Greg Dea: Feedback and Cueing – Part 2 – Reliable Strategies

Part 1 can be found here.

Movement is an output, a performance, a behavior.
When coaching, we decide if a movement is satisfactory or not.

Remember the last client you trained. You stood nearby, watching. If I stopped you at a moment in time and asked you, “was that movement satisfactory, yes or no?” could you answer right away? Further, could you tell me why it was or wasn’t? If it wasn’t, do you have a “what is next?” idea?

If it is satisfactory, we load that movement to develop work capacity. If it is not satisfactory, we need to evaluate to reveal what requires correcting.

The keen eye of the professional uses the process of training movement to look for mistakes that are outside the realm of acceptable.

Many of us would watch a set and be daydreaming, or watch the clients form but without using a yes/no process in our mind of whether it is acceptable or not and needing intervention from us.

This “realm of acceptable” is also known as a “performance bandwidth.”

To decide whether a movement is acceptable, that is, within the bandwidth, the keen professional must adjust judgement based on three elements of the specific population, specific task and peer-accepted safety ranges of movement (Richard A. Schmidt & Lee, 1999, 2014). If any of these elements reveal a movement to be outside acceptable, we will know that the mistake will:

  1. reduce the efficiency of the movement,
  2. lessen the chance of success, or
  3. increase the risk of injury.

When we see these movements outside the bandwidth, we can use the coaching strategies of feedback and cueing to change the persons movement. In this second in a two-part series of articles, I’ll reveal the main forms of cueing used to change behavior in movement, that is, performance. In the first article, the different forms of feedback were revealed.

Now, before you jump into cueing, there’s one important piece of feedback to seek.

Does that hurt?

Any pain with movement needs evaluating since there are medical reasons for pain that manifest with movement and may not be movement-related problems.

Movement screens and assessments like the FMS and SFMA use these three bandwidths to help reveal whether movement is competent or not, thus helping us make fewer mistakes. 

Cue for Change, Rather Than Coach for Change
If you couldn’t speak to your client, like I rarely could in China, you could still cue them to move differently. Doing it well can be reproducible by following research-guided cues. By “move differently”, I mean to be more mobile, more stable against movement (static stability) or more stable with movement (dynamic stability) or before adding capacity.

The restoration of motor control and stability occurs best via:

  • task cues, and
  • constraint cues that implicitly cause change rather than verbal cues to explicitly suggest change.

Task cues and constraint cues are examples of externally focused movements. These are more effective and more efficient than internally focused movements. (Marchant, 2010; Marchant, Greig, Bullough, & Hitchen, 2011)

An external cue usually has built-in benefits, known as implicit consequences. The internal cues aim for explicit behavior changes. There’s a time for both, but there’s a benefit balance that favors external cues with implicit benefits.

Implicit vs. Explicit Cueing
A cue that is directed towards a result that is external to the person but has hidden outcomes within the person is an implicit cue. These types of cues stimulate patterns of movement and overcome the problem of trying to control many parts or trying to control many degrees of freedom of movement of parts. These are often referred to as task-focused cues, since the cue is to get the individual to complete a task that is outside of them. An example is to reach for a cup. Another example is to throw a medicine ball towards a spot on the wall. Built into both of these tasks is the coordination of multiple parts into a pattern, something that is not addressed by simply activating a part explicitly.

A cue that is directed towards an internal outcome is an explicit cue. These types of cues stimulate movement or control of parts, i.e. individual muscles.

Implicit cues are preferred over explicit cues, except where the specific goal of cueing is for muscular hypertrophy. Implicit cues enhance efficiency of movement and torque at a joint.

Cueing patterns uses implicit cues while cueing parts uses explicit cues.

There are times when cueing parts for performance plays a role – for example, to stimulate the neuronal activity in the area of brain that is responsible for movement of a particular part. It is a process that is often adopted in neurological rehabilitation. It is also used in bodybuilding, to direct local activity to muscles. This is training that is focused on local performance of parts, compared to training that is focused on performance of tasks. A progression away from parts-focused training to task-focused training produces better efficiency and improved torque relative to internally focused movement.

There is a lot of evidence to indicate explicit cueing, or isolated parts training, leads to cortical reorganisation of the motor cortex. Isolated training displays high electroymyographic (EMG) activity compared to externally cued, task-focused training. A higher EMG, however, is not the goal of performance training. Externally cued, task-focused training displays lower EMG but incorporates more efficient context-specific patterns, often with higher torque than isolated contractions (Marchant, 2010). Externally cued, task-focused training of patterns also has implicit benefits of overflow and irradiation (see below), concepts that demonstrate improved torque in general movement patterns. Torque is enhanced as a preferred benefit, rather than local EMG. (Adler SS, 2007)

The Benefit and Science of Auditory Cues
The role of audition and how it is used in motor performance is a largely understudied area, with some exceptions. The goal of auditory cueing is to gain attention, to break patterns and to improve learning retention.

In general, auditory information is processed faster than visual information, but visual information seems to provide more useful information than auditory.

Consider a loud clap at the beginning of a command. Or a yell! The goal of such an auditory cue is simply to get attention, to break a pattern. Auditory cues primarily remain useful for breaking patterns by getting attention. Here’s why:

  • Best performance behaviors are high quality movements, with high force for a long time.
  • Improved performance doesn’t happen until behavior changes and it is the nervous system that permits behavior to change.
  • The process of changing behavior starts with getting the attention of the individual – whether they know it or not.
  • Conscious and subconscious attention-getting are the domains of coaching, or programming of training.
  • Each (conscious and subconscious) has a place.

Getting the attention of the individual requires a nervous system with healthy receptors to stimulate. When you talk to an athlete to provide a cue, it requires healthy hearing. Since auditory information is processed faster than visual information, it remains a pivotal tool for breaking patterns by gaining attention of the nervous system. (Reference: In: Chapters 5 and 11, Schmidt, R. A., & Lee, T. D. (2011). Motor control and learning : a behavioral emphasis (5th ed. ed.). Champaign, Ill. ; Leeds: Human Kinetics.)

The Benefit and Science of Visual Cueing
In movements requiring rotation, flexion or extension, where extra mobility is required, directing the eyes in the direction of movement will stimulate the required pattern. Conversely, where more stability is required, directing the eyes away from the direction of movement will stimulate more stability. This is based on the righting reaction. (Cech DJ, 2002; Hoogenboom, Voight, Cook, & Gill, 2009; Piper MC, 1994). This is also based on the concept of overflow and irradiation.

Overflow or irradiation might be defined simply as the help that is delivered to key areas by doing something else.

More scientifically speaking, overflow or irradiation is the increase in facilitation that alters the excitatory threshold level at the anterior horn cell. Irradiation is the spreading and increased strength of a response. It occurs when either the number of stimuli or the strength of the stimuli is increased. The response may be either excitation or inhibition.

Normally, overflow occurs into those muscles that offer synergistic support for the prime movers used during a motor task.

Visual cueing is linked to using flexion and extension to advantage
The vestibulo-ocular reflex ensures that when the head turns towards a target, the eyes will rapidly move first and then move in an opposite direction to the head rotation, to remain fixed on the target while the head catches up (Bizzi, Kalil, & Tagliasco, 1971). The eyes initiate activity with the arm and neck (overflow). This central pattern organization of movement provides us with a clue to stimulate direction-specific patterns.

It has been shown that manual aiming (including reaching and grasping) is more accurate when the head is free to move than when it is fixed (Biguer, Prablanc, & Jeannerod, 1984; Vercher, Magenes, Prablanc, & Gauthier, 1994). This reinforces the need to clear neck pain and movements with faulty shoulder patterns.

Practical tips:
To improve movement in a direction, turn your eyes towards.
To improve stability against movement in a direction, turn eyes away.

The Benefit and Science of Tactile Cueing
Compression and distraction along a kinetic chain are tactile tools to enhance motor control. The goal is to stimulate reflex stabilization. Typically, the reflex response to compression and distraction is for the person to express a pattern of movement that can be described as extension. This includes abduction and external rotation. It can be said, then, that preferentially using tactile cues to promote extension leads to reflex stabilization.

The amount of force required depends on the richness of the sensory environment. For example, an individual who has restricted joint mobility may not feel subtle compression cueing, since the joint is somewhat compressed already, and the mechanoreceptors may not detect strain or accessory joint movements. This person may respond better to distraction of the joint. A person with hypermobility may respond better to compression than distraction.

The action of compressing and distracting along or across the long axis is known in the coaching world as reactive neuromuscular training (RNT). It is a form of tactile cueing that is colloquially know to be exaggerating the mistake, or feeding the mistake. It is an action that can be used to increase stabilization of body parts that are meant to be stabilised, but for some reason have not stabilised. In some circumstances, prime movers muscle groups may become active to stabilize segments. This reduces their ability to express mobility. In those circumstances, stimulating stabilization through compression and distraction can facilitate improved stabilization by local muscles, relieving prime movers of that role to continue expressing mobility of the pattern.

Practical tips:
In a pattern that requires more than one limb, watch the non-moving limb (known as a stabilizing limb) for loss of extension. For example, in rolling from supine to prone using the upper limb to lead movement, we often see a hip flex when that same hip should be stable.

In a single-leg dead lift, we often see the “swing” leg display some hip and knee flexion when it should remain extended relative to the forward leaning torso. A coach/instructor can exaggerate the mistake, or feed the mistake, by compressing along the long axis. This will cause the leg to flex even more and the individual will reflexively resist this, pushing into extension and stabilizing the hip and torso. This will give the client a feeling of how to pattern in the correct direction. The cue is to push the stabilizing leg into more hip flexion via long axis compression.

Reactive Neuromuscular Training (RNT) in tactile cueing is predominantly used to exaggerate movement mistakes via the language of feel, not words.

Reactive Neuromuscular Training is the cue of applying forces at a distance from the joint(s) being targeted, to exaggerate the mistake and stimulate reflex stabilization.

Reactive Neuromuscular Training introduces more risk of going outside the bandwidth of acceptable movement, thus stimulating the individual to correct their movement back within the bandwidth of acceptable movement. (Cook, 2018; Cook & Voight, 1996; Guido & Stemm, 2007)

Practical tips:
For example: where valgus collapse occurs at the hip and foot, applying a further valgus stress at the knee will exaggerate the mistake. The force application can be done as an isometric or oscillating application. You can include or exclude instructions to “not let the force disturb the stable position of the lower limb.” This is most commonly applied in exercises such as the Turkish Get Up, and any exercise in the half-kneeling positions but can be applied in any position including supine and prone, sidelying, bilateral stance, single-leg stance and split stance.

Practical tips:
It is important that tactile cueing does not do the following:

  • It should not cause pain;
  • It should not cause unwanted fatigue;
  • It should not cause unwanted irradiation in the wrong direction or into an undesired part of the body;
  • Both the therapist and the patient should avoid breath-holding.
    To increase the individual’s strength and active range of motion, the individual and coach should use timed and controlled inhalations and exhalations.

The Benefit of Cueing by Task Constraints
This strategy is a form of cueing, with feedback, that reduces the need for both. It involves applying a constraint to the task such that if the mistake occurs, there is a consequence. The consequence should be meaningful to the competitive nature of the individual to force them to organize their pattern to avoid the mistake. This is called self-organization. Self- organization occurs best when the task is “on the edge of ability,” giving the individual the opportunity to manage their mistake and learn.

Practical tips:
An example is in half-kneeling chops and lifts:

Place a traffic cone with a tennis ball on top besides the weightbearing hip, or a foam roller vertical with football on top.

If the individual collapses into hip adduction or hip flexion on the weightbearing hip, the strategically placed cone or roller will be knocked over.

In some circumstances, applying task constraints can be compensated for by the individual, particularly if they are not competitive to learn the best pattern. In these circumstances, completing the movement with capacity, but still within a bandwidth of acceptable movement quality, takes precedent over learning. To do this, rather than using reactive neuromuscular training to feed the mistake, we simply note the mistake and create a circumstance where the mistake cannot happen. We saw a form of this earlier in physical-guidance feedback. There are other ways, without external physical guidance, to remove the mistake when the individual cannot or will not learn. It’s called “locking out the mistake.” We lock out unwanted movements by creating a task to prevent maladaptive movements.

Here is an example:

In motor control training, where there is movement instead of stability, change the task or environment to lock out unwanted movement. This volleyball athlete, post ACL-R, is doing a tall kneeling overhead med ball throw. Less a motor control training task than a loaded pattern for power expression. In this drill, how she generates power is less a concern, since when she plays as a middle blocker, she will block with shoulder extension and anterior trunk stabilisation which may include bilateral hip flexion when she's off the ground. So, we see bilateral hip flexion when she is tall kneeling, and that's fine for the purpose of the drill, which is a powerful throw. It takes one small change to the drill to make it a static stability drill for the hip that's weightbearing in extension – switch her to split kneeling. The change to hip joint position on one side makes it much harder to kick into hip flexion, and the power is generated from upper limbs and trunk, on a stable pelvis. It's not a better or worse drill, just re-purposed for different training. One is a powerful pattern involving hip flexion, the other is a powerful pattern that reflexively requires static stability on the weightbearing extended hip (and of course on the weightbearing front foot).

Posted by Greg Dea, Sports Physiotherapist on Sunday, August 2, 2015

In motor control training, where there is movement instead of stability, the instructor can change the task or environment to lock out unwanted movement. In the linked video, this volleyball athlete, post ACL-R, is doing a tall-kneeling overhead med ball throw. It is less a motor control training task than a loaded pattern for expressing capacity of power. In this drill, how she generates power is less a concern, since as a middle blocker, she will block with stable overhead arms and anterior trunk stabilization with bilateral hip flexion. When she is tall-kneeling, we can see some extra force is generated by hinging at the hips and that’s fine for the purpose of the drill, which is a powerful throw.

It takes one small change to the drill to make it a static stability drill for the hip that’s weightbearing in extension. The small change is to switch her to a split-kneeling, or half-kneeling position. The change to hip joint position on one side makes it much harder to hinge at the hips, and the power is generated from upper limbs and trunk, on a stable pelvis.

It’s not a better or worse drill, just a drill that has been re-purposed for different training. One is a powerful pattern involving hip flexion, the other is a powerful pattern that reflexively requires static stability on the weightbearing extended hip (and of course on the weightbearing front foot).

Cue to enhance stabilizers so that mobilizers can express themselves
Corrective exercise is not a rehearsal of the faulty pattern. It is the correction of inputs first followed by cueing the pattern. The correction of inputs includes improving the mobility of parts within the kinetic chain and also within regionally complicating parts. (To read more about regional interdependence and limiting factors to performance, read here).

Practical tip:
To enhance mobility in a target body part, cue stability in a body part that is away from the moving part. This introduces a cue to introduce stability to the system so that global mobilizers can better activate. “Activate the stabilizers to untie the mobilizers.”

Here’s an example: in the video of the middle blocker, I cued stability in her lumbar spine by taking her from tall-kneeling, where she extended her spine in the throw, to half-kneeling. This made it harder for her to extend her spine, thus stabilizing it. The stability here led to more throwing activity required in the upper quarter, i.e. throwing prime movers.

Summary
Watch your athlete move and decide if they are within a bandwidth of behavior that you can tolerate. Ask them how they felt when they behaved that way. Cue them to behave differently. Use scientifically reliable and valid feedback strategies and cueing strategies to get consistently better results.

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