Now I’m not shy of a bit of controversy on The Sports Physio, I like my blogs to be interesting, informative, and different. So in keeping with tradition my good mate Tom Goom, aka the Running Physio has done a blog on finding that elusive and slippery thing, the G-Spot. So if you like your blogs with more innuendo than a Julian Clarey speech, you’re in luck as this one is rather long, hard, and intense. So without further ado, I will hand over to the smut meister himself to explain more…
What is the G-Spot?
I suppose I should start this blog by clarifying what the G-Spot actually is. I’m afraid it’s going to be a bit of a disappointment to those of you who were googling ‘G-Spot’ and have come across this site (possibly poor choice of words). In sports and rehab terms the G-Spot refers to finding the right level of exercise to achieve your goals. It takes its name from 2 things; Goldilocks theory and Tim Gabbett.
Goldilocks Theory refers to a classic fairy tale where a young blond woman merrily jumps from bed to bed while stealing food and harrassing bears. Somehow she’s seen as the heroine of the piece despite a litany of crimes including breaking and entering, vandalism and cruelty to animals. Within this harrowing tale though Goldilocks does succeed in finding a decent bowl of porridge. Not too hot. Not too cold. Just right. This is, in essence, what we mean by Goldilocks Theory – finding a level of exercise that is not too much (too hot) or too little (too cold) but is just right.
Tim Gabbett’s research has added a great deal to our understanding of finding this optimal level. His recent BJSM paper illustrates the concept perfectly;
Source: Gabbett et al. (2016) open access.
For some reason he calls it the ‘sweet spot’, not sure why that is! With Goldilocks and Tim Gabbett at the fore when developing this concept it seems wholely appropriate that the term ‘G-Spot’ be used to describe it. When you consider Phil Glasgow’s work in Optimal Loading too it seems even more appropriate!
How do you find the G-Spot?
The G-Spot is an elusive, slippery target. I pushed too hard searching for my own G-Spot and ended up with buttock pain! It helps if we know what the G-Spot looks like and how it changes from person to person;
First up…a ‘normal‘ G-Spot
If we hit the G-Spot and exercise at the optimal level we can achieve our goals (increased strength, ROM, power, reduced pain etc etc.). If we load beneath this level we risk ‘underloading’ the tissue. This may just mean we don’t see improvement as quickly but if we reduce load enough it can result in deconditioning and negative consequences (pain, weakness, stiffness, increased fear of movement etc). If we load above the optimal level we risk excess tissue ‘overload’, potentially leading to pain, fatigue and injury. This is of course a big simplification but it can assist in our understanding of load management and how we communicate it to patients.
It helps to consider how a G-Spot might vary;
Irritable pain vs non-irritable pain
In the example above if the patient has very irritable symptoms it will be easy to cause a flare up by loading excessively (in terms of pain). Likewise very low levels of load may result in deconditioning so we end up with a small G-Spot to aim for. In this situation we want to expand the G-Spot by addressing why symptoms are irritable. There can be a number of factors involved, tissue state, central-sensitisation, pyschosocial considerations, acuteness or chronicity of symptoms etc etc. We may want to explore pain education, pacing and analgesic options to make symptoms more manageable and broaden the exercise options for this patient.
It’s worth considering too that most types of exercise have some analgesic effect. Kelly Naugle’s excellent work has highlighted this but also shown that there’s likely to be considerable individual variation in its effects, for example gender and level of catastrophisation has been shown to modify response (Naugle et al. 2014). Careful discussion with the patient can reveal which type and level of exercise they can manage.
The ideal situation is a patient with clear rehab needs and low-irritability where we are more likely to have a wealth of exercise options to choose from.
Novice vs elite athlete
We’re likely to see different G-Spots in elite athletes compared to novices. This might be applicable both in terms of cardiovascular exercise and strength and conditioning (S&C). Take an elite runner, for example, to achieve their performance goals they’re likely to need to maintain a certain level of training. Below this will be ‘underload’ in the sense that their training won’t be enough to achieve their goal. There is a sweet spot to hit here as there is often a thin line between peak load for performance and overload leading to injury. Elite athletes usually ‘periodise’ their training to expose themselves to peak loads at the right time prior to competing and as part of a long term training programme.
By contrast a novice athlete may have a broader G-Spot. A wider, less specific range of exercise type, volume and intensity will stimulate strength or fitness change as illustrated in the General-to-Specific Model (below). However a novice athlete won’t have built the load tolerance an elite athlete may have and, as a result they are vulnerable to overload if training is increased too quickly. This is part of the reason why novice runners, for example, may be more at risk of developing an injury (Buist et al. 2010).
Source: Kraemer and Ratamess (2004)
In a practical sense when designing an S&C or rehab programme for a more novice athlete a general approach may be sufficient but in an elite athlete we are likely to have to search somewhat for their G-Spot. This might mean the tests we commonly do won’t be adequate to demonstrate an ‘impairment’ or rehab target. We might need to find the G-Spot for our assessment strategy too;
Different types of activity
The body responds quite differently to different types of activity and different types of load. When finding the G-Spot we need to consider multiple factors for what is optimal for that particular stage of rehab including load magnitude, frequency and volume, load rate, direction and location of applied load. Type of load; tensile, compressive, shear force etc can also have a big impact.
How does this apply to bone stress or tendon rehab?
I must point out the images above are just ideas really and where the G-Spot would be would vary hugely depending on the patient and stage of rehab. Research suggests bone may respond better to short bouts of dynamic exercise separated by a rest period (Turner and Robling 2005). By contrast long duration exercise can cause muscle fatigue which is thought to increase bone load, if this exercise exposes the bone to a bending force it’s thought to be more likely to lead to bone stress reaction (Warden et al. 2014). Tendon adaptation appears to be more dependent on load magnitude than contraction type (Bohm et al. 2015) and a combination of compressive and tensile load is thought to be more provocative (Docking et al. 2013).
Is there a stress G-Spot?
It looks like it!…
Source: Sapolsky (2015)
Too little stress leads to understimulation, too much leads to distress but the right amount appears to be beneficial.
…and an immune function G-Spot?
Source: Adapted from Neiman et al. (1994)
It’s a similar picture; being sedentary doesn’t appear to benefit immune function but moderate exercise does. Push too hard with high training volume or intensity and the risk of infection increases.
There’s even a G-Spot for drinking beer!..
How do we achieve optimal G-Spot stimulation?
There are 5 key principles:
- Hunt for it.
- Make it bigger.
- Hunt for it again.
- Tell the patient how to find their own G-Spot
- Do not actually describe it to the patient as a G-Spot!!
We aren’t likely to hit the G-Spot straight away, we often need to hunt for it. It’s good to explore. Delve into things. Clinical reasoning is like an onion, it has many layers and sometimes it makes you cry. We might need to hunt by asking the right questions e.g. how far can you run without pain? Does speed change your symptoms? Is it better offroad? We might delve and explore by varying exercise load, reps, sets, frequency, type, range or speed of movement, order of exercise, rehab environment etc etc until we get things right to achieve the patient’s goals.
It helps if we can make the G-Spot bigger. Addressing pain can do this to make symptoms less irritable and give us a broader choice of interventions that won’t lead to flare-up. Good communication and explanation to the patient can help, as well as appropriate pain education. If you’re good at stimulation maybe size doesn’t matter?! The more exercise options you know and understand how to vary to achieve your goals the bigger the G-Spot will appear to you as a clinician.
Just when you think you’ve got your finger on the G-Spot it will move and you’ll loose it. We need to be prepared to keep hunting. I had a nice example of this recently. A young, elite tennis player post patella dislocation. His 10 Rep Max on the leg press more than doubled in a week from 30kg to 80kg! I think he had some quads inhibition due to pain and as this settled his strength tests improved drastically. With this change though we needed to review his rehab again and explore to find the optimal level. Staying at 30kg would be well below his ideal load range.
We need to constantly ask ourselves if we’re at the right level but this can be a challenge on our own. In an ideal situation we can teach the patient how to find their own G-Spot. I think it’s important patients understand not only how to do an exercise but how they can progress or regress it to find their level. Instructions will vary based on rehab objectives but something simple like this can help;
The final point here is it’s probably best to choose your words very carefully with a patient. Don’t say, “Next session we’ll hunting for your G-Spot. We’ll try a number of moves and positions and you might be tired by the end… Then the following week we’ll do it in a group.”
On a serious note, we can actually use this concept as a positive way to explain an injury to a patient. It helps us move away from very mechanical descriptions that can be received quite negatively. Instead we can use the patients own language and keep it simple, for example, “you’ve overdone it a little and your [insert body part] is a bit irritated. We need to calm it down and help you find the right level of exercise then build up from there.”
As this nice tweet from @CombatSportPhys at #IFOMPT2016 this week illustrates we need to make sure the patient knows what the problem is, what they need to do about it and why they need to do it. Understanding that exercise has a positive impact but they need to find the right level is an important part of this.
Closing thoughts… Apologies if this blog has read like a cross between a CPD session and a Carry On film! There was a reason for the smattering of smuttery! We’re introduced to so many ideas and concepts it’s hard to remember them all but if you add a little innuendo it tends to stick in your mind! At least it’s not half as filthy as the rhymes people use to remember cranial nerves!
What I’m hoping people will take away is that we need to explore and experiment to find the right rehab for each patient. In doing this we should consider what the patient enjoys, what resources they have available (both time and physical resources) and their pain. We should factor in how different tissues respond to load and consider time frames and appropriate progressions.
…and remember, that G-Spot won’t find itself?!
Tom is doing his Running Repairs courses up and down the country and his schedule can be found here
And he has an up coming course in London here