Conversation with Sean Gallagher: Part 2

We are continuing our conversation with Sean Gallagher of Gallagher Performance. I absolutely love his insight on how he works with patients in a rehab setting, using the mindset of strength training, which I found to be very similar to the protocol I use when I write strength training programs.

In his phases of rehab Sean stresses on the importance of proficiency, consistency, and load.

Let’s delve deeper into Sean’s insight:

Sean: What drives most compensation in the body is fatigue strain, load strain, and speed strain. Once I see proficiency and consistency. I will then start to test the waters and see how fatiguing I want it to be. I want the person to manage the fatigue and become aware. 

How are you selecting load?

Sean: We are not going to get great return on investment with a 1 rep max. It’s best to ease in so we use a 3-5 rep max with the quality I want to see. 

If I am on a strength training model, we can do predictive maxes, and I will then piece that into a rehab program. 

For example: If i am doing a shoulder exercise. I find a band tension that seems to work for my patient. And if I see them falter by 6-7 reps — there are a ton of people I work with who don’t have high capacity — Ideally I’d like to work someone up to do 5 sets of 5. They have their resistance (any type of band); I will keep them doing this for 3-4 weeks, then test. Ideally I want 21-28 days of adaptation before I test. 

I use the calculation weight x reps x .033 and add back in the weight that they use to get a rough calculation of their capacity.

You can have your training max, but then you have a competition max. Some people try to train with their competition max, which isn’t great to train with your competition max. You need to think about it this way: are you going to be capable of doing your competition max daily when you are training? We want to be conservatiive in the training and rehab setting.

So the neurological buffer?

Sean: Yes, I take their competition max into consideration in their rehab and give them that buffer. We will go back to proficiency, consistency, and load and walk them through that. 

Gary: That last statement I think is something that I don’t know if a lot of people really practice but still it’s a hard-core kind of like strength mindset applied to your rehab approach. I want to circle back to this at some point. Let me give you a real world example that I dealing with in practice. 

This is maybe an extreme condition but let’s say we decide in a flight attendant, that yes she has a rotator cuff problem. Due to travel and work,  I won’t see her for probably 10 days so. I need to continue to progressively load her in a way that I need her to safely climb the ladder of intensity. So when you’re faced with a similar issue through your concept of defining load. How are you going to try to educate your patient to undulate in a way that fits your pattern?  Do you have any fail safes built in? How do you know that they don’t over train when you’re not under your watch? How do you manage that?

Sean: I think a lot of it has to start by first getting to know the person and helping them understand that necessarily overworking isn’t always going to get them from point A to point B quicker.

With the physiology of the body, we don’t change rapidly, sometimes for the better. You can force adaptation, but I don’t want you to try to fix the shoulder and then create another issue in the long run by forcing it.

I want to learn the person and see what they can do. From there, with the shoulder example, if I have them carrying certain bands; I want them to use their own and learn how to have proficiency over that. Whatever the rep range you do, I want you to have the consistency where you feel like that every rep comes naturally.

I remember a story I heard about someone watching Kobe Bryant practice, and he spent hours working on the absolute basics.  The person watching asked them in kind of a suprised way, “Is that all you do?” Kobe replied something to the effect, “what do you mean is that all, this is where I live and breathe.” So when I write a rehab program for someone I think about that, where do they live and breathe.  What I am going to give someone from a home care perspective is something that their body gets exposed to the most. If I can get them more proficiency in the basics that is great. 

Let’s take your flight attendant example.  If I can teach her a better way to press and get overhead than that is something she can take with her into her approach to work.  So her home care might be something that gives her access to a better shoulder pressing pattern. She might have trouble with exercise that improves tissue capacity outside of the office but will have success building a better motor pattern.

Gary: Let me make sure I understand.  You have selected load on day one, or you have selected a band tension that you are comfortable with?

Sean: Let me say this.  I view every exercise as a test.  I am always looking for threshold and if I can get a band in their hand, great.

Gary: Sure but now you are not going to see this person for the next 10 days and you don’t want them to spend too much time in the middle ground absent of adaptation. So I guess that is what I am getting at.  You want her to progress. You sent her home with something you are comfortable with. Are you educating her into how to progress on her own, or are you the gatekeeper to load progression in this type of a model. 

Sean: Well first off I would try to send her home with whatever we found to be successful in the office.  But then I would try to implement some creative problem solving. Maybe we would use something like side lying or a position she can use for pattern activation.  Maybe it is not to the quality of what we are doing in the office but it still has the impact we are looking for to get some sticking power. The strength training is difficult with the model you are talking about.  When I can see someone 1-2 times a week that is usually fairly sufficient. If I can give them some way to replicate resistance at home and they can get maybe another day or two in. Then that training volume will be typically work for my population.

I would like to get your opinion on an approach I have been using for several years. And what I was trying to bait you into was a concept based on developing mitochondrial density.  I am of the belief, and I may be in a small camp of one here, but that in a rehab setting the oxygenation or acidity of the tissue has a lot to do with driving adaptation.  I have taken the approach to upping the acute rep range to 45.

Gary: I know that is quite a jump from the 25 rep range that you prefer. My reasoning for this is that I appreciate the need for small amounts of lactate build-up.  Just enough to be perceivable in the tissue like “ooh okay its burning”. That now becomes my tissue threshold because I have already done everything from a movement quality standpoint and I am happy with the way they are performing the exercise.  The revelation that pushed me in this direction was advice from Dr. Dale Buchburger in that the best load for the rotator cuff directly is 5 pounds or less. I thought to myself, if I am restricted in the load, I had better add some volume to get the type of change I am looking for.  Since then I have been really upping the rep range in these early rehab phases. As I was reviewing our notes from last conversation you cited a quote with something to the effect that “the internal capacity needs to be enough that the brain trust using them in larger movements.  So I feel like I need to regulate my load based on what prime movers I am looking at to carry out that exercise. If I lose load variation based on the target tissue, then I only have volume variation to increase adaptation.

This leads me to the model I learned going through the McKenzie training.  Dr Mark Miller taught me the rule of 50%. If the volume of exercise is tolerated and the lactate response is dwindling. Increase reps by a factor of 50%. For example if I send a person home with 4 sets of 8 and it is well tolerated then can take 50% of that set volume and Increase it by 4 reps per set.  If that jump doesn’t go well, then they can reduce that increase by the same factor. In this example a 4 rep jump created too much burn to finish all sets, we then reduce the reps by 50% and we go from +4 to +2 reps/set. For me this gives my patients the ability to make decisions without having too much of an emotional decision.  This insulates me from the person who will just do more and more because the goal is 4×15 and if 8 is good 15 is better. Or on the other side the patient that feels pain and wants to quit entirely because the “exercise” is hurting them. This is the way I teach them to progress on their own. I am having them systematically search for tissue threshold based on the lactate response to exercise.  I feel like as practitioner I can’t let my patients or athletes make an emotional decision on exercise volume.

Sean: To your point, I see the benefit to acute threshold of the lactate system.  I don’t want them so flooded with lactate that they shut down metabolically.  Citing some of James Smith’s work: lactate can be detrimental to physiological adaptation that you want to make but also recovery. In my rehab sessions I try to tease out compound vs isolation movements. But then tempo comes into play.  If I am doing a 5×5 but I add some strategically placed pauses or eccentrics I can change that time under tension and get some of that acute lactate response.

Then that in essence increases the total volume of the rehab session in addition to any other exercise that may address the same tissue.  We are monitoring, much like in a performance setting, the total volume of exercise on the system. So that is where for me I expose them to a number of different exercises to get that same volume that you are speaking of but maybe in a different pattern. So I guess in a session we are certainly getting to those upper 40’s and even into the 60’s as far as volume is concerned and is incrementally increasing.  But I love the points you make I just have not been as comfortable with those high rep ranges. Not that I am averse to them, especially if I am trying to build tissue mass like in a post ACL case. I will definitely be looking for that type of tissue response. Most of the time people are coming to me in a really acute phase and I need to slow cook them a bit. Where the situation you are describing I will get to in latera phases. But I love the thoughts.

Gallagher Performance approach: Proficiency, consistency, and load. I want to thank Sean for his time, hospitality, and the insight he shared when working on rehab for his patients.