a client or patient has a goal of getting from their current status to a future status.

The GPS selects the driver’s route, similar to how a professional selects a training program or plan of care. Many routes are possible akin to no single program is the only option.

Along the route to point B, the driver may encounter squirrels running across the road or other drivers stopping short causing the driver to acutely adjust by braking or changing lanes, but the driver still remains on the initial route.

Acute changes in physiological cost such as decline in HRV or soreness will require similar braking adjustments perhaps via increased sleep hours or alterations in diet, but the client still progresses through the program.

Then what if all of a sudden the driver encounters a traffic accident, or the client begins to have significant decline in performance? Maybe then the driver must select a new route to point B. Longitudinal analysis is the tool to help the driver select a new driving route.

The Efficiency Score

Another method for assessment is the Efficiency Score. The Efficiency Score is a way to monitor progress over time without implementing any formal assessment. Standardized fitness assessments are not fan favorites, so how does a coach assess the players’ level of fitness without them knowing?

The Efficiency Score analyzes the players’ internal load response to a consistent external load, key word being consistent. In order for an effective Efficiency Score, all variables must remain constant during the external load stimulus. In the context of energy systems, here are examples of constant external loads:

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Over time the coach tracks the internal load response either through self-reported rate of perceived exertion (RPE) or heart rate response.

Repeatedly program the consistent external load into the client’s training program. The client thinks that the exercise or game is part of the training program yet the professional is actually assessing their fitness.

In addition to assessing their level of fitness, the Efficiency Score can be used as a marker of readiness.

If the physiological cost, the internal load, is significantly higher in comparison to previous assessments, then chances are the client is not in as optimal of a state as once previously.

Consistency is King

The single most recurring problem that a professional will encounter when implementing technology is consistency.

In order to develop reliable data there needs to be sufficient volume to develop an acceptable range of variance – commonly measured by standard deviations.

The primary driver to developing reliable data is to consistently assess time and time again.

If assessment protocols are not consistent, then there will be too many variables that can influence the success of the intervention. Below are a few examples of what to consider when collecting the data:

  • Time of day
  • Environment
  • Person performing assessment
  • Caffeine consumption
  • Activities prior to assessment

The goal of technology is to supplement practical skills.

Consider the earlier analogy – the application of technology in training is similar to a supplement in a diet. The dietary supplement is only as good as the ingredients that comprise it.

Technology and data collection are no different.

Master consistency and include good ingredients as part of the technology application process.

Did We Honestly Learn Anything New?

The art of coaching is undeniable and the ability of the coach’s “feel” for a session cannot be understated.

My experiences working with both a tenured coach and young coach have both been unique. (I highly recommend reading On Intelligence by Jeff Hawkins (thank you Bill Hartman) to further understand coach’s intuition.)

On Intelligence is one computer scientist’s perspective on how the brain works. Jeff Hawkins explains how it is our ability to recognize patterns and parts of patterns that allows us to predict what certain behaviors, people, or situations may be.

Why is it that veteran athletes are able to read plays of a game better then rookie athletes?

Why is that a veteran coach can pick up on innate qualities of players to determine if they will be successful?

Perhaps it is due to repeated exposure to patterns or parts of patterns that allow for easier pattern recognition for tenured players or coaches because they have had more exposure.

Consider Jeff Hawkins’ concept of pattern recognition and the coach’s “feel” for the sport in the context of this example.

On a regular basis I will ask my tenured sports coach who he thought were the 3 least performing players of training that day. I would separately then look at the GPS data to examine particular metrics that commonly are related to players’ performance.

Majority of the time, the tenured coach and I were in agreement based on his subjective analysis and my objective findings. His pattern recognition from years of exposure to training sessions and players was comparable to the algorithms provided by the GPS system.

Did we honestly learn anything new?

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Granted there have been instances when objective data has presented findings not consistent with the coaching staff’s appraisal of the players’ performance.

Certainly disagreements have occurred.

I simply suggest not living behind a computer screen, like I once did in my early experiences with technology, and rather develop meaningful relationships with players and staff.

The power of trusted relationships are truly remarkable and often are just as valuable as some of the technology on the available market.

Person First, Technology Second

My experiences thus far in my young career have led me to want to attain these three objectives with every athlete or client, with or without technology:

1st gain person’s respect. 2nd gain their trust. 3rd have them understand you care. Then __________ (insert your training or rehab beliefs).

I have been very fortunate to have the opportunity to speak with many companies about technology and furthermore be able to utilize or demo those technologies. Some of those technologies I have been exposed to are:

  • OmegaWave
  • Fit for 90 subjective questionnaires
  • GPS systems (Catapult, Statsports, GPSports)
  • Fatigue Science sleep bands
  • Middleware software that store/analyze data (Coach Me Plus, Edge10)
  • Kitman Labs
  • Polar HR watches
  • Polar Team2 system.

Yet, still after all of those technologies mentioned above, I believe one of the most important pieces of technology on the market right now is conversation, which at its root is a verbal appraisal of the client’s system.

Dynamic Systems Theory and Myopic Technology

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Recall from earlier about Dynamic Systems Theory. The above diagram to the left is a representation of a few sub-systems comprising the human system and to the right are examples of technology that assess each of those sub-systems.

I offer the consideration of this idea – many technologies are myopic.

Many technologies only examine a single sub-system, but literally everything matters so how can we possibly rely on technology that appraises only a few of the many sub-systems?

There has yet to be a successful piece of technology or app that has the ability to effectively collect and interpret all data from varying technologies to truly assess the overall state of the system. In addition to the myopic nature of technology, each technology has its own proprietary algorithms, which can increase error and complexity in data collection.

Consider the research article below discussing how variation exists and reliability is questioned amongst technologies attempting to perform the same function:

Monitoring Accelerations With GPS in Football: Time to Slow Down? Buccheit et al.

Why is conversation the most valuable technology?

Perhaps the reason is because the brain is the only available technology that has the ability to appraise all sub-systems within the human system and deliver that appraisal through verbal communication.

If asked the appropriate question, then that individual will be able to effectively appraise more sub-systems than technology could.

The individual has the ability to consider previous experiences, future implications, and the interactions of various sub-systems within the context of their current environment.

Perhaps developing a meaningful relationship and understanding that a client’s verbal answer to the appropriate question might be the most powerful technology because the professional is listening to that entire system’s appraisal of where that system falls along the health-performance continuum on that given day.

Furthermore, there is evidence to support the power of the individual’s ability to appraise their readiness. A systematic review came out of Australia published in BJSM about how subjective questionnaires are just as reliable as common objective measures collected from various technologies:

Monitoring the athlete training response: subjective self-reported measures trump commonly used objective measures: a systematic review. Saw et al.

Science and a Unique Caveat

Based on my own experiences, I would rather listen to myopic technology for younger players and listen to the conversations of veteran players.  

The conversations with a veteran player may be better than many of the algorithms that data analysts may create, granted a trusting relationship has been established.

The reason I believe in conversations is rooted in neuroscience.

The natural development of the prefrontal cortex (PFC) does not fully mature until the 20’s and the brain itself may not fully develop until the 40’s.

The PFC is a filtering system of thought, actions, and emotions that is responsible for executive decisions. The veteran player who has a matured brain has gained memories and learned the impact that certain feelings, soreness, and fatigue may have on their performance. Over many years the veteran has been able to recognize patterns and refine their “algorithm” to effectively appraise their state of readiness better than what any technology is capable of.

Consider this caveat that was shared with me at the Seattle Sounders Sports Science Weekend. A performance staff of a professional soccer team created an injury risk model in which they were able to accurately suggest when their soccer players were at risk for injury expressed in a percentage format

“Adam Loiacono is at 28% risk for injury today.”

A resourceful concept and powerful tool to a head sport coach when determining who shall train today – but here is the caveat I learned. In order for that injury risk algorithm to be most accurate, the age of the starting 11 needed to be:

  • 1-2 players < 21
  • 6-8 players < 29
  • 2-3 players > 30.

Considering neuroscience, perhaps the reason this model is successful is because those younger players under the age of 29 lack the pattern recognition, memories, and refined algorithm to appraise their own readiness due to pure human development of our body’s appraisal system – the prefrontal cortex.

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Consider Everything – Including Yourself

Everything matters.

Maybe the player drank a cup of coffee before the Omegawave reading or the patient only slept 4 hours the night before therapy.

Hopefully an appreciation for complexity has been gained with an understanding that we need to keep things simple for the sake of practicality, but not at the expense of undermining complexity.

Utilize technology to help find practicality, yet do not lose sight in the value of people.

$1 on technology = $6 – $8 on people.
– Dr. Ben Sporer, Exercise Physiologist, Vancouver Whitecaps FC

I also ask you to consider your own personality.

I am an outgoing, personable individual.

Maybe the reason I preach on the concepts of gaining respect, building trust, and having the clients know I care is because my personality is conducive to conversations with clients and colleagues.

I will talk with them first then go to the data to support or refute what my conversations are telling me.

Perhaps your personality is different than mine. Perhaps having those conversations do not come as easily so you may need the technology to start the conversation with the client.

On a final note about Applied Technology in Training & Rehab 101, I would like to leave you with a quote that has resonated with me from renowned Australian sports scientist Dr. Tim Gabbett.

Dr. Gabbett made the following statement in the context of speaking to an audience of sports scientists, strength and conditioning coaches, and rehab professionals:

“We will never be the reason the team wins a game, but we can certainly be the reason the team loses a game.”
Dr. Tim Gabbett

About the Author

loiacono_head-shotAdam Loiacono has been with the New England Revolution of the MLS since 2009. His role has evolved from youth a soccer coach to now in his 4th season as a fitness coach for both the professional and youth academy players. Previously Adam held coaching roles in soccer and fitness at NCAA Division III schools and is currently in his final year of a Doctor of Physical Therapy degree.

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