Mastering regressions and progressions of the Nordic Hamstring Curl with Adam Johnson

In this episode with Adam Johnson, we discuss his Research Review of a recent article looking at 20 variations (regressions and progressions) of the Nordic Hamstring Exercise. We discuss the implications of an individual dropping into a hip flexion pattern, the last 30 degrees of range of the exercise, and the perceived and actual intensity of the exercise the patient is performing.

See Adam’s full Research Review here - https://physio.network/reviews-johnson

Adam has worked in full time football for over eleven seasons now at Reading FC, Millwall FC, Brighton & Hove Albion FC and Stoke City FC in both academy and first team environments. He is currently working as First Team Physiotherapist at Everton FC which involves providing injury rehabilitation support to the first team players at the club.

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @James_Armstrong_Physio from Physio Network

👏 Become a better physiotherapist with online education from world-leading experts:

https://www.physio-network.com/

Transcript

SPEAKER_01 0:00

In the standard Nordic, the peak contraction time is at 26 degrees of knee flexion, so just about sitting in that final 30. Whereas when you take them into a 90 degree hip flex position, the peak bicep femoris long head activity kicks in at 50 degrees. So they're only just over halfway down through that Nordic when they get in the peak activity.

SPEAKER_02 0:32

Do you use the Nordic Camstring exercise in your practice? Are your patients really achieving what you think they are from this exercise? Or are you not using this exercise perhaps due to its intensity and difficulty for some of your patients? Well in this episode we look at all of this as we discuss the Nordic Camstring exercise with Adam Johnson and the recent paper he reviewed for the Physio Network Research Reviews. Adam is currently working as first team physiotherapist at Everton FC and has worked as a physiotherapist in full-time football for over 11 seasons. Adam has a special interest in injury prevention strategies and more specifically hamstring injury prevention. To learn more about the research reviews and how they can make keeping up to date with the research so much easier, do click the link in the show notes. This is a really insightful episode that gives some directly applicable tips that you'll be eager to apply in your practice after listening. Perhaps you'll be looking at the Nordic exercise in a new light after this. I'm James Armstrong and this is Physio explained. Adam, it's great to have you on the podcast. We've obviously had you doing some research reviews for us on Physio Network, so welcome to the podcast.

SPEAKER_01 1:46

Yeah, thanks very much for having me. Yeah, it's a paper I'm really looking forward to chatting through with you and I think hopefully we'll get some value out of it and yeah, a really good chat.

SPEAKER_02 1:55

Brilliant. Yeah. So today we're going to be chatting about the interesting paper that you did a research review for us on, which was the modulating the Nordic hamstring exercise from zero to hero, which is a stepwise progression exploring the high performance athlete. Really interesting paper. Fantastic review. Going to throw it straight over to you, Adam, just to give us a brief overview for those who haven't seen the review. What's the paper we're chatting about today?

SPEAKER_01 2:21

Yes, this paper was one from the lead author, Tobias Ault, who has done some previous work in this area around kind of assisted Nordic, which is one that I found really useful in the past. And what they looked to do was basically look at 20 different variations of the Nordic hamstring exercise with one athlete who's a long jumper well kind of accustomed to the Nordic hamstring exercise and they took him through all these different kind of progressions and regressions and looked at the kinematics and the kinetics and the EMG analysis of that to try and see how to make, as the title says, that stepwise model of getting your athletes through the Nordic hamstring exercise and what influence these different progressions and regressions have upon performance really. Brilliant.

SPEAKER_02 3:10

It's a really, really interesting study. It obviously has its limitations, as you rightly highlighted in your review in terms of it is just one athlete. But I think it's really interesting to kickstart this conversation around the Nordics and how we can adapt that Nordic exercise to an appropriate level for our patients and athletes. But I think we're going to kickstart this today with what's the key importance to look for when you're prescribing the Nordic hamstring exercise? What are we looking for?

SPEAKER_01 3:39

Yeah, so I think it's a really good question. There's been some previous work done recently by people like Matt Bourne and people in that area looking at intensity versus repetitions. And I think that's probably where this paper comes in really nicely of having an understanding about the intensity of the exercise that you're prescribing, what you think you're prescribing or what you think your athlete is doing is actually what you are getting back from them. And the kind of EMG analysis on this hopefully gives a nice indicator about what you might think are quite small changes in technique, actually having quite a large influence upon performance and potentially the outcomes that you're getting within

SPEAKER_02 4:26

that. Yeah, so that coaching aspect this exercise actually becomes quite an important part of it. So should we dive straight into hip flexion, Adam? Should we talk about the influence of hip flexion in this exercise with our athletes?

SPEAKER_01 4:39

Yeah, so hopefully your listeners will probably recognise this pattern of performance when people are maybe performing the Nordic for the first time or when they're under fatigue or anything like that, when they're not familiar with the exercise. They'll generally drop into a hip flexion pattern as they lower down. And this is an area that's really well reported within this paper, where the author suggests that they're shifting essentially their center of mass closer to the knee joint and therefore making the exercise easier. And that's reflected within the findings within this individual paper. Because compared to a standard Nordic, as they call it, where they're in a zero degrees of hip flexion, it's a purely knee dominant exercise. They'd report peak biceps, femurs, long heads, EMG activities being about 107% of their maximal voluntary contraction. Whereas when someone sits into that hip flexion position at 90 degrees they see that the peak bicep femoris long heads contraction as being at 25 percent of their maximal voluntary contraction so in terms of that emg activity it's less than a quarter of what you'd expect from a standard nordic and also something that tobias out talks about in a A criticism of the Nordic as well within the research and the literature is that people can't perform it into those kind of last 30 degrees of range. And ultimately, that's probably where a lot of the injuries occur at those longer lengths. And again, that's reflected within the findings of this paper where in the standard Nordic, the peak contraction time is at 26 degrees of knee flexion. So just about sitting in that final 30 degrees. Whereas when you take them into a 90 degree hip flex position, the peak bicep femoris long head activity kicks in at 50 degrees. So they're only just over halfway down through that Nordic when they get in the peak activity and it's that bell shaped curve. So by the time they get towards that bottom 30 degrees when we really want them to be working, we're showing that that isn't the case. And again, so a lot of the things that we're wanting and the desirable characteristics and outcomes of this exercise are really being taken away by going into a hip flexion position. So I think that's a massive take home for me in terms of when I'm seeing these athletes performing it, like say if they've never done it before or if they're under fatigue, then actually just drop into hip flexion. And this is a real moment for me thinking about this, thinking, okay, yes, I might still be getting them to do it. And I think, okay, that's great. I've got my athletes to do my two sets of four Nordics as Matt Bourne talks about, and that's going to be sufficient. But actually the intensity that doing it at is way below what maybe I thought they were doing it. I definitely wouldn't think it'd be a quarter, a standard Nordic.

SPEAKER_00 7:51

Are you struggling to keep up to date with new research? Let our research reviews do the hard work for you. Our team of experts summarise the latest and most clinically relevant research for instant application in the clinic, so you can save time and effort keeping up to date. Click the link in the show notes to try PhysioNetwork's research reviews for free today.

SPEAKER_02 8:15

dropping maximal voluntary contraction, isn't it? When you're looking at that, what we might normally see is, yeah, it's not perfect, but does it matter? Well, actually, yes, it really does. If you're looking for that level of contraction, as you say, has been reported previously to have the effects that we want, it's possibly not if we're doing that. How can we maybe use that, though, in other populations and other patient groups that maybe we find struggle with the Nordics as a progression?

SPEAKER_01 8:41

Yeah, so I think this is, again, where the paper's really useful, A, because they've come up with 20 variations, which is quite impressive. But what it does is just makes us think about, okay, what do I want from this exercise? Do I just want a small bit of load if I'm going through a rehabilitation process and I'm early on? Do I need them to perform a standard Nordic that early on within their early eccentric loading phase? No, potentially not. That might be something for me as a clearance criteria, something like that. Can they perform this standard hit neutral Nordic? And therefore, I'm comfortable with them starting at 90. I'm aware of what that is going to give me. What I might want early in those rehabs is for it to be 25% of their maximal voluntary contraction because I feel comfortable with that. They'll feel comfortable with it. But then as we go through it, we gradually change. look to change that hip flexion position, and it gives us something to work towards. So we might still prescribe the same sets and reps, and that's, again, something they talk about in the paper is not going chasing repetitions just because we're not getting maybe the intensity that we want, but building up to the correct intensity rather than just trying to offset that with big volumes of sets and reps, which, again, historically... when the Nordic was probably first being researched, was where it was going and was, again, a criticism of it because it gave really bad doms and therefore people lost buy-in and people don't go into the programme. So it's about trying to figure out, as the paper is, how to get there and not just saying, oh, that's unacceptable, thinking, okay, when is that acceptable for me? Is that acceptable? Again, under fatigue, we might be like, okay, this is under fatigue. I'm not going to get intensity I want, but I'm comfortable with this level of intensity because they're doing it under fatigue. And for me, we might think, oh, that'll offset doing it fresh at higher

SPEAKER_02 10:47

intensity. Excellent. Yeah, definitely. What patient populations do you think this is doing the standard Nordic? At what level do you think that's really important? And in terms of injury prevention or injury reduction?

SPEAKER_01 10:59

Yeah. So again, I think that's potentially where the limitations of this paper really come in, because the athlete that performed this was very familiar with it. They'd been performing the exercise for a number of years. So maybe that's why the performance of the standard Nordic for them shows such good technique in terms of being able to get their peak contraction within that last 30 degrees. So I think maybe this does help with this thinking, okay, in a population where people are used to it, we know that this will be there or thereabouts what they're going to get. And we can transfer that into our cohorts and think about those people that are used to it, just giving us an understanding of exactly what they are getting. And I think that's where it is really, really useful for the standard Nordic. We know what intensity we're getting. And again, this goes some way to not completely allay the fears because ultimately it's a case study. But again, thinking back to some of the criticisms where it says it's... medial hamstring dominant exercise and some of the counter arguments against that where it is but it's still the highest volume kind of intensity exercise for the lateral hamstrings at the same time even though it's preferentially recruiting medially this paper actually says within this athlete by a couple of percent it does actually preferentially recruit lateral hamstring so i think that's really really interesting maybe when you get into a point where you're coaching And maybe someone's gone through these progressions. You've taught good technique, good familiarization. We can see actually maybe it's closer to giving us what we want and what we would like, encountering some of the criticisms versus just going in and expecting everyone to be able to do it. And that lack of technique or lack of coaching means that then they aren't getting what we want. It

SPEAKER_02 12:52

really is really directly applicable to practice, isn't it, this? Although it's a case study whereby you've got one athlete, it is something that's really useful. And I think listeners will be able to take away from this a massive amount and be able to put this into practice with their patients. Would you say that still being able to use that 90 degree of hip flexion with a lower level patient is useful? Or would you say that if you're going to that low level of the Nordic, is there another exercise that you think actually for your hamstrings, if you're going to go to 90 degrees hip flexion, you're probably better off going with something else.

SPEAKER_01 13:23

Yeah, I think that's definitely, again, thinks about what you're trying to achieve. So if you were, say, in a pre-season phase or something like that, and you've got a group of athletes that weren't familiar with it, I think, again, for me, a lot of the thing around the Nordic is the negative connotations around DOMS and that affecting subsequent performance. So, yeah, when this would come in is as a really nice build up to get there. If you're with an athlete who is at the end stage of their rehab and still can't perform this Nordic for whatever reason, then yeah, I think definitely that's where we look to bring in all those different things. Some of the work of Matt Taverner around like the sliding bridge curl to get another version of a knee dominant eccentric hamstring exercise. Um, Again, some of the original Askling work, looking at real basic eccentric loading and then all the progressions that come from that. And ultimately, that's the exciting bit about physio, isn't it? Having that scope and freedom to go. But I think definitely where this does come in is maybe, yeah, in that group setting where you're trying to build up to something as a prevention or as a maintenance, but utilising this alongside other things as Because if you're only at this intensity, are they going to develop where we want? So this is complementary to other bits as opposed to being the mainstay and the only thing. And I think that's, again, for me, maybe where the Nordic gets some bad press because people see the literature and it's so well reviewed and researched and think, oh, they're just telling me this is the one exercise I've got to do and that I've sought everything. And I think That isn't the case. What it is, is just a very well-researched exercise that we think gives us some desirable outcomes, but alongside all those other risk factors and everything else is never going to solve everything. And I think, again, within professional elite football, Ekstrand's paper that's come out in the last couple of months bears that out. It's the hamstring injury is the biggest injury, most common injury that we're all seeing. So obviously this isn't the thing. And maybe that is a problem if people have gone down the route of thinking this Nordic will sort everything. We've forgotten about those other things. I don't know. But yeah, definitely this is part of the picture and how we use that is the skill. And this model hopefully helps with that and helps with our clinical reasoning, our thinking. But it's not there, shouldn't be the one thing that solves everything.

SPEAKER_02 16:09

Yeah. And as you so rightly said, that there isn't a silver bullet in physiotherapy, in rehab, in strength and conditioning. It isn't just one thing. And as you've said, this is all part of a wider package of rehabilitation or strength and conditioning that just, as you say, is well evidenced and can work. But what you've highlighted brilliantly today, Adam, is the importance of how we recognise how a patient's completing the exercise. And so we're aware of the limitations if they're not doing it to a certain standard that we might not be achieving what we thought we might once have been achieving, if that makes sense. And also, I think hopefully sort of alleviated some fears that some clinicians may have about using the Nordics, which is going to be really, really useful. So Adam, I can't thank you enough for your time today and also the fantastic review that you did on this paper for Physio Network, which is brilliant. So thank you so much, Adam, for your time today. So for the listeners, if you're interested in reading this research review, which I no doubt you absolutely are, we have put a link in the show notes for you to try the Physio Network research reviews for a free trial. So do head down into that link. And so you can read this review by Adam and get your teeth into modulating the Nordic hamstring exercise in your practice. Adam, thank you so much again. And I'm sure, absolutely sure we're going to get you back on the podcast in no time at all to talk more about hamstrings and other rehabilitation and around sport.

SPEAKER_01 17:34

Yeah, brilliant. Thanks very much for having me on. Really enjoyed it. And like I say, hopefully people enjoy clicking on the link and seeing that research review for free, which is fantastic.

SPEAKER_02 17:44

Brilliant.

SPEAKER_01 17:44

Thanks

SPEAKER_02 17:45

so much Adam. Take care.