Today, we’re going to be covering a bit of an industry wide topic, which will be the top down approach, the bottoms up views of physiotherapists and strength coaches – when it comes to tackling any issues that we tend to see within common practice.

When we’re talking about issues, it can be injuries, it can be movement/technical problems, or it could be any host of a combination of either of them.

Disclaimer

Now, just as a disclaimer, I do want to stress that I’m not saying for a second that either a strength coach or a physiotherapist should step beyond their professional code of conduct. I do believe that the referral system is in place for a reason.

However, I’m a pragmatist at heart, and I believe that within your professional career at some point, you will always come across a scenario in which you have to fix a problem as a strength coach – like I said, whether it be a technical issue within the squat or something similar to that – or as a physiotherapist where you have to continue physical development of the individual, that might stem beyond the rehabilitative stage.

So, again, not saying to step beyond that professional code of conduct, just being a pragmatist in that, you’re going to have to encounter these situations. And I want you to be aware, both as a strength coach or a physiotherapist of the opposing systemic view that we tend to see.

Anecdotal Observation

Now, this is coming from real-world experience.

Meathead Mechanics

I’m not saying that this is something that is indoctrinated, but we do see the top-down approach, also known as the “Meathead Mechanics”, as I like to put it, with a strength coach or the bottoms-up view or the very conservative-management approach of a physiotherapist.

Strength coaches tend to be individuals that are fixated more on the performance mentality. This is, again a very stereotypical prejudicial view but I’m just looking at it from a standpoint of observation. They tend to be more fixated on the ‘output’ than the care of the individual. Now care will always be at the forefront. But if it meant getting that the athlete getting the individual to win a gold medal, but it might cause an injury further down the line, then they’re more than happy to take that sacrifice. Because, as I said, the performance is the key.

Conservative Management

Whereas a physiotherapist in their very nature is taught to be the exact opposite. And they should be understanding that a conservative approach is key to keep the body healthy and focus on things like longevity.

And what I’m trying to say within this podcast is bridging the gap between the two…

Whether or not you choose either end of the spectrum in terms of your application will depend heavily on the “context of the individual” rather than your presuppositions of how training should be applied.

Origins

So just there’s a little bit of a history lesson.

Strength coaches tended to come primarily from the weight room. We’ve started to step away into more diverse training methods. But there’s a reason why shouldn’t coaches tend to reside within “iron-based” settings – And there’s a lot of weights there because you will get a lot of these professionals are focused on lifting heavier weights.

Problems with Conservation

From a historical standpoint with the world of physiotherapy, we tended to see that a lot of the early research and a lot of the early work came primarily from post-war trauma or even spaceflight; and the physical toll that the body ends up experiencing during these scenarios. Both of which are primarily focused on healing or treating an acute problem -treating a problem that is causing the individual pain.

And as a result, inherently, there’s going to be some form of conservative management there. Throw that into the mix with this notion of medical negligence. If you work in health care, there’s always going to be this approach of conservation and making sure that you don’t do too much and cause any further problems.

The issue with this side of things is: what happens when you don’t necessarily give the stimulus that is should be potent enough to create overload for that individual?

And 18 months down the line, they’ve not actually fixed the problem. So they end up coming back into practice.

Antibiotic Scenario

And this is something that we see, something that now that’s called the “Antibiotic Scenario”, where people are given 14 days worth of antibiotics; they stop taking it at 10 days because the symptoms, “clear up” and then they get reinfected and they’ve actually gone through the whole process.

And again, I don’t need to tell you that as a sports rehab professional or as a physiotherapist, this is something you’ll come across on a regular basis.

You need to understand this notion of progression and draw lessons from the strength coach world to be able to continue the development of the individual so they don’t come back into practice.

What’s the Problem?

So, first thing that we need to cover, whether or not you are a physiotherapist and coach: what is the issue?

And does it even need to be fixed?

I know it sounds like an incredibly obvious question, but a lot of people, particularly new and early-stage practitioners, aren’t actually aware of the power and the responsibility that they have over someone’s physical health and physical performance.

You Have the Power

And with the language that you use and the methods of communication that you choose when interacting with the individual, you actually have the power to create problems that don’t exist.

And I know that sounds like it’s a bit of a fantasy scenario, but put yourself in the mind of the athlete or the patient that you’re working with, OK?

A lot of patients, if they’re under a significant amount of pain or they’re in a scenario and they have an issue that is causing a hindrance to their quality of life, they might be afraid. They might be anxious about the situation – especially if it’s chronic there’s a lot of scenarios in which the mental health can be impaired as well.

On the flip side, if you’re working with an athlete that’s been at the top of their game and had it taken from them, again, this has a significant psychological effect.

And we know now that when we look into the world of pain science, the Biopsychosocial issues that are present simply from the language that you use and the scenarios and the factors that you choose to focus on will actually have a direct effect on this individual and it can exaggerate symptoms or obviously dampen them.

So,  like I’ve spoken about before, in terms of developing skin in the game and that type of thing, as a reflection – you need to be aware of what you choose to focus on when you’re working with that person. And this will all make sense a little bit further on, because it sounds like, “Obviously you’d focus on the injury”, but that’s not necessarily the case.

Is a “Fix” Necessary?

So, does it need to be fixed? Is it a problem that needs to be tackled directly? Is there acute tissue trauma, or is it something that can be worked around?

If people are familiar with that, “We’re going on to bear hunt” poem, the idea of you can’t go over it, you can’t go under it, you need to go through it. There are scenarios in which you can actually shift the psychology of the individual you’re working with to focus on a slightly different narrative which will promote this recovery that you want to see within the tissue and the injury that you’re working with.

So what’s the solution and how do these two approaches tie-up?

Well, ultimately, the bottoms-up view is very, very useful.

Bottoms-Up Approach

Starting with a really remedial exercise. Let’s take an example of lumbo-pelvic stability or tolerance of load through the lumbar spine. You might start out with, in really early stages, an abdominal hollowing approach and teaching the individual an abdominal brace. You might progress to the ‘McGill Three’ – the McGill curl, different point variations etc. You might then go into a lying leg lift to be able to tolerate the stability of the lumbar spine, prone hip extension. And then you might work your way up there.

And as you’ve seen with all the different models, such as the FMS Model; you can start from the supine to the prone to the half kneeling and build your way up to compound, multifaceted, coordinated movement.

And in this scenario, if there is acute trauma, if there is one that’s called ‘controlled tissue reconstruction’, then yes, a bottoms-up approach is obviously always going to be useful. But again, who is the individual that you are working with in that scenario? If they are a very weak person, so if they don’t have a pre-existing physical health status, that is impressive, or that is deemed of a high quality prior to the injury.

Downsides

Then, yes, a bottoms-up approach is going to be very, very useful. However, if you’re working with someone that was a high level athlete and they have a very, very high reservoir, so to speak, of strength and of physical development; then taking this very, very remedial approach can often result in detraining of other tissues that might, as I’ve said before, be the fortification of the framework around that injury.

So what do I mean by this?

Well, again, let’s take a real-world. Anecdotal example. When when I had my ACL reconstructed, OK, when I was going through the sports rehab process.

I was given a list of exercises. And the exact same exercises were given to someone to my right in this ACL class that we had going on. That was 20 years older than me and had never really do exercise a day in her life. In those scenarios, those exercises aren’t progressed or regressed based on the individual.

Now, I know you’ve got the whole logistical constraints and everything like that, but after discussion with the physio, he said himself that I need to be starting on high-level exercises, the highest level exercise possible to be able to try and maintain the strength of those tissues.

And again, as a conservative view from a lot of physios, you can get caught up in the notion of thinking there has to be this linear progression and they have to start from the bottom end. But ultimately, you need to be able to assess as a practitioner where do they lie on that spectrum and what is the highest level exercise I can start them on.

Top-Down Approach

Which is where we tie into the top-down approach. Now, the top-down approach, I think, is incredibly useful, particularly with things like overuse injuries, but again – it does actually tie into post-operative scenarios as well, dependent upon the individuals you are working with.

Essentially the top-down approach would be starting off with the most advanced exercise you can do, regressing your way back from there, to find the pain free, the safe, effective version of that movement and then building your way back to the movement that you need to do.

As we spoke by in the range motion exercise, let’s take that as an example.

We know range motion is obviously task-specific. So if the individual is a powerlifter that you’re working with and they have to be able to deadlift from the floor but they get pain around the SI joint, let’s say, or the L4-L5 junction, you get pain at that point when the bar on the ground. In which case you can regress the barbell back up to the higher heights in which the range of motion is a little bit more restricted. The pain isn’t present there. You can continue to load from that position. And this is the top-down view.

Rather than getting them straight onto the mat, straight onto all these really remedial exercises, you can start and continue on with exercises that are actually quite advanced in nature, but for that individual are suitable and are a pain-free regression.

Helping the Client

So why would we do this? Why what is the benefit? And beyond simply just the physical stress on the tissue, what is it about the client or the patient that will allow them to benefit from this top-down model?

Well, ultimately, you’ve got to remember one key thing, OK? And this is this goes for any topic within fitness…

If it if you remember one quote from today, this will be the quote,

“Just because you can see the link between two things doesn’t mean the person you’re working with can.”

So, you can see as a practitioner, the gradual progression, but the very tenuous, albeit real link between a lying leg lift, and the ability to deadlift. But as a powerlifter who has no interest in that area, the client that you’re working with might not care or even be able to comprehend the link between the two.

Who Are You Speaking To?

Remember that most clients and patients that you work with won’t have a pre-existing knowledge of anatomy and overall physiological, kinesiological function. And as I’ve said before, although your job as a coach and as a practitioner is to ‘educate and empower’ that person, it doesn’t mean that you have to teach them the link between every single exercise that you’re going to perform.

And like I said, nine times out of ten, even when you do, they won’t necessarily have the same motivation as they would if they were starting with a regression of the movement, the provocation, the pain – but they can still actually form the association.

A Transparent Process

Let’s take another example, a basketball player who wants to be able to jump, but it’s the stability on landing that is causing the pain. Getting them to do a box jump. You’re mitigating the forces on landing. You might find that they can do that without any pain. You’re not going to struggle to convince a basketball player the relationship between a box jumper and their performance.

Yet. If you get them to do 200 reps of terminal knee extensions to help with patella tendinopathy, for example, and then you get to do a couple of wall sits and more remedial movements that will still help and that are a key component of a program – but you’re not giving the other stimulus at the same time – they will struggle to find that same association.

You’ve got to go back to the 4 Laws of Training, as I’ve said before, Consistency, Specificity, Individuality and Progression.

When we look at the top-down model, there is immediately going to be greater adherence because they can form associations straight away.

So they can form the association, which shows that there is an element of specificity within the movement that will obviously cause greater adherence, which means they’re going to be more consistent with the movements that they perform.

And then on top of that, they can see that clear pathway of progression.

And the regression will always be individual to that person.

So there’s the 4 Laws taken care of straight away and not only for you as a practitioner, but the four laws are blatant and obvious to see for the patient that you are working with.

Shift Their Focus

And one final tip as one of the other benefits that we can take from it, and as a general recommendation, is that I strongly advise that you set goals outside of the pain.

OK, even if they are incredibly arbitrary or incredibly simple, the line that I like to use, from a strength coaches perspective, is if it doesn’t hurt or doesn’t load the acutely injured tissue, you should train as normal.

And you should, as I said earlier, it depends where you place the focus – dependent upon the severity of that injury, a lot of the times it might actually be more beneficial to place the emphasis of your work with that person on the arbitrary goal. On getting them to focus on something outside of the pain and work towards that because a lot of the time you can’t underestimate the potency of the psychological state of the individual on the pain that they experience or the problem that they are currently having.

OK, so you can get into a situation where you get someone to focus on a slightly different narrative and it boosts their motivation. It makes them feel better about the scenario. And then all of a sudden their report of pain and their overall movement capacity starts to improve as well.

Again, as I said right in the first episode, you’ve always got to remember that you are giving solutions, not information.

So you need to be in a scenario in which you can decrease the pain of that person, improve the tissue resiliency (if that is a key problem – if it’s been an acute issue) but continue to have that individual to train.

And although the bottoms-up view is very effective when it comes to post-operative care and working with scenarios in which there has been a significant injury to the tissue, it doesn’t always make it the most effective method of application of exercise selection or the dose that you would even prescribe – because a lot of the time the individual doesn’t need to be that remedial and they can work at a slightly higher intensity using the top-down approach.

So I hope that makes sense. Again, as always, if you have any questions about any topics you want to go through, then please just read in the comments below and we’ll get them started for Episode four.