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Enhancing Back Pain Rehabilitation: The Role of Effective Communication with Nick Winkelman

In this episode we discuss the importance of the quality and timing of WHAT is said to athletes/clients/patients, adapting the approach to an individual’s personal communication and learning styles, and directing attention to the right things at the right time. This ensures we can drastically reduce the confusion, frustration and overwhelm that can be experienced by patients. If you feel that you don’t understand what is being said in the clinic room, or in the gym, don’t shy away from asking for clarity so you can get the input you deserve.

Enhancing Back Pain Rehabilitation: The Role of Effective Communication with Nick Winkelman

Welcome to the Back Pain Solutions Podcast – Enhancing Back Pain Rehabilitation: The Role of Effective Communication with Nick Winkelman

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Episode Introduction – The Language of Great Coaching

In our latest podcast episode, we delve into the language of great coaching. Join us as we interview Nick Winkelman, head of athletic performance & science for the Irish Rugby Football Union, to gain insights into effective rehabilitation strategies.

We emphasise the importance of finding a practitioner who can provide the guidance and empowerment needed to return to your favorite activities. This involves not only executing movements correctly but also reducing any risk of further injury.

Nick shares his expertise on the quality and timing of communication with athletes, clients, and patients, stressing the significance of adapting communication styles to individual learning preferences. By directing attention to the right aspects at the right time, confusion and frustration can be minimized, leading to more successful outcomes.

Discover why it’s crucial for clinicians and coaches to speak the language of their audience and ensure clarity in explaining treatment plans and exercise routines. Nick highlights the importance of understanding movement beyond theory and being able to execute it safely.

Join us as we explore the impact of language on effective pain management and injury rehabilitation. Don’t miss out on valuable insights to enhance your back pain treatment journey.

Key Takeaways:

  • Importance of clear communication in rehabilitation
  • Tailoring communication to individual learning styles
  • Maximizing the effectiveness of treatment plans through effective language

Tune in to our podcast episode to learn how effective communication can transform your back pain rehabilitation experience.

The language of great coaching.

Episode Highlights

Discover why effective communication is vital for successful pain management. Learn how challenging your clinician for clarity can enhance your understanding of your condition and treatment plan.

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Episode Transcription

When we’re young, we move with freedom and confidence with a great resilience to injury. But somewhere along the line we develop poor habits and become more vulnerable to back pain. Back Pain solutions features evidence based and practical advice to help you take back control of your health and get back to the activities you love. This is your guide to better back health through movement. So join us as we demystify some of the commonly held beliefs about back pain and build your confidence to a stronger back the smart way.

Ben James 0:28
Welcome back to the back pain solutions podcast Everybody with me Ben Jane’s and today we welcome a special guest on to the show. Nick winckelmann is the head of athletic performance and science for the Irish Rugby Football Union. His primary role is to oversee the delivery and development of strength and conditioning and SPORT SCIENCE across all national that’s men and women and provincial teams. Before working for Irish rugby, Nick was the Director of Education and Training Systems for XOS formerly athlete’s performance located in Phoenix, Arizona. As the Director of Education, Nick oversaw the development and execution of all internal and external educational initiatives. As a performance coach, Nick oversaw the speed and assessment component of the ex NFL combine development program, and supported many athletes across the NFL, MLB, NBA, national sports organizations and military. Nick completed his PhD through Rocky Mountain University of Health Professions with a dissertation focused on motor skill learning and sprinting. Nick is a recognized speaker and consultant on human performance and coaching science, and has numerous book chapters and peer reviewed papers, focusing on the intersection between coaching language, and athlete learning. So Nick, welcome to the show. Thanks for joining me on the back pain solutions podcast.

Nick Winkleman 1:54
Ben, it’s my absolute pleasure.

Ben James 1:56
So I listened to you on the clinic, gym hybrid podcast not too long ago, and was very much intrigued by your coaching background and coaching input. And we’re very much focused here on back pain solutions and an exercise movement based approach to back health. But we know that in prescribing exercises, we’ve got to make sure that people do really well, because it’s all very well doing an exercise. But you’ve got to do that exercise well to for it to be effective. And certainly with backhaul for it to be safe. So it was a great opportunity I felt to reach out to you and talk around coaching specifically talk about your background a little bit, and and your philosophy on coaching and why it’s important to do it well. So to kick us off, Nick, why don’t you just tell us a little bit about your background, your experiences, and how you’ve got to where you are today?

Nick Winkleman 2:43
Yeah, no, absolutely. Well, I’ll try to give the short version the story seems to keep getting longer every every year that I’m invited on to podcasts. So by trade, I’m a strength conditioning coach and I have been now for almost 20 years. So all degrees, Exercise Science, that good stuff. My career has really always been two paths, one as a coach, educator, and one as a strength conditioning coach. And so I’ve always had an interest and how we develop ourselves as coaches as teachers, as communicators alongside of actually getting into the crucible of coaching and developing the craft and sharpening the sword as they say. And so my career has spanned probably two major chapters at this stage. The first part was 10 years at a company called exos, where I oversaw and primarily worked with NFL so American football players, elite military, alongside other professional sports, the way I describe it is our in season as an organization was every professional sports offseason. And so very much so I worked in develop my craft in the heart of these these offseason developmental windows. And within that, my specialty, if you want to put a fancy word on it was in movement, skill development, primarily helping athletes go through the NFL combine. So going in preparation for the draft, so 40 yard dash, vertical jump, broad jump, all that good stuff. And and that movement, skill development space created this canvas for me really to enquire and become curious around coaching, notably communication. So kind of that the intersection between what we said as coaches and the impact that has on focus, and learning of movement of technique, and certainly, the motion of the back was a big part of everything that we did in teaching sprinting. And so I was there for 10 years, in that in that time, I ran a coach education department as well and inevitably pursued a PhD, and I pursued a PhD to become a better coach. I wanted to understand again more about motor learning and skill learning and that’s inevitably what my my dissertation work was in As of 2016, I’ve now dropped jumped to this part of the world. And I’m the head of athletic performance and science for Irish rugby. And so it’s a bit more of a leadership coach development role, where I oversee s&c across our national, and our four provincial teams. And the way I describe it to many people is all of our strength conditioning coaches throughout the country in the sport, are the bricks doing the work on the ground. And I’m very so very much so the mortar, trying to connect it all together. But throughout all of this, throughout all this, Ben, I’ve had a central interest in communication, which has culminated in in my recent book, the language of coaching.

Ben James 5:37
Awesome. Also, what got you into it at the outset? If you’re like, Where did the kind of inspiration and interest begin for you?

Nick Winkleman 5:47
Yeah, yeah. So there’s there’s two key points in time, I recall that really wrap into how I how an s&c coach starts talking about linguistics and language. One was I was in college, and I was working under this other personal trainer, as I was still cutting my teeth on coaching and teaching movement and personal training is a great way to start that out as a young college student. And what I found was that somehow, the results and the impact he could make notably, in service of what we’ll be talking about today, in technique was profound, rapid and sticky seem to be able to make changes to your basic hindering patterns and pushing patterns and pulling patterns at a rate that was far greater than any of the other trainers at the time that I was watching. And I just became curious as to why because he was still bench pressing on Monday, and squatting on Tuesday, he was doing all the basic programming pieces on par with what you’d expect. But somehow his results were superior. And over time, I came to recognize that he protected the moment before the movement, it was sacred to him. And in the space in the breath, before the movement began, he would always offer up some kind of a coaching cue that was delivered with great precision and purpose, you know, oftentimes had a bit of flair, there might have been an analogy or a visual, but it tended to always be singular. And it was very precise and considered for the individual. Now, I was not new to the idea of cueing or instructing or providing feedback. But he almost took it to an art form in the way that he actually practiced it. Now, the interesting thing is Ben had you asked him, Hey, what’s the greatest skill set you have, he would say, Oh, my technical knowledge in specific range of motion, and anatomy and programming, and so very much so he did this intuitively, okay. But his intuition led to something that I was able to consider and do precisely on purpose. Now, I park that for many years, but then the spark came about, again, in 2009, it was almost probably five, six years later, and I was overseeing this NFL combine development program. I had 30 players who are about to go to the NFL combine and draft to become, you know, NFL, future NFL stars. And I realized it was a January morning, I was coaching a speed session. And I just I was listening to myself coach, and it was like monologue that I was giving all these cues. And they were precisely timed. And they were detailed, and they were technical. But I realized that all I was doing was outputting, I was broadcasting, I was not actually paying attention in any real meaningful way. As to whether or not the queues were making an impact as to whether I was getting the eyes opening and the nods as to whether it was actually changing the technique. What was the motivation for the queue in the first place, okay. And so in quite a literal sense, I woke up, and I stopped staring at the proverbial program in my mind, and started focusing on the person. And that has led me now on a journey that’s over a decade long of studying, as I said earlier, the intersection between what we say when we say and how much we say, and the way we say it, and its impact on Learning and Performance.

Ben James 9:36
Thats really interesting to me, because it something I’ve recognized in in clinical practice, is you you the danger is you kind of start to go through the motions. You’ll do these tests for individuals and for a low back pain case. And you kind of get into the rhythm of doing it and you’re not really what the the danger is, you’re not really thinking about the specific response from that individual because you just I do this test to do this test to do this test and what is it at the end, but not really staying tuned into the feedback you’re getting for the individual and that individual test. And I think it’s really interesting what you say there that you’ve picked up on, on that intersection. Because communication, I realize is so, so important, particularly when we’re, we’re dealing with people in pain, because those cues and those things that you say, can have an impact on that thought process that thinking and ultimately that, that recovery. So it’s quite a fascinating subject, I think that you, you bring up there. And so where did you go from there, you kind of realized that almost you were, you were, I guess, relatively prescriptive in what you were saying, rather than being specific and individualized for the individual, or that kind of evaluation of what you were saying was was lacking. So where did you go from there in terms of in terms of your progression and development to, I guess, resolve that? Y

Nick Winkleman 10:57
Yeah. So the first thing I think, is probably the way I can answer that question best is, by way of a quote from the late UCLA basketball coach, famous basketball coach, john wooden. And john wooden said, You know, I have not taught until they have learned. And so it’s this whole idea that you need to connect your your teaching methods, you need to evaluate your teaching methods and the efficacy of the way you convey and communicate in terms of what is absorbed, what is owned by the athlete, or in your case, the patient. And so I was sharing with someone just the other day that this idea of trial and error only works when you know what you’re trying, and you know where to look for the error. And so, unless I’m purposeful in my communication, and unless I look for the impact of my communication, in eye contact, body language and movement, I’m not actually going to create here’s the word, the feedback loop to get better at communicating, connecting and queuing. And so it was it was during that time, that simply I became aware that wow, our words what we say matters. And I just started to pay attention. As you articulated, that can be difficult at times, I just started to pay attention to what I was saying. When I was saying it, how I was saying it how much I was saying, and really benchmark to tune myself to its impact on the athlete. Now, if you do that, you inevitably will recognize when your words are not working. And when your words are not working. And you don’t have any system or tool to call upon, the only thing you can start to do is ask questions of the patient, ask questions of the athlete, whereby I might say, let’s use your context, hey, during this movement, we know that your back will feel much better if it kind of stays in this neutral or this kind of zone. Now, right now, you’re outside of that zone. And I might even offer an analogy, I might say, you know, when you hit a bend nail, what happens to the nail? And they’re gonna say, assuming they’ve ever hit that nail, it continues to bend anybody? Yeah, exactly. So the problem is, when our body kind of gets in this position, it lacks that stability, it continues to bend, it becomes vulnerable. So I might say to you, what do you think you can think about? Maybe it’s a hip hinge? What do you think you can think about to keep that body in a bit more of a neutral position that that feel good? And we might even say safe zone? Because right, then you talked about language and pain, if I say safe zone, that suggests to them that there’s an unsafe zone. And that implies fear, danger. So I might say this is the feel good zone, which is less threatening than safe. In from where I sit? Yeah. So what we now start to do like a jazz band, like a jazz band, we riff a little bit like okay, well, maybe I could think about being flat or long or stretched like a bungee cord or, and you’ll be surprised at times what people come up with. But the key thing you’ve done is, you’ve framed in simple terms, what needs to happen. You’ve done this because you’ve recognized none of your cues are working. And we have to understand that sometimes, not sometimes all the time. We always speak from our place of truth. We always use words and phrases that by their very nature, otherwise they wouldn’t be uttered. That makes sense to us. The challenge in the medical profession the SEC profession is we have to learn to speak their language. We have to learn to frame our meaning in their words. And so one of the best ways to do that is to articulate what needs to change, and give them an opportunity to offer up possible solutions, things that they can think about to help them move better. And so that’s more or less in a long winded way, some of the strategies I would lean into, now we can get into this in a moment. Over time, I realized that there were actual systems and strategies that I could use models, if you would schemas that I could use to accelerate my ability to identify cues that work, words that work when it comes to coaching. But I’ll be honest with you, Ben, even now, over a decade of doing this, the strategy I use more than any other to get to words that work is involving the athlete or the patient in the conversation, tapping into their language locker.

Ben James 16:02
That’s interesting, because I was about to ask that question. Before you, you kind of just finish that point there that what I, what I took from what you’d said previously, was that you’re you’re almost getting the buy in of the, the individual the patient in in understanding what you want them to do. So you’re almost kind of you’re you’re educating them by asking them what what they would do, if that makes sense in terms of that safe zone or that, that feel good zone. And, and I think that that’s another thing that we we often do, or the danger that we do as practitioners is we just kind of tell, we just tell the patient, we just tell the patient, but if they don’t fully understand it, we I see this a lot with trying to get them in, in neutral spine and to to find neutral with the pelvis. And they really can’t, they can’t get that concept. They can’t get that disconnect with that with the pelvis. Now I’ve done it a million times. Just makes sense to me. But if I don’t kind of cue it correctly, or if I don’t get that individual to think about it, or kind of discuss it and ask them the question in terms of how they do it, then they they find it really challenging. So I think that’s fascinating that you you make that point?

Nick Winkleman 17:17
Well, so so a couple different anecdotes that I think both patient and clinician can relate to. And that is your Firstly, firstly, Ben, have you ever met a clinician? Who doesn’t move very well? Yes. Okay, many. So let’s, let’s just let’s just play, let’s just play that out for a second. What that means is with his clinician that doesn’t move well. I would argue, though, that likely, you could show them 100 videos of a person doing a hinge or a squat or a lunge. And they probably could point out the good, the bad and everything in the middle. If you were to ask them to describe what should the body do anatomically during the hinge or a squat to push or pull pattern, again, they likely could verbalize it. So what that tells us is, they are visually and verbally attuned to understanding the movement. Fantastic. But ultimately, that’s not enough. We have to know how to perform the movement. So where am I going with this? Well, where I’m going is what that demonstrates, clearly, is that just because I can verbally describe a movement, and just because I can visually discern, across the spectrum of technique, it does not follow that information by itself is enough for me to have the physical know how the motor know how, as to perform it. Otherwise, all of these clinicians and coaches I might add, with this unbelievable visual and verbal knowledge could perform the movements with absolute proficiency. And for the individual thinking, Well, what about they’re older, they’re physically unfit? No, we’re talking about fresh young clinicians and young coaches who still cannot necessarily demonstrate everything they talk about. Okay. And so what does this start to tell us? Well, now it tells us, okay, as a coach, then, if I’m only offering up verbal information, Hey, your back needs to be flat head, shoulders and hips aligned visual information. Here’s a demonstration of it being done perfectly. It doesn’t follow that that will ever be enough. Sometimes it is, but ever be enough for that person to extract from that the physical knowledge to know how to do it. And again, let me add in an anecdote and I’ll wrap up the point. Have you ever had a patient say to you, Ben, I know what to do. I just don’t know how to do it. Yep. Okay, so once again, this person has a representation of what needs to be done. Likely they can verbalize it, they certainly can visually identify it, yet they can’t necessarily physically manifest it. And so this gets into a distinction between knowledge of what to do knowledge of what to coach, and knowledge of how to do it, knowledge of how to coach it. And so ultimately, what my work, and by that it’s not mine in terms of creating it, but what my work is now championing is the science and practice that recognizes that there are two different information sources, we need to be masterful with as communicators of movement. And that is, yes, I need to be able to describe to you what needs to change. But then I need to be able to access either language, or environmental constraints that convert that into a cognitive currency, that helps you know how to do it. And so that’s the key did, that’s the key difference. And so we can get into what defines that the difference between language of what and language of how.

Ben James 21:11
Yeah, well, let’s do that. Because I think, you know, there’ll be there’ll be people listening to our show that are back pain sufferers, but certainly there’ll be, there’ll be people that are practitioners, and their natural kind of question is going to be well, how can I improve on this communication? How can I improve on on my skills to make sure that I’m confidently getting the message across to the patient and, and that patient is, is understanding and executing? Well, because I myself have have experienced instances where you try, try and try again, and you can’t get that patient to do what you want them to do. And it takes a lot of work and takes a lot of time to get there. And, and you’ve got to have the patience to do that. But there’ll be certainly people listening that I think that will have the experiences with those patients. And they’ll certainly be people listening as well that that have no they need to do an exercise and just haven’t been able to do it. So I’m interested to get your thoughts on that.

Nick Winkleman 22:02
Let’s so let’s let’s make it very tangible. Let’s think of a hinging pattern. One that is very common, I’m sure in your your own clinical work in terms of returning to activities of daily living safely. So we can think about like a two leg RDL hinge pattern or even a single leg RDL, right, where we’re just hinging at the hip with minimal minimal knee bend. And we know that this for many clinicians and individuals and sport coaches and coaches alike, is one of the hardest to teach, because it requires this dissociation where you know, we’re just hinging at the hip, the upper body is quiet, the lower body is quiet. And oftentimes, we see it’s a very noisy movement, people bend their knees too much. But notably in the contents of the back, there’s a lot of flexion. And we want that to stay relatively neutral. Because if the back is obviously flexing, then we’re not absorbing to the hips, which is where we actually want the power and strength to come from. So let’s now map on to this, let’s map onto this, these two different forms of language. The first form of language is what we’re going to call the the internal language, or the descriptive language. synonyms for this would be the anatomy of the movement, the biomechanics of the movement or the technique. And so we look at the technique of a single leg RDL, I could say things like, I want your your bottom, knees slightly bent, from head to heel of the free leg, I want you to be straight, we might even be more specific, I want the shoulder blades back, the chest up, the stomach tight and everything neutral. Then once you’re there to move, I want you to purely hinge or to be specific, I want you to flex only at your hip. Now, if people are listening to this, and they’re not bio mechanist, they’re not clinicians, they’re not sport coaches. It’s as if I’m speaking another language, the my Oh, yeah, I’ve heard of backs and flexions. And they know you’re gonna pick up on words that they recognize, but they’re not going to be able to visualize that whole movement as easily as you and I can, because we were trained quite literally, in kinesiology, which is the language of human motion. And so still, though, I might want to offer if I was doing a live demonstration, that literally from head to heel, I want you to be straight. And the goal of this is to just flex and hinge at the hip without breaking at the back without bending. So what this is doing is it’s signaling to the patient technical expertise, because when they hear these things, they Okay, that knows what he’s talking about. And that makes me feel comfortable as as a patient. It also allows them with your visual, so you’re giving them verbal and visual. We call that dual coding, and kind of the learning world. That gives them two different ways to form a picture and just call it general conceptual understanding. categorical understand, like, hey, that’s a dog versus a cat. That’s a hinge versus a squat. It just allows them to another Understand the movement, but understanding the movement conceptually and performing the movement. Ben, will you agree here are not the same thing?

Ben James 25:08
Yeah, absolutely.

Nick Winkleman 25:10
Okay. Okay, so what we’ve just done there is in my own work, I refer to that as description. I’ve literally described the movement. And I say, as little as in my world, I say as little as I need to, sometimes nothing at all, if I don’t find it to be important. But for most people, a little bit of just general, triangulation, or what they’re about to do is, is beneficial. Especially if there’s any safety concerns. So a lot of your work, there might be safety concern. So you use a lot of that language to set them up correctly in a movement. But now now, right? It’s the moment before the movement, that sacred moment that my mentor seemed to master intuitively. So now it’s like drum roll. Okay, now, how hw, how am I going to get them to do that? Because remember, when I watch you move, then I can see the hinge, I can see the alignment. But they’re, they’re not controlling their body and some bird’s eye avatar, Video game perspective, should vary variance. They, like check this out. For a lot of people to hear this, it kind of blows their mind. They are the movement. They are the coordination, okay, they experience the flexion the alignment from a first person perspective. And so I need to offer up, I need to offer up coaching language, the language of how cueing language that helps them from a first person perspective as the Dewar actually understand it in a way that positively influences the movement, rather than interrupts it. Because you’re banned. Have you ever given a patient too much information, or the wrong information? And they kind of look at you and say, so what do you want me to do? Right, so we’ve all run into these walls again, and again and again, where we are not understood, as we intend them to understand. So let’s just offer up a couple example cubes. Now I could say to you, okay, keep your back straight. That.. let’s say that doesn’t work. Where do I go from there? That’s like, queueing bedrock, I bet at the bottom, I say flex your hip without bending your knee? That doesn’t work. Right? Where do I go from there? There’s only one hip to flex, I’ve run out of anatomical language. I have no no more linguistic luggage to help coach and qu. And so is there any other way to articulate the movement? Yeah. Okay. Rather than referencing the body, let me reference what the body is trying to do, which is always in a context, it’s always in the environment. So if it’s a single leg, RDL, I know I want to hinge and I know, I want you to be long from head to heel. How do I pursue that? Okay, one cue I might use is, I want you to think about as you’re hinging, and I’m demonstrating this, as you’re hinging, put your footprint on the back wall. So literally put your footprint on the back wall. Or maybe I see there’s a door behind you there, Ben, I say, hey, as you hinge down, I want you to reach as if you’re going to close the door with the bottom of your foot, or if I’m on the field with my athletes with the bottom of your boot. And that alliteration helps with memory. So just imagine if someone’s listening, stand up and try this, doing a single leg already yell, okay, reach that, like what it does is as you hinge down, as you hinge down, guess what happens, the back leg gets in finally a position where it’s parallel to the wall. And so if I’m thinking about putting my footprint on the wall, that’s going to encourage me to do two things, it’s going to encourage me to lift my leg, which decreases the likelihood that I just flex my spine, because then my body operates more like a wheel barrel, where my back leg is the actual handle and giving you another analogy here. The other thing it does is because I’m not literally at the wall, it encourages me to reach well what happens when you put tension at a joint, it creates centration and stability, further decreasing the likelihood that I’m going to overly flex. Right, so now there’s really simple accessible footprint on the wall. We can now nerd out and talk about all the technique it’s promoting. Let me get to others. The other one I might say is, hey, do you have a bungee cord in your garage? Oh, yeah, yeah. Okay. And so, you know, if you have a if you have a bungee cord, right, you can pull it. Yeah, absolutely. But it has a lot of tension. Yeah, it does. Okay, so I want you to imagine from head to heal, from head to heel, you are a bungee cord, you have now become the bungee cord, as you’re hinting. I want you to imagine your body is being stretched, stretched the bungee cord as you go down. So again, we can imagine if a bungee cord is being stretched, it lengthens it lines, we take the slack out of the court, which might be a cue, take the slack out, take the slack out, reinforcing that length. And what it does is it does not ask them to highlight their back, or their shoulders or their knee or their hip. But it’s like a kid, Simon says, act as if, and as far as the mind is concerned, it’s as if I’m mirroring the cord. And the cord, then is not me thinking about my body, it’s mapping my body to something external, this invisible cord, which still in the mind’s eye feels very real. And so both of these cues, use a comparison, they’re a nap, they’re there. Well, the first one will do we call an external cue, because it focused their attention on something in the environment, the wall behind them. And then the second one was an analogy. I compare it something familiar, a bungee cord, they get straight, when you pull it to you’re unfamiliar movement, you’re learning the body position in the RDL, the needs to get strengthened, lengthened as you lower down. And so hopefully, as people are listening to this, they recognize, okay, it’s an and not an or meaning, I can provide you with the technical description. So we have common ground in common language to discuss the movement, but recognizing that that is not the language of motion, that is not first person language that actually helps you achieve the end goal. How many conductors in an orchestra? One, how many instruments, many, ah, many joints, many muscles, but one focus to harmonize it together? How many addresses do you put in a satnav? One. And so what we’re trying to do is to come up with that one contextually relevant cue that is highly attuned to the outcome hides the technique. And usually this comes in a reference to the environment, or some kind of analogy.

Ben James 31:56
Love it, love it. And I think you know, for those people listening that are practitioners that that that will be a kind of a bit of a lightbulb moment, I think, because it really makes in questions there. There can be communication style now, but also gives them a bit of a an insight into how they can improve, because I will, we’ll all have experienced those patients that really, really struggle on I think from a patient side, then it gives you the opportunity to really challenge your practitioner, if you don’t understand it, be honest and ask for for those anecdotes or things that will help to to explain it for your practitioner, because it is so important to get that technique right. And if you don’t have the patience for it, then unfortunately, patients are going to get the wrong technique and therefore, how do they improve? You know, so I think that’s fascinating.

Nick Winkleman 32:42
Well, in here’s the thing, one we know, across the current field of physio therapy, physical therapy, strength conditioning, there is a, a primacy, an emphasis on using technical language. What I’m referring to here is internal language, just just asking and inviting people to think about the body while they move the body. It’s like trying to, you know, see your eyes or smell your nose, okay? We’re asking people to think about the body while they use the body. It’s paradoxical. Yeah, we do it all the time. Now, the reason we do this is because it is the language that we are taught in. We are taught in anatomical kinesiological and biomechanical terms. That is the language the common currency we are given to describe and discuss movement. And it’s been a failure of omission. We omitted something, we forgot to tell individuals that that is not how real people communicate. And it is certainly not how people think about movement. No baby has ever thought about hip position. When learning to stand, walk, run, ride a bike, skip rope, and do the backflip my son taught himself how to do on our trampoline. yet. So often, we treat individuals as if they need to have a semantic Dictionary of body parts in motion to learn how to move, and it is absolutely false. It is a unfortunately, an inadvertent consequence of how we are taught motion and movement in our profession. And so the key thing is to recognize that we need to be able to bring this other form of communication relatable analogy and external cues into into the floor. That is absolutely critical. Now, since we’ve recognized that the vast majority of tactics fall to the internal, we now need to start to see about how we can convert over but I want to bring another piece of evidence to this discussion that’s specific to pain. Not only do we have medical professionals prioritizing by a significant percentage, so approaching you 70% of what they say when they’re teaching being internal language. We also know that when people are in pain, even after the injury has ceased, and even if they don’t still have pain, that there’s an increased natural internal focus on the pain or the prior pain site. And so they’ve shown this in pitchers elite pitchers who had elbow surgery, and elite hitters in baseball who had knee surgery, that they’re able to probe their attention implicitly. And they find that they pay more attention to what the knee and the elbow respectively are doing. So now we have someone that’s already body centric, naturally, because pain is signaling them to do so we then have a practitioner that is drawing further attention, albeit with good intentions back to the body. And yet we have mountains of evidence across healthy and injured population showing clearly that an external focus that focuses me on the environment I’m interacting with, like push the ground away, or the outcome I’m trying to achieve hop as far as I can, resulting in better performance and learning. And also what it does is it dissociates them from the pain site. And in dissociating them from the pain site. For me, it allows for more smooth, effective coordination, and thus the promoting of the self efficacy that hey, I can do this, I have healed. But when we bring attention back to the pain site and the joint, what that does, is it prioritizes the micro over the macro, not only likely, you know, possibly enhancing the pain sensation, but more importantly, it’s promoting a constrained action, a constrained movement performance, which certainly is not going to promote recovery, healing and a self belief that I can do this.

Ben James 36:43
Yeah, I think that’s a that’s a fascinating point, again, because when we’re talking about patients about pain and trying to particularly chronic pain, there’s there’s obviously the concern from them that they’re going to do further damage. And we try and talk them around, you know, we’ve got to expose, we’ve got to expose them and expose that joint. But I think what I’ve got from you there is again, back to that communication of of how you’re asking them to do that, rather than focusing on that injury site, you’re trying to kind of externalize it. And therefore, that thinking and that focus on that pain is is is much reduced, in which case, then we can desensitize, and we can start to move past that pain and recovery. And that’s.

Nick Winkleman 37:26
Yeah, yeah. And let’s be honest, there’s you guys, as clinicians know when you need to be protecting, and when you’re protecting. That’s the coaching mode you’re in. But the second, you know that protection and hyper vigilance is now counterproductive. They are protecting a joint by all accounts that is now healed from a tissue and integrity perspective, yet they still present with hesitation fear and or chronic pain, and you are trying to desensitize them and build up a body literally and figuratively, have evidence here that they can, in fact, do this. And so you know, often times a dissociation from self is remarkably valuable that, hey, when you land, I want you to imagine that you are a stiff spring, show me how you would load the stiff spring. And so now what you do is you place the attention on the stiff spring knot on the self pretending to be the stiff spring, we remove at one level, and that for many individuals, assuming that the actual integrity and ability of the joint segment is there, based on your clinical evaluation, that should in many cases, if it’s the right analogy, targeting the right aspect of movement should improve efficiency, reduce pain and reduce hesitation and thus engender confidence and improvement.

Ben James 38:49
Brilliant. Yeah, brilliant. Love it. Love it. Um, I’m interested to ask you, Nick is an ex point because a lot of people will probably think your work is very much focused on strength and conditioning, it’s to make them clearly stronger, your athlete stronger, but how much of your focus in terms of your coaching and the work that you do on very much really focused on injury prevention, because one of the things that I quite passionate about with my patients is to try and look at it as a continuum, from pain to trying to get to some level of performance, and, and frustratingly, a lot of patients, they just want to be out of pain, get it understand it. But actually, if we moved them past that, and empowered them and inspired them and, and coached them to be more athletic, then the likelihood of re injury and the resilience is, is much greater. So I’m keen to kind of get your thoughts views on that in terms of inspiring and motivating patients and those people suffering from back pain that it’s the The aim is not necessarily or the goal is not necessarily just to be out of pain, but it’s to just be far more connected. Because as a society, the lives that we lead is leading to these problems. We’re just not doing the work that we need to do to be better conditioned. I’m interested to get your views on that.

Nick Winkleman 40:10
Yeah, yeah. So So, you know, we, we try to stay away from language like, injury prevention, as if it’s anything we can truly prevent, you know, we will use phrases like risk reduction, certainly, but we, you’ve nailed it on the head. If you are performing, you’re not injured. So if all I ever do is pursue optimal performance, it is implied that I am not injured in so I think that’s why with RTP, you know, we’ve moved away from return to play, which is returned to now perform is really this idea where performance takes on this, this this other this other level of actually pursuing, optimal or maximal whatever it might be. And so I think even in a patient practitioner setting, that performance oriented mindset, you know, asking a patient, do you do you want to actually feel better and have capacity and be able to perform these movements with resilience? Yes, then that is the the feed forward energy that we’re trying to perpetuate. And what I think is as well, a lot of the, the communication strategies that I’m offering up with our discussion today, Ben, are laced with with energy, and emotion, and vitality, by their very nature, they carry this, this motivational essence about them, right, in terms of stretch the bungee cord, if people just imagine that, again, their body was a bungee, and they’re stretching it, they’ll feel the energy and the vitality of that cue, compare that to, you know, stay long, or chest up, or keep your back flat, it just doesn’t carry the same motion. So I want people to think about this from a practitioner in a patient perspective, right? emotion is an inner energy, it’s an inner energy, that ultimately has the goal of moving you physically, right into a good place. And so the more my language as emotion that people can naturally, unavoidably resonate with, the more will perpetuate better motion, and motivation on the back end of it. And so this is, this is why it’s, this is so important. Language moves us, you know, when you watch a scary movie, or you listen to an amazing song, or poem, it can transform you, it can transform your form, physically your formation of your body, we talked about technique and form. So listen to the words, it can transform you, quite literally. And so language is, is likely the single greatest tool we have in our toolbox. Yet it is one that for the vast majority of movement professionals, is invisible. And what I’m trying to promote, is let’s make it visible. Let’s respect it, let’s understand it and get so much more out of it. And ultimately, our patients will be the ones that benefit.

Ben James 43:29
And that’s a brilliant point. That’s a brilliant point. And, Nick, we’re coming to the end of the show, I’m really keen to ask you for those practitioners listening, what would be your advice in terms of resources or approach, whatever it might be in order to improve that area, because there’s often particularly in in my profession, a focus on courses and continuing professional development. That’s very much, you know, on the tools of the trade, that would passively helping patients, but I’m with you that language is hugely, hugely important. And that’s not just being coach, but in terms of that pain management. So I’m keen to get your thoughts in terms of you’ve gone on and doing a PhD, what, what would be some great resources for them as a finishing point?

Nick Winkleman 44:17
Yep. Before I give you that, I just want to put one more anecdote in the listeners mind. And in doing so, I’m exemplifying the point. And that is the clinicians narrative becomes the patient’s narrative. If that doesn’t trigger you to think about what you say, I don’t know what will. What we say to them. Manifest is their self talk. And so, the Hippocratic oath, do no harm. Now that we know that there is significant evidence on par with the efficacy of all the other evidence we use For ebp, evidence based practice, this has to be an area people continue to look at. and academic institutions were developing, these respective therapists need to be looking at as well. So what are those resources? First and foremost, you know, language, verbal, is only one of the major call it ways to impact movement. The other one has to do with the way we set up the environment. And so I want to be clear that there, even though we have omitted other ways to influence movement, it is in no way a statement of it being lesser importance, it’s equal importance, but we are talking about how do we upgrade our verbal fitness? So what are the resources? First and foremost, what we are talking about in the literature is what is referred to as attentional focus. So this is to help people with their Google Scholar and their PubMed searches. Okay, so what we’re talking about is attentional focus. Those are your key words, and specifically, the difference between internal focus and external focus, thinking about the body that’s internal while you move versus thinking about the environment and the outcome or analogy that’s external. Okay? So those are your words attentional focus, internal focus, extra focus, that’ll get you the evidence from Google Scholar, and PubMed. Now, the the key author, in this space, there’s many, but the key author is Dr. Gabrielle Wolf, she’s at U and o v. And she has written a wonderful book called attention and motor skill learning, it was first published in 2007. Now, my work has since now been, I have done studies myself as well to PhD and since then, but my book is the language of coaching. Now the language of coaching, is it’s not right coaching in this case, is the process of coaching. So it’s equal for a therapist, as it is for a strength coach or sparks for coach. So it’s the verb, right? The act of coaching. And so the language of coaching, my book provides, if you would, the practitioners guide to translating this into practice, written in an accessible narrative format. And so to that end, those that prefer video content I have produced all of my book clubs and videos are all available on the language of coaching, comm completely free. And that you know, if you kind of want to stay in touch with this space, and you know, when I’m thinking about it, my I try to stay fairly active on Twitter, and Instagram, putting out articles and comments at Nick winckelmann. So those those are going to be your core resources. Now, the final thing I would say, is a big part of the there’s a performative aspect of communicating, right, almost like presenting how we say it, body language, tone, these types of things. And so to get better, and what we might call the more interpersonal communication toolbox, I would encourage people to pick up the book, how to be heard by Julian treasure, and watch Julian treasures, Ted Talks. He has a TED talk on speaking, and a TED talk on listening. And that’s treasure like our pirate treasure, Julian treasure. And he is one of the foremost authorities on verbal fitness, communication, and how to speak so that people listen and how to listen. So people want to speak to you. And so those would be the resources, I think that would get people well down the road of upgrading their communication skill set.

Ben James 48:30
Fantastic. That’s awesome. And we’ll make sure that all those links are in the show notes for when this episode is published so that people can find and take advantage of those, Nick, so many questions that I could still ask I’m sure we’ll, we’ll have to arrange another episode because this is such an important area I feel but some fantastic insights there and a great introduction. I think it’s such an important topic. So I really appreciate and value your your input and learn a lot myself today. I really appreciate it.

Nick Winkleman 49:00
Yeah, Ben, I appreciate the opportunity to be on today. Cheers.

Ben James 49:03
Thanks so much, Nick. And we’ll be in touch no doubt and get you back on the show again in the future.

Nick Winkleman 49:08
Looking forward to it.

Transcribed by https://otter.ai