Embracing Complexity: The Mountain Stream Metaphor

• "For every complex problem there is an answer that is clear, simple, and wrong" -H.L. Menken

Keeping “it” simple is important at times.  It prevents us from becoming overwhelmed, clarifies concepts, aids in general understanding, and directs the focus towards a single goal.  Most importantly, keeping it simple is necessary when communicating new topics or concepts to others.  However, the problem occurs when keeping it simple is used a substitute for understanding the complexity.When we oversimplify complexity it increases the chances of a blunder occurring.  Assumptions, cognitive biases, and ignorance all become more prevalent when we start to overlook the dynamic and intricate patterns of problems, situations, and systems.  This can be seen in everything from politics to healthcare.  Even everyday discussions are often plagued with people over simplifying a topic to support their perspective (whether they know it or not).Thus, to avoid these cognitive traps and mental errors it is important to embrace complexity and attempt to identify and study it, not to ignore or eliminate it.One way to understand complexity is through the Dynamic Systems Theory.  More specifically, I have found the following metaphor from Esther Thelen to be an interesting  thought experiment.  She invites you to become aware of the ever-changing complexity of something as “simple” as a mountain stream.

The Mountain Stream Metaphor

“The metaphor is of a fast-moving mountain stream. At some places, the water flows smoothly in small ripples. Nearby may be a small whirlpool or a large turbulent eddy. Still other places may show waves or spray. These patterns persist hour after hour and even day after day, but after a storm or a long dry spell, new patterns may appear. Where do they come from? Why do they persist and why do they change?No one would assign any geological plan or grand hydraulic design to the patterns in a mountain stream. Rather, the regularities patently emerge from multiple factors: The rate of flow of the water downstream, the configuration of the stream bed, the current weather conditions that determine evaporation rate and rainfall, and the important quality of water molecules under particular constraints to self-organize into different patterns of flow. But what we see in the here-and-now is just part of the picture. The particular patterns evident are also produced by unseen constraints, acting over many different scales of time. The geological history of the mountains determined the incline of the stream bed and the erosion of the rocks. The long-range climate of the region led to particular vegetation on the mountain and the consequent patterns of water absorption and runoff. The climate during the past year or two affected the snow on the mountain and the rate of melting. The configuration of the mountain just upstream influenced the flow rate downstream. And so on. Moreover, we can see the relative importance of these constraints in maintaining a stable pattern. If a small rock falls into a pool, nothing may change. As falling rocks get larger and larger, at some point, the stream may split into two, or create a new, faster channel. What endures and what changes?”

A Movement Assessment Example

Let’s take the example of someone who can’t touch their toes.It may be useful to give this person a specific, simple exercise (ex. KB ASLR) and education (ex. thought viruses) to help cause an immediate shift in their movement pattern - kind of like a rain storm quickly altering the way the stream runs.  The benefit of this approach is that it offers control and predictability, which are two main factors when working with stressed and painful systems.  However, as many of us have experienced in the clinic, these quick changes are usually temporary and are neither complete nor permanent fixes in themselves.  The rain storm passes and the stream returns to it’s former pattern.  To truly affect the path of the stream it’s important to direct some attention to the entire mountain system.In the example of someone who can’t touch her  toes it is important to acknowledge the mountainous (sorry, couldn’t resist) complexity of “why”... Maybe she can’t touch her toes because she has a stiffer body that lays down more collagen - her parents can’t touch her toes and their parents’ parents couldn’t touch their toes (epigenetics?).  Maybe her allostatic load is too high because she’s overstressed from her job or relationships.  Maybe she’s not motivated.  Maybe she has a psychological issue - depression, anxiety, history of trauma, etc.  Maybe it’s behavioral.  Maybe she grew up in a very sedentary lifestyle and prefered to read or play video games for the first 26 years of her life.  Maybe she was taught to lift weights or perform athletic techniques improperly and hammered those patterns into her body over many years.  Maybe she believes that rounding her back or lengthening her hamstring is dangerous.  Maybe she has a cold (neuro-immune connection).  Maybe her microbiome is a mess.  Maybe she doesn’t sleep well and has a circadian mismatch.  Maybe it’s her vestibular system, stomatognathic system, or vision.  Maybe it’s neurodynamics.  Maybe it’s her respiration.  Maybe it’s an osseous abnormality.  Maybe she can’t IR her femur because of her pelvis position.  Maybe a joint is tight in her cervical spine that decentrates the rest of the body.  Maybe it’s a forefoot varus.  Maybe it’s her posterior hip capsule.  Maybe her paraspinals are unable to eccentrically control the movement.  Maybe it’s her core. Or maybe it’s one of the other many things that could prevent any human from touching their toes.It’s important to acknowledge the intricate, evolving interaction of these variables, which then becomes another variable in and of itself.  It’s the perspective of “the whole is greater than the sum of its parts”. Once all this is considered it will be easier to determine which variables can act as a control parameter to cause the desired phase shift of the system. In other words, maybe for the aforementioned patient a neurodynamic exercise would provide an adequate stimulus to shift her system into a place where she can perform a full, pain free toe touch.  Or maybe it will require a combination of stimuli such as a core strengthening program, improved sleep hygiene, and graded exposure.  Or maybe...The success does not lie in the intervention, but how the system responds as a whole.This complexity is why one exercise, manual technique, or communication style will work well with one patient, but have no effect on another “similar” patient.  Or why someone may not do well with physical therapy, but feels better after going to a dietician or getting a new job.Some people may be able to alter their stream easily with a simple passing weather pattern, while others will need a long-term tectonic shift.  The art is finding where the change needs to come from.Simple will work at times, but it is not a solution for all.  The human species is far too complex to be simple.

Bottom Line

It’s great to keep it simple on some levels.  But don’t make the blunder of convincing yourself that it is simple.  Instead, embrace the complexity.  How do you do this?Dig deeper.  Try to gain a better understanding.   Always look to learn more.   Learn to enjoy the state of not knowing - curiosity.  Find the quality.  Never be satisfied.  Always ask why.  Then ask why several more times.  And dedicate yourself to the lifelong effort of finding the elusive truth.Again, to reiterate, this isn't to say simple is bad. It's just that oftentimes I find the beauty of simplicity comes from understanding its complexity.

• “A philosopher is a person who knows less and less about more and more, until he knows nothing about everything.” -John Ziman

Thelen, E. and Smith, L. B. 2007. Dynamic Systems Theories. Handbook of Child Psychology. I:6.-- The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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Coaching & Cueing (Part 5 - Visual Cues)

Since our species is vision dependent ( >50% of cortex dedicated to processing visual information), visual cues can be an easy way to invoke a sensory change that alters movement patterns.  This includes not only the sensory input from our external environment, but also our unique ability to create an internal vision (motor imagery).

Visual Cueing

External Visual Cue

An external visual cue is simply a change in the environment that the person can see.  The lines on a road are a simple example of this.  The visual input of the lines creates  “barriers” that we have to keep our car between.  It creates an external reference point in the environment to assist with choosing the correct motor output (driving in a straight line).Of course, these visual cues must be used in conjunction with an external verbal cue.  Driving would be pretty dangerous if people didn’t understand that external verbal cue of “stay between the lines when driving”.Specifically with movement training, this type of visual cue can quickly change a movement pattern faster and more efficiently than most other types of cuing.There are two main ways to visually change external environments.  

1. Create a Barrier
2. Create a Target

In the deadlift example I often will place a rolling stool in front of the patients knees, give them the simple external cue of “don’t touch the stool”, and watch them hip hinge cleanly.But you can just as easily perform the same movement with a target cue.  Stand up a foam roller behind them and have them try to hit their butt with it (see picture below).  Butt target practice for proper hinging.  Avoiding or reaching for an object usually creates a better movement pattern than an internal cue of “flexing your arm outward” or “push your knee out” (examples: shoulder - knee).  It avoids clogging up the processing system and allows the brain to figure out the most efficient way to accomplish the task.  It prevents the biggest mistake - the user error.

Can't get your hip patients to stop passively leaning into their labrum and hinging at their backs? Try the visual external cue of a half foam roller. #coach #Cueing #hip #constrainedactionhypothesis #movebetter

A video posted by Aaron Swanson (@aswansonpt) on Sep 1, 2015 at 6:00pm PDT

The examples could go on forever.  Since the visual environment is an open system, there is an infinite amount of ways to alter the environment to change movement patterns.  Creativity is the only limiting factor here.

Internal Visual Cue - Motor Imagery

Motor imagery can be defined as:

• “an active cognitive process during which the representation of a specific action is internally reproduced in working memory without any overt motor output ”-Decety & Grezes, 1999

In other words, it’s giving yourself an internal cue without performing the movement.  The simple act of thinking about internal movement activates some of the same neurons that would fire if you actually physically performed the movement.It stimulates the “top-down” part of movement.  And we know that the cortex is an important variable when it comes to strength.  So think of motor imagery as reps for your brain.This may be the most underutilized coaching and cues in the movement field.  Reading some of the research on this makes me wonder why this isn’t a common thing.  We are missing out on a ton of potential benefits.There’s a decent amount of research out on this, however, most of it has been through the lens of neurological rehab or disuse from immobilization.  But why not use this to help everyone move better? The basic study is this:

• They put two groups in restrictive wrist-hand casts to induce atrophy.  One group performed only motor imagery of the involved immobilised muscles.  The other group did nothing.  The outcomes: the motor imagery group had 50% less strength loss.  They essentially strengthened the muscle without using the muscle.

 Strengthening the body without using the body?  Pretty profound stuff.

Vision

Changing someone’s vision can have profound changed on movement.  As a species we are very dependent on our vision and our culture increases this dependency everyday.  The easiest way to affect vision is to have the patient close their eyes or to alter fixation, which will have a significant effect on their sensory information.  Another way is to cue directional eye movements to change muscle activation and/or challenge stability.  The latest vision sensory change trend seems to be with external devices.  This can be as expensive as strobe glasses or as cheap as smearing vaseline on swimming goggles.However, vision can get much more complicated.  Working with a dysfunctional visual system can give poor information to the system and influence movement negatively.  This is where optometry can have a huge effect on the way people move.  This is it’s own deep rabbit hole to jump down.  The people at PRI have done a tremendous job at bringing this to light and are a great resource for more information.

Summary

Vision may be the easiest way to change sensory information to augment movement.  It can be as easy providing a mirror or as complicated as detailed motor imagery.  Which one you choose depends on you and your client’s goals and your patient population.

References in Previous Articles

Coaching & Cueing

Part I – IntroPart II – The CategoriesPart III – Verbal Cues – ExternalPart IV – Verbal Cues – InternalPart V – VisualPart VI – ProprioceptivePart VI – Summary[subscribe2]   --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

Problem & Solution

Our brain is quite complicated.  It is constantly going through extremely complex processing to achieve many different outputs (movement, speech, vision, thoughts, emotion, pain, allostasis, etc.).STRESS is one of the most influential factors on our brain's ability to process efficiently.  And in today's society everyone has had it, many people live in it, and some people can never escape it.Stress an epidemic and it will likely get worse with time.

• “Stress-related ailments cost the United States an estimated $300 billion per year in medical bills and lost productivity, and our usage of sedative drugs has shot off the charts: between 1997 and 2004, Americans more than doubled their yearly spending on antianxiety medications like Xanax and Valium, from $900 million to $2.1 billion. And as the psychologist and anxiety specialist Robert Leahy has pointed out, the seeds of modern worry get planted early. “The average high school kid today has the same level of anxiety as the average psychiatric patient in the early 1950s,” he writes. Security and modernity haven’t brought us calm; they’ve somehow put us out of touch with how to handle our fears” | Excerpt From: Clark, Taylor. “Nerve.”

Fortunately, this situation can be improved with mindfulness.But first, it is important to understand why stress is a problem for the brain.

The Problem = Stress

Arnsten, Amy F. T. "Stress Signalling Pathways That Impair Prefrontal Cortex Structure and Function." Nature Reviews Neuroscience Nat Rev Neurosci 10.6 (2009): 410-22

• “Stress impairs higher-order PFC (Prefrontal Cortex) abilities such as working memory and attention regulation.  Thus, attention regulation switches from thoughtful ‘top-down’ control by the PFC that is based on what is most relevant to the task at hand to ‘bottom-up’ control by the sensory cortices, whereby the salience of the stimulus (for example, whether it is brightly coloured, loud or moving) captures our attention.”

Stress clogs up the brain's processing ability.  It creates excessive noise (e.g. increased alpha power) and disrupts the system's ability to process normal sensory information (among other things). 

The Solution = Mindfulness

Kerr, Catherine E., Matthew D. Sacchet, Sara W. Lazaret al. "Mindfulness Starts with the Body: Somatosensory Attention and Top-down Modulation of Cortical Alpha Rhythms in Mindfulness Meditation." Front. Hum. Neurosci. Frontiers in Human Neuroscience 7 (2013)

• “Higher-order cognitive processes including selective attention and working memory are enabled by the basic ability to filter irrelevant sensory information while focusing on relevant information”
• “Localized attention to body sensations enables subsequent gains in emotional and cognitive regulation by enhancing sensory information processing in the brain”

Mindfulness practice of specific internal sensations (e.g. body scan) helps to modulate the noise in the system (improved alpha power regulation) and promotes improved sensory information processing. 

An Analogy - Your Brain as a Concert

Let's consider the brain as the concert venue and the people as the different parts of the brain.When you have stress the concert venue (brain) becomes a loud rock show in a small club.  You can't really hear anything else that's going on (increased alpha power).  You can't communicate with anyone without shouting (why you only feel pain and discomfort when you're stressed).  You can barely move.  People keep bumping through because they "know someone up front" (poor attention).  That guy that's crowd surfing kicks you in the head.  Someone spills their drink down your back.  You can't see the stage because some idiot in front of you is trying to film it with his iPhone.  And it's just a matter of time before someone starts to yell out something no one wants to hear - "freebird!".Needless to say, this is not the best environment for communicating and organizing plans.In contrast, when you focus on the present sensations within your body the concert venue (brain) becomes a calm symphony concert at an outdoor amphitheater.  Everyone has space.  It's not too loud, you can have a conversation with the person next to you (decreased alpha power).  You can easily walk over to the other side of the venue (attention regulation).  You can not only the stage, but the rest of the venue as well.  And no one is shouting anything you don't want to hear.Don't get me wrong, I love going to rock shows just as much as anyone else.It's important to make sure the noise comes from the Marshall Stacks and not from inside your head.

Conclusion

Unfortunately telling people to quit their jobs, stop paying their mortgage, and hire a nanny are not realistic.  Some people will not be able to modify their lifestyle and will continue to have high stress levels.So what do you do about this?The same thing you would do for someone that has a structural dysfunction that you can't change.  You give them an exercise to help strengthen the system and improve resilience.For these overly stressed individuals this can be anything from a simple body scan meditation to an hour long Qi-Gong class.  It doesn't have to turn them into a vegan hippie, it just has to bring their attention focus to their body.  It has to bring them back to their internal sensations.

• “If you are depressed you are living in the past.  If you are anxious you are living in the future.  If you are at peace you are living in the present.” ― Lao Tzu

There is nothing more present than your own body and breath, right now.

[subscribe2]*There are many apps, websites, and albums with mindfulness practice.  I've put together a playlist of some of the free body scan meditations below.  Feel free to leave your favorite meditation app or track in the comments.

Coaching & Cueing (Part 4 - Internal Verbal Cues)

Unfortunately, the rise in popularity of external cueing has led to a bad stigma of internal cueing.  After reading the last article in this series you may be thinking why would you ever internally cue someone?Here’s why:

Benefits of Internal Cues

• Improved Mapping / Body Awareness
• Creates Reference Points
• Teaching Technique/Form
• Muscle Activation - Increased EMG
• Alter Synergistic Muscle Activation
• Mindfulness

3 Topics in This Article

1. Why internal cueing is important
2. The concepts/science behind internal cueing and body awareness
3. Elaboration of the benefits

Disclaimer

Unfortunately, the concepts behind internal cueing aren’t quite as simple as those of external cueing.  Many of these concepts (attention, perception, neuroplasticity, mindfulness, interoception, neuroscience, embodiment, etc.) could each be an article series on their own.  I’ll try to summarize them within the context of internal verbal cueing for movement, but it may be worthwhile to dig deeper in order to better understand these concepts.

Why Internal Cueing is Important

It’s Not Always About Motor Learning or Performance

One of the major concepts that is often overlooked is the fact that most of the research and arguments for external cueing has been done through the lens of motor learning and performance.  But what about all the other variables that we work on with our patients?If you remember from Part I, not everyone is trying to PR their deadlift or improve their free throw percentage.  And not everyone has a history of athletic movement and weight lifting.  There are beginners out there that have no idea what their body is doing when they try to accomplish a physical task.  There are people who haven’t tried a new movement in decades.  There are people who only think externally all day.  There are people who have simply lost their body awareness.So why would you use the same cue for someone who is trying to max out their deadlift that you would for someone who can’t even intrinsically feel their pelvis position on the table?

Why is Body Awareness Important

To reiterate, with internal cueing we’re not talking about performance or even motor learning.  We’re talking about body awareness and control.  You can only control what you can feel.  And if you can’t intrinsically feel a part of your body, that’s a problem.If this were any other sensory input this wouldn’t even be a question.Imagine you are a piano teacher.  You are teaching your student the notes of the C scale. If you started playing the notes on a piano one by one, and your student couldn’t hear anything when you hit the E note, you would consider that a big problem.  If you went to a museum and could see everything but the color orange, you would consider it a big problem.  If you went out to a restaurant...you get the point.  So why do we give our bodies a free pass and just move on despite the fact that we may be missing an essential sensory component?For some patients, intrinsic cueing is a prerequisite for more complex motor tasks and external cueing.  It’s like understanding the notes on the piano before you try to learn classical music.

Semantics - Body Awareness

In the spirit of simplification, I am going to use the term body awareness to express the concept of feeling your body and the associated internal forces.  It’s your brain’s ability to “feel” the internal sensory input.However, it is important to keep in mind that just because we are simplifying this concept for the sake of the topic, it does not mean it is a simple concept.

• “Body awareness is hypothesized as the product of an interactive and dynamic, emergent process that a) reflects complex afferent, efferent, forward and back-projecting neural activities, b) includes cognitive appraisal and unconscious gating, and c) is shaped by the person's attitudes, beliefs, experience and learning in a social and cultural context.”-Wolf Mehling

Since most people don’t even see the top of the internal cueing iceberg, arguing about what’s at the bottom is beyond the scope of this article.

Body Awareness Concepts

Attention for Wiring

• “Remember that it's an attention economy in the brain: where we put our focus determines the wiring that we create.” — David Rock

There is an overwhelming amount of input that is flooding the brain at every moment (visual, auditory, internal processing, viscera, proprioceptive, smell, mechanoreceptors, thoughts, beliefs, etc.).  To avoid going into a seizure, we filter much of this information in order to achieve our “normal” state of being.  One of the things we use to modulate this information is our attention focus.Body awareness is essentially the attention focus of internal sensory information.  This attention focus allows us to “feel” our bodies.Right now there is a plethora of internal sensory information that is ignored so that you can use your attention to read this article.  But if you bring your focus towards feeling your hands you will all of a sudden become “aware” of them. Your hands have not changed, but your attention focus has, which has subsequently changed your brain.This isn’t just a fleeting perceptual change.  It’s a change in the neural connections of your brain.Just like muscles, each time you activate a neural wiring it demands blood flow and nutrients.  This promotes growth and adaptation.  So activating specific neural connections through internal sensory attention focus will “strengthen” one’s body awareness.  It will build the central synaptic body awareness.But it’s not just the “strength” of these neural connections that matters.  The more important part is what these connections represent.

Homunculizing

By paying attention to internal sensory information, your brain can map a better homunculus.  This improved representation gives the brain a better reference point from which it can select the optimal motor strategy for a task.This concept has been discussed over the years as Cortical Smudging.Without an attention focus of a bottom-up feedback, a  pre-selected top-down pattern could be negatively affected.  When top-down references are “off” it causes dysfunctional bottom-up feedback.  When this happens we usually see pain and poor movement.An example of this concept is learning braille.  If you just run your fingers over the bumps without paying attention to what you’re feeling, you’ll never learn.  You need the internal cue to “feel” the bottom-up sensory information so that your brain can start to map out the necessary reference points.  An external cue of push into the paper would not help you read braille.

• “Directing attention to sensory stimulation can increase perceptual sensitivity and modulate neuronal activity” -Heidi Johansen-Berg

Mindfulness

Essentially, internal cues help to improve body awareness through mindfulness.  Research shows mindfulness is  successful for treating various dysfunctions, including stress related responses (anxiety, depression, chronic pain, etc.).We know that stress increases the “noise” in the brain and makes it more difficult to hear other stimuli (i.e. your body).  We see this in the clinic when our patients are struggling to perform a simple exercise despite all the external cues.So how do you quiet the “noise” so that the patient can somatically listen to themselves?Research has shown that paying attention to internal body sensations can help to modulate the alpha rhythms of the brain can quiet the “noise”, thus making it easier to feel internal sensations.Practicing mindfulness with internal cues is like taking them from a rock concert in a small club to an outdoor symphony.

Benefits of Internal Cueing

Internal Cues Provide the Map

One of the factors that influences how we move now is our history (immediately and long term).  And this is where internal cueing can be useful.Take the deadlift for an example.  If someone has had back pain, sits for the majority of their day, hasn’t paid attention or felt their glutes in years, and barely works out, then they will not have their hips mapped out very well in their brains.  They won’t have the body awareness to know the difference between their hips moving and their lumbar spine moving.  Often in the clinic you see these people perform a bridge with an excessive amount of lumbar extension tone.  You ask them where they feel it, and they say their back.  Should you be progressing this person to a deadlift with external cues?Without a proper body map, the motor output will be compromised.  The feedback hasn’t been wired properly, so the feedforward output won’t have a strong reference point.  It’s as if the body will bypass the poorly mapped area (hips) and rely on other areas that are more robustly mapped (back)This is why I think internal cues to improve body awareness are important.  You have to make sure people can intrinsically feel and control their body - which would represent adequate cortical mapping.Once they have this body map awareness, you can confidently progress them to more complex motor tasks and use external cues to achieve the desired output.

• Internal cues provide the map, external cues give you the directions

Changes Focus / Distraction from Pain

Another benefit that I’ve seen clinically from internal cueing is the simple distraction it provides patients.  Often times people will obsess about their pain and it becomes a part of every movement.  Instead of feeling the rest of their body, they focus on the painful area with all of their attention.  Thus, the brain writes more painful wiring for that area.  It’s a vicious cycle.Current research supports this empirical evidence - people in chronic pain have difficulty shifting their attention away from the painful area.Having people focus on internal cues away from the painful site can not only distract them from pain, but it will help the brain wire pain-free movement connections.  And more pain-free movement connections is a great thing for anyone in pain.https://www.youtube.com/watch?v=AGnGRgyLwMs

It Worked for Arnold and the Brosephs

7 time Mr. Olympia, Arnold Schwarzenegger, has discussed his use of internal cues and motor imagery to increase local hypertrophy.  And I think we can all agree that he’s been fairly successful when it comes to local hypertrophy.Ask any bro at the gym what they’re focusing on and the answer will likely be the local muscles.  But don’t judge them, if they’re just trying to increase local hypertrophy then they’re doing the right thing.  We now know that internal cues aren’t great for complex movements due to co-contraction and the constrained hypothesis theory, but they do lead to increased EMG activity.

Ways to Influence the Internal Map

Internal verbal cues may be enough to help change your patient's internal map.  But when this fails, there are many other options to help facilitate the brain change and improve body awareness.

• Attention Focus Internal Cues
• Body Scan / Mindfulness
• Exercise Modification (isolated, slow, groundwork, load, etc.)
• Manual Therapy / Acupuncture
• Dissociation Exercises
• Stretching (Dynamic & Static)
• Somatics (Qi Gong, Alexander Technique, Feldenkrais, Yoga, etc.)

Summary

If you’re working in high level athletics with people who need to improve performance, then external cues are preferred.  However, if you’re working with a much wider population that includes non-athletic people, people in pain, or people that live too externally, then internal cues may be very useful in improving movement and/or pain.  If you are unsure if this type of cueing is needed, simply ask your patient during an exercise - “where do you feel this?”.[subscribe2]

Coaching & Cueing

Part I – IntroPart II – The CategoriesPart III – Verbal Cues – ExternalPart IV – Verbal Cues – InternalPart V – VisualPart VI – ProprioceptivePart VI – Summary

References

Pincivero, Danny M., and William S. Gear. "Quadriceps Activation and Perceived Exertion during a High Intensity, Steady State Contraction to Failure." Muscle & Nerve Muscle Nerve 23.4 (2000): 514-20.Cafarelli, Enzo. "Peripheral Contributions to the Perception of Effort."Medicine & Science in Sports & Exercise 14.5 (1982)Lind, Erik, Amy S. Welch, and Panteleimon Ekkekakis. "Do ‘Mind over Muscle’ Strategies Work?" Sports Medicine 39.9 (2009): 743-64Lewis, Cara L., and Shirley A. Sahrmann. "Muscle Activation and Movement Patterns During Prone Hip Extension Exercise in Women."Journal of Athletic Training 44.3 (2009): 238-48.Snyder, Benjamin J., and James R. Leech. "Voluntary Increase in Latissimus Dorsi Muscle Activity During the Lat Pull-Down Following Expert Instruction." Journal of Strength and Conditioning Research 23.8 (2009): 2204-209.Clark, B. C., N. K. Mahato, M. Nakazawa, T. D. Law, and J. S. Thomas. "The Power of the Mind: The Cortex as a Critical Determinant of Muscle Strength/weakness." Journal of Neurophysiology 112.12 (2014): 3219-226.Yao, Wan X., Vinoth K. Ranganathan, Didier Allexandre, Vlodek Siemionow, and Guang H. Yue. "Kinesthetic Imagery Training of Forceful Muscle Contractions Increases Brain Signal and Muscle Strength." Front. Hum. Neurosci. Frontiers in Human Neuroscience 7 (2013)Ranganathan, Vinoth K., Vlodek Siemionow, Jing Z. Liu, Vinod Sahgal, and Guang H. Yue. "From Mental Power to Muscle Power—gaining Strength by Using the Mind." Neuropsychologia 42.7 (2004): 944-56.Kerr, Catherine E., Stephanie R. Jones, Qian Wan, et al. "Effects of Mindfulness Meditation Training on Anticipatory Alpha Modulation in Primary Somatosensory Cortex." Brain Research Bulletin 85.3-4 (2011): 96-103.Mehling, Wolf E., Judith Wrubel, Jennifer J. Daubenmier, Cynthia J. Price, Catherine E. Kerr, Theresa Silow, Viranjini Gopisetty, and Anita L. Stewart. "Body Awareness: A Phenomenological Inquiry into the Common Ground of Mind-body Therapies." Philos Ethics Humanit Med Philosophy, Ethics, and Humanities in Medicine 6.1 (2011)Lebon, Florent, Christian Collet, and Aymeric Guillot. "Benefits of Motor Imagery Training on Muscle Strength." Journal of Strength and Conditioning Research 24.6 (2010): 1680-687.Fox, Carl Gabbard Ashley. "Using Motor Imagery Therapy to Improve Movement Efficiency and Reduce Fall Injury Risk." Journal of Novel Physiotherapies J Nov Physiother 03.06 (2013)Masters, R. S. W. "Knowledge, Knerves and Know-how: The Role of Explicit versus Implicit Knowledge in the Breakdown of a Complex Motor Skill under Pressure." British Journal of Psychology 83.3 (1992): 343-58.Johansen-Berg, Heidi, and Matthews P. "Attention to Movement Modulates Activity in Sensori-motor Areas, including Primary Motor Cortex." Experimental Brain Research 142.1 (2002): 13-24Gomez-Ramirez, Manuel, Natalie K. Trzcinski, Stefan Mihalas, Ernst Niebur, and Steven S. Hsiao. "Temporal Correlation Mechanisms and Their Role in Feature Selection: A Single-Unit Study in Primate Somatosensory Cortex." PLoS Biol PLoS Biology 12.11 (2014)Clark, B. C., N. K. Mahato, M. Nakazawa, T. D. Law, and J. S. Thomas. "The Power of the Mind: The Cortex as a Critical Determinant of Muscle Strength/weakness." Journal of Neurophysiology 112.12 (2014): 3219-226Stoykov, Mary Ellen, and Sangeetha Madhavan. "Motor Priming in Neurorehabilitation." Journal of Neurologic Physical Therapy 39.1 (2015): 33-42.Wondrusch, C., and C. Schuster-Amft. "A Standardized Motor Imagery Introduction Program (MIIP) for Neuro-rehabilitation: Development and Evaluation." Front. Hum. Neurosci. Frontiers in Human Neuroscience 7 (2013):Kerr, Catherine E., Matthew D. Sacchet, Sara W. Lazar, Christopher I. Moore, and Stephanie R. Jones. "Mindfulness Starts with the Body: Somatosensory Attention and Top-down Modulation of Cortical Alpha Rhythms in Mindfulness Meditation." Front. Hum. Neurosci. Frontiers in Human Neuroscience 7 (2013)Iriki, Atsushi. "Faculty of 1000 Evaluation for Temporal Dynamics of Plastic Changes in Human Primary Somatosensory Cortex after Finger Webbing." F1000 - Post-publication Peer Review of the Biomedical Literature (2006)Merzenich, Michael M., Randall J. Nelson, Michael P. Stryker, Max S. Cynader, Axel Schoppmann, and John M. Zook. "Somatosensory Cortical Map Changes following Digit Amputation in Adult Monkeys." J. Comp. Neurol. The Journal of Comparative Neurology 224.4 (1984)Lazar, Sara W., Catherine E. Kerr, Rachel H. Wasserman, Jeremy R. Gray, Douglas N. Greve, Michael T. Treadway, Metta Mcgarvey, Brian T. Quinn, Jeffery A. Dusek, Herbert Benson, Scott L. Rauch, Christopher I. Moore, and Bruce Fischl. "Meditation Experience Is Associated with Increased Cortical Thickness." NeuroReport 16.17 (2005): 1893-897.Farb, N. A. S., Z. V. Segal, and A. K. Anderson. "Mindfulness Meditation Training Alters Cortical Representations of Interoceptive Attention."Social Cognitive and Affective Neuroscience 8.1 (2012): 15-26Craig, Ad (Bud). "Interoception: The Sense of the Physiological Condition of the Body." Current Opinion in Neurobiology 13.4 (2003): 500-05.Mehling, Wolf E., Viranjini Gopisetty, Jennifer Daubenmier, Cynthia J. Price, Frederick M. Hecht, and Anita Stewart. "Body Awareness: Construct and Self-Report Measures." PLoS ONE 4.5 (2009)Hamilton, Roy H., and Alvaro Pascual-Leone. "Cortical Plasticity Associated with Braille Learning." Trends in Cognitive Sciences 2.5 (1998): 168-74.Polley, D. B. "Perceptual Learning Directs Auditory Cortical Map Reorganization through Top-Down Influences." Journal of Neuroscience 26.18 (2006): 4970-982.Arnsten, Amy F. T. "Stress Signalling Pathways That Impair Prefrontal Cortex Structure and Function." Nature Reviews Neuroscience Nat Rev Neurosci 10.6 (2009): 410-22Roosink, Meyke, Bradford J. Mcfadyen, Luc J. Hébert, Philip L. Jackson, Laurent J. Bouyer, and Catherine Mercier. "Assessing the Perception of Trunk Movements in Military Personnel with Chronic Non-Specific Low Back Pain Using a Virtual Mirror." PLoS ONE PLOS ONE 10.3 (2015)Arntz, Arnoud, Laura Dreessen, and Harald Merckelbach. "Attention, Not Anxiety, Influences Pain." Behaviour Research and Therapy 29.1 (1991): 41-50.Garrison, Kathleen A., Juan F. Santoyo, Jake H. Davis, et al. "Effortless Awareness: Using Real Time Neurofeedback to Investigate Correlates of Posterior Cingulate Cortex Activity in Meditators' Self-report." Front. Hum. Neurosci. Frontiers in Human Neuroscience 7 (2013)Schabrun, Siobhan M., Edith L. Elgueta-Cancino, and Paul W. Hodges. "Smudging of the Motor Cortex Is Related to the Severity of Low Back Pain." Spine (2015)Rock, David. Quiet Leadership: Help People Think Better -- Don't Tell Them What to Do: Six Steps to Transforming Performance at Work. New York: Collins, 2006.Qi Gong Classes with Tina Zhang.  New York City.  2014-2015.Alexander Technique Inservice - Emily Whyte.  New York City.  2015.Feldenkrais Workshop - Art & Science of the Method with David Zemach-Bersin.  New York City.  2015.--The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

Coaching & Cueing (Part 2 - The Categories)

We need to first clarify an important concept before we go into coaching and cueing:

• NOT ALL MOVEMENT REQUIRES COACHING

To Coach or Not to Coach

If someone is performing a movement/exercise correctly, all you have to do is shut your mouth and smile.If someone is performing a movement/exercise incorrectly, you should ask yourself two questions:

1. Do they need a different environment via a sensory change/coaching and cueing?
2. Is this a professional error?  Is this the right exercise for this patient at this time?

So if someone can’t perform the deadlift correctly, they either need some coaching and cueing (a sensory change) or they need a different exercise.

3 Types of Coaching

I break down coaching into 3 different categories:

• 1) Verbal - External & Internal
• 2) Visual - External & Internal
• 3) Proprioceptive

Each of these categories are a change of the inputs from the environment.  Each section has a specific attentional sensory focus.  Below is a brief introduction to each type of cue.  For a more in depth look at specific cueing types, stayed tuned for Parts III-IV in this article series.

1) Verbal

Verbal cues are by far the most common and one of the most researched coaching cues.

External Cue

Focuses on how the body’s output affects the environment (outcomes, objects, etc.)

Internal Cue

Focuses on the body processes and internal systems (muscles, kinematics, pressure, etc.)

2) Visual

Visual cues are rarely discussed in the coaching realm.  However, there are some interesting concepts in this category that can have a huge impact on your clients’ movement.

External

Influences movement through visual input (visual field, objects, orientation, demonstrations, eyewear, etc.)

Internal / Motor Imagery

“Motor Imagery is defined as an internal rehearsal or reenactment of movements from a first person perspective without any overt physical movement. From another perspective, MI, also known as kinesthetic imagery, is an active cognitive process during which the representation of a specific action is internally reproduced in working memory without any overt motor output” -Carl Gabbard and Ashley Fox

3) Proprioceptive

Proprioceptive cues are very common in both rehab and training (whether the practitioner knows it or not).  It’s a common sense type of approach that can have more profound effects than any other sensory change.  These proprioceptive cues can be divided into MANY different sub-categories.

• Postures
• Load
• Speed
• External Stimulation (tactile, tape, surface, footwear, etc.)
• Regressions
• Progressions
• Lateralizations
• Modifications
• Modulations
• [Insert Latest Terminology]

 

Summary

Which type of cue the patient needs depends on many factors.  A greater understanding of each of these types of sensory changes will help one determine which one to use.  Keep the overall goal in mind and match your desired outcome to they type of cueing.And remember, if someone isn’t performing a movement correctly despite your coaching/cueing, you either need a different sensory change or a different exercise.

Coaching & Cueing

Part I - IntroPart II - The CategoriesPart III - Verbal Cues - ExternalPart IV - Verbal Cues - InternalPart V - VisualPart VI - ProprioceptivePart VI - Summary [subscribe2]

Coaching & Cueing (Part 1 - Intro)

My co-worker was on vacation recently and I was seeing one of his chronic pain patients (years of pain).  She was doing very well and was becoming independent in a full exercise routine.  I did a quick evaluation and noticed one thing that she could improve on from a movement perspective.  I didn’t use any dangerous pathoanatomical language.  I just simply pointed out that she could be stronger if she kept her rib cage down when she performed certain exercises.  We went over this cue a bit more with some basic proprioceptive exercises before she started her exercise program.About 20 minutes into her routine, she stopped and approached me.  I was worried she was going to complain of pain or be confused about the “ribs down” cue.  But instead she said with a smile, “you know, it’s nice to think about something other than my pain for once when I exercise”.As a physical therapist who works with people who have pain with simple movements, this was quite profound.I have been hearing from many professionals that external cues are far superior to internal cues.  Some people even go as far as saying you should never use internal cues.  However, this all or none approach doesn’t seem to be the case in the clinic. With this specific client, internal cues were beneficial on a few different levels.  So I wanted to dig in a little deeper and look at cueing from a different perspective.  I did some research and will summarize my findings in this series.

Disclaimer

Keep in mind this is from a physical therapist’s point of view.  The world of sports performance is always a hot topic.  The exciting things people are doing with professional athletes are always interesting and fun to integrate into rehab.  But what works for the NBA’s Lebron doesn’t always work for the AARP’s Betty.  Not everyone lives their life to improve their sports performance.  So keep in mind:

• Performance Training is a Luxury.  Movement Training is a Necessity.

Chronic Pain

Yes, this patient has been educated on pain science thoroughly, she has read books, watched videos, and has seen a psychologist for her chronic pain.  This post series will be focused on coaching and cues used for improving movement.  For more information regarding pain, I highly recommend starting with Adriaan Louw’s work and ISPI.

Andreo Spina's Functional Range Release

I was lucky enough to be invited to another one of Dan Park’s quality continuing education classes at Perfect Stride.  This time it was for Functional Range Release (Upper Extremity) with Andreo Spina.  I had been reading a lot about Spina’s work and was excited at the chance to learn about the FR/FRC techniques and principles.

Andreo Spina

Andreo Spina is the creator of FR (Functional Range Release) and FRC (Functional Range Conditioning).  He is an intelligent, articulate, and opinionated speaker.  He has a great knowledge base and a fresh perspective on the human body.  I’ve taken many continuing education courses over the years; Dr. Spina definitely set the record for most rants.  However, all of his rants have a point and are very educational.  He uses sound logic, conventional wisdom, literature, and dry humor to discuss current practices and clinical beliefs.I walked away from his course with a new perspective on the human body, knowledge of how to influence tissue at the histological level, and became a much more efficient manual therapist.*This is my interpretation of the class and how I conceptualize the approach.  For a more complete understanding I recommend taking one of Dr. Spina's course.  He provides an extensive amount of information and resources (9 on-line learning modules, quality lectures, lifetime membership, and social media support).

Bringing it Back to Histology

Neuo-based approaches have really boomed over the past decade.  And for a good reason - they improve clinical care.  While I love these neurological approaches and understand their value, I also think we can go off the deep end with it.  Sometimes it’s easy to forget there’s a physical human body with constantly adapting tissues.  Just as the nervous system has an influence on tissues, the tissues have an influence on the nervous system.  Even renowned neuroplasticty lover, Lorimer Moseley, has mentioned that we should be considering the role of Bioplasticity.Andreo Spina has done a tremendous job of expanding on this tissue concept and making histology clinically relevant.  FR/FRC focuses on addressing the human body from controlled and specific inputs to influence the histological processes and subsequently, the entire human body.To understand this concept, it is important to recognize that the body is constantly turning over at a cellular level (watch this - tissue remodeling).  I think the quote from the class was “if you look at a picture of yourself from 10 years ago, there won’t be one cell that is the same”.How these cells turnover and in what manner depends on many variables.  Specific to Spina’s work, one of these variables is force.  The force that these tissues “feel” dictates how they turnover.  Force influences cellular activity (fibroblast).  And direction is one of the most important variables of this force.This is a very detailed and scientific rabbit hole to go down.  It involves the piezoelectric effect, tensegrity, mechanotransduction, solid-state biochemistry, collagen, fibroblast activity, cellular signaling, etc.  While it's beyond the scope of this review to discuss these concepts in detail, I'll try to briefly summarize them since it is essential to understanding the FR/FRC system.The influence of force on cellular activity deals with the connections between collagen and cells.  Force is applied to the body and imparted on collagen.  Collagen connects to a cell via integrins.  Different cells grab onto the same collagen fibers (via integrins).  When collagen gets a directional force input, it transmits this signal to multiple cells (tensegrity).  This force is then transmitted from the cell cytoplasm to the nucleus (DNA/RNA).  FORCE IS THE LANGUAGE OF CELLS.  One example of this is Wolff's Law.To put it in clinical terms, your sedentary 45 year old patient that has been wearing high heels for over 30 years is going to have some adaptive tissue changes.  There’s going to be a histological tissue adaptation.  After years of not using ankle dorsiflexion, her body will remove the cells that foster normal dorsiflexion.  There isn’t a neurological trick you can do to change tissue in one session.  In fact, there isn’t any one input that will change tissue immediately.  To adapt and influence that tissue, you will need frequent, long duration, directional force inputs.

What Are We Really Feeling?

Another main concept of the course was to question our manual assessment/intervention.I think an analogy might help explain this concept.Lets take a single-leg stance assessment.  You notice that there’s a significant compensated trendelenburg.  A decade ago we may have accused a weak glute medius and then just hammered the patient with isolated hip abduction exercises (movement blunder).  But now we know there are so many possible causes of this movement pattern that it is nearly impossible to pin it on one thing.The same thing applies for manual therapy.  All we have is our hand contacting another person’s body.  There’s just a hand to skin interface and we are trying to feel for something.  But can we really say what that is?  Is it a fat pocket, malaligned collagen, a tissue anomaly, a genetic difference, or tone?  By saying it’s scar tissue or a knot are we bringing the movement blunder to manual therapy?Adreo Spina thinks so.

• “It is not logical to think that a practitioner can feel 'scar' tissue or 'adhesions.' At the level of 'micro-scarring' in connective tissue, the target is much too small for human touch. Not to mention the abundance of overlying tissue making it impossible to feel alterations in collagen directionality. Our hands can however feel forces. It is the forces generated by movement, or tension, that we attempt to feel. We can also think of it as feeling resistance to passive movement in a particular direction. We feel for aberrant tension…and we treat aberrant tension.”

By focusing on feeling for aberrant forces with movement, we have a more honest assessment.  It takes out the assumption blunder and reduces confirmation biases.

Assessment / Approach

For me, Dr.Spina’s approach is best understood from the Dynamic Systems Theory and Degrees of Freedom Problem point of view.  The premise is that there is an infinite amount of ways for the human body to move.  This is because there is a collective Degrees of Freedom that incorporates ALL the complex variables/sub-systems (in the continually changing internal & external environment) required to achieve a task.  One of these variables/systems is the state of the body’s peripheral tissues.  More specifically, an important tissue variable is the degrees of freedom of the joints (articular ROM).  If there are adaptive histological tissue changes that prevent normal joint movement, then the collective Degrees of Freedom will decrease.  The brain will have less motor control options.  The body will lose movement variability.  The attractor state will deepen.Losing degrees of freedom at the joint level can have a significant impact in the body's ability to manage movement.For an example, lets look at a simple digit lock.  It is not a complex open loop system (actually the opposite), but it'll hopefully help explain how this concept pertains to FR/FRC.Take a 3-digit-lock.  Each digit requires a specific number to match the right combination to unlock the lock.  With the numbers 0-9 and a 3 digit combination, there are 1,000 possible combinations.  If you add just one more digit and make it a 4-digit-lock, the number of possible combinations goes from 1,000 to 10,000.  Pretty significant, right?  Simply adding just 1 digit has a massive effect on the amount of variable combinations.One variable can significantly affect the whole system.You could look at the body the same way.  Having minimal joint motion may provide for some adequate movement options (3-digit-lock).  But having even just a little more joint motion can have significant impact in the movement options (4-digit-lock).  What if you needed the 1,001 movement combination to safely land from a jump?  If you only have 1,000 options, you'll compensate and risk injury.  This analogy works for the entire spectrum, from your 1-digit-lock medicare patients to your 100-digit-lock gymnast.

• Articular DOF = Nervous System DOF = Movement DOF

This is why Andreo Spina’s assessment approach is to first check every articulation of the body (joint ROM).  His philosophy is that if you don't have the prerequisite articular motion then your movement will suffer.  Why not focus on the other variables?  Because you can't build strength, stability, or motor control in ranges you don't have.  Developing the optimal ROM takes priority over developing strength in an inadequate range.Once he assesses the joint articulations, he will assess the soft tissue with palpation and passive movement.  If the person is in pain, he tries to reproduce it with palpation to determine a specific tissue diagnosis.  If there is no pain, he palpates the local area to asses how well the tissues are moving.* (=) is influence

Don’t Hang Up

Force is the input that tells the fibroblasts how to lay down.  Research has shown that it takes 2 minutes for these fibroblasts to become activated.  If you’re constantly changing direction or moving, then the cells won’t get the right input.So if you’re trying to influence tissue, you need to hold the directional force for 2 minutes.  He had a great analogy of a phone call.  You need to stay on the line long enough to get the message across.  If you keep hanging up (e.g. pin and stretch manual techniques, STM, etc.), then the communication won’t go through to the fibroblasts.Keep patients in the same posture, don’t pump through ranges of motion, hold tension longer, think directionally.

Isometrics

Isometrics are extremely beneficial.  Here's a list of 10 reasons why:

1. Gives directional force input (communication)
2. No joint shearing
3. No inflammatory reaction
4. Teaches body how to develop tension in a muscle (motor unit recruitment)
5. Increases strength
6. Least provocative strengthening modality
7. Patients can do it frequently
8. Backs up / covers manual therapy intervention
9. Resets the muscle spindle
10. Safe mechanotransduction

Spina has created a very user friendly system for applying isometrics to influence tissue and improve range of motion.  These are PAILs and RAILs (Progressive Angular Isometric Loading & Regressive Angular Isomeric Loading).  These are very direction specific interventions.  These techniques are best understood in the context of the class, but I will briefly describe them here.PAILs I (Communication)

Guiding Soft Tissue Remoulding/Healing

Does not intend on expanding range

Low level, frequent contractions

PAILs II (Expand Range of Motion)

2 minute passive, direction specific stretch

Followed by ramped isometric contraction in opposite direction (20-30 seconds)

PAILs III & RAILs (Expand ROM & Training Stimulus)

2 minute passive, direciton specific stretch

Ramped isometric contraction with 100% effort (longer duration)

Followed by RAILs (inner range hold, actively pulling deeper into the stretch)

Followed by another deep, passive stretch (and repeat)

Anatomy Pearls

During the palpation aspect of the course, Dr. Spina revealed this disconnect between what we were taught and what is actually in the body.  Here's some of these revelations.

• Levator Scapula is medial on the neck

• The "Levator Scapula TrP" that everyone has is really just where the rhomboid and erector spinae cross

• That thing you poke on the front of people’s shoulder is not the biceps tendon, it’s usually the anterior deltoid

• Teres major/minor and long head triceps is a commonly gunked up area

• The subscapularis tendon becomes transverse humeral ligament

• The long head of the triceps becomes the inferior labrum

• Deep muscle grow off bones (like chia pets) - Examples - quadriceps, brachialis, subscapularis, flexor digitorum profundus

• The pec minor, upper trapezius, and latissimus dorsi are disappointing muscles - thinner than you would think

Randoms

1) We all come from one cell - every cell has the ability to be every other cell2) Pain is a terrible outcome measure (Touch Induced Analgesia)3) Epimysial Groove is an important area to treat4) Mechanical Tension = specific aberrant force, Neurological Tension = can be felt during static palpation and is felt throughout the whole muscle (video demonstration)5) “We’re trying to palpate the forces that are restricting movements”6) In the fascia superfiscialis there are small pockets of adipose tissue - this might be the grittiness you feel with IASTM7) BioFlow - continuum of tissues - it all blends together - tissue types are just a different expression of connective tissue8) Fibroblasts - undifferentiated connective tissue cell that can become a precursor cell for many different types of connective tissue (tendons, bone, cartilage, muscle, etc.)9) It doesn’t matter which type of tissue, the response to load/signal will be similar10) “Never use a cannon to kill a fly” -Confusious11) Van Der Wal (article, video)12) No passive structures, just structures whose tension is tuned by the muscles (active structures)13) Force to one cell will cause a cascade of signaling throughout many different cells14) For plastic changes you need >2 minutes (induce thrixotropy and piezoelectric)15) Injury = Fibrosis = Friction/Loss Of Relative Tissue Motion16) After injury - the body recalibrates the stretch reflex threshold = faster activation of muscle spindles during movement = reflexive contraction, prematurely17) Don’t bring a mechanical intervention to a neurologic problem18) The more the neural drive, the less the access to the connective tissue for manual treatment19) Without direction, fibroblasts smear collagen all over the place and create fibrosis20) Deep tissues are mostly proprioceptive/afferent structures (when these are dysfunctional, superficial tissues have high tone)21) Adjust for skin slack or everything will feel like tension22) No single input causes permanent changes - “we’re not fixing anything”23) “I can’t rub someone flexible”24) Flexibility is governed by the nervous system.  You have to train it in the gym, not manually fix it with your hands.25) Inputs

• Muscle responds to NS quickly

• Connective Tissue responds to longer force inputs

26) 1st Job of Rehab = Guide the way the tissue is healing - tell the fibroblasts where to lay down collagen27) Rehab in the injured posture to repair/strengthen damaged tissues28) "Any fool can make something complicated. It takes a genius to make it simple." -Woody Guthrie

• Load > Capacity = Injury

• Load < Capacity = Rehab

• Capacity >> Load = Prevention

29) The deeper in the body, the more the connective tissue (pedunculation)30) Muscles can contract in various ways - Different fibers pull in different directions - Attachments don’t dictate all movement31) “Create the joint…THEN control the joint…THEN strengthen the joint - this concept is central to the FR and FRC systems.”32) “If you can control the scapula in space, does it matter if it’s winging?”33) Improving skin slide, especially over bony prominences, makes a big difference34) “You’re not palpating muscles, you’re palpating the connective tissues that makes muscles”35) NS only gives you access to the ROM it knows it can control36) “Adding passive mobility is where people get hurt”37) Osteoarthritic Rant

• Age doesn’t decrease flexibility, lack of movement decreases flexibility

• Joints maintain their health with movement

• If your joints moved everyday, an osteophyte can’t develop

• OA occurs from lack of motion

38) “RTC should be called the compressor cuff”39) The best way to assess joint motion is with axial rotation40) Opening vs. Closing restriction

• Opening is normal, tissues have to adapt

• Closing is not - comes from a decentrated joint, or tight opposite joint

41) The more contact you have with the patient, the better you can assess (close the circuit)42) Cyriax Knowledge - The longer a muscle is at contraction, the more the load goes to the tendon43) “Think of the body as one group of CT and proteins are added where movement needs to occur”44) One of my favorite quotes from the course

• “Changing posture is about habitual cueing”

45) Tensegrity model runs through the entire body, from DNA/RNA nucleus to ECM46) Give the cue “hold strong” (good psychological priming)47) “You don’t do PAILs for a muscle, you do it for a direction”48) Check the hands in elbow patients - It’s like the plantar fascia in achilles patients49) “Articular independence first….articular interdependence second”

Bottom Line

Overall this was one of my favorite courses I've ever taken.  It gave me a new lens on the human body, provided a simple and effective way to influence tissue, reduced my need for manual therapy, and gave me a direct treatment approach to achieve long term goals.  I highly recommend this course (or the FRC) for all movement professionals.One of the greatest things about Dr. Spina's work is that it can easily be incorporated into any approach.  You can still do all the neurological stuff, but after you get them FN/Centrated/Neutral/Whatever, just add in some inputs that will influence the tissues in the new and improved position.  It's important to work with the nervous system after an injury (motor patterns, pain, ANS, neutrality, etc.), but it's also just as important to work on the tissues themselves.  We are lucky to have so many approaches out there that identify the neurological needs of the system.  Now we're lucky to have Dr. Spina's approach to address the histological needs of the system.

Dig Deeper

Cellular/Histological/Bioflow

This is a big rabbit hole to go down.  There is plethora of research and articles.  It is difficult to just reference one.  FR/FRC Instructor, Michael Chivers, recommends starting with Helen Langevin and Donald Ingber.

Motor Control/Dynamic Systems

This is similar to researching cellular adaptations and histological changes to input.  There is so much out there that it becomes difficult to reference.  If you are new to these concepts, start by researching the different types of motor control theories.  Then research Bernstein's work and the degrees of freedom problem.  Then dive into the Dynamic Systems Theory.

My favorite article in this field is from Esther Helen and Linda Smith (Thelen, E. and Smith, L. B. 2007. Dynamic Systems Theories. Handbook of Child Psychology. I:6)

Fascia/Tensegrity

This has become a standard in the movement sciences (or at least I hope so).  Most clinicians are familiar with this approach thanks to the work of Tom Myers, Robert Schleip, Jaap Van Der Wal, and Leon Chaitow (among many others).

Andreo Spina - YouTubeSolid-State BiochemistryMechanotransduction (Jaalouk 2009, Khan 2009)Jeff Cubos - Phases of Healing & Spina's Work, Notes & Quotes from Dr. SpinaDewey Nielsen's Instagram Account (great examples of the FRC approach in practice)Jason Ross - Part I, Part IIVeeWong Course ReviewKevin Neeld - Dispelling the Stretching MythsArmstrong InterviewThe Nominalist has a ton of posts with clinical applications of FR & FRC   --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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An Open Letter to Crossfit: The 2 Mistakes (Part II)

Be sure to check out Part I for my thoughts on Crossfit and Mistake #1.

Mistake #2 = Not Training Unilaterally

Our bodies are inherently asymmetrical.  Don’t believe me?  Here are a couple examples of this natural asymmetry: we have a liver on the right, a heart on the left, 3 lung lobes on the left, 2 on the right, the stomach is tilted, one kidney is higher, the right diaphragm has a better zone of apposition, each brain hemisphere is lateralized for different tasks, and our left-otolitic dominance makes our motor system prefer the right side of our bodies.  On top of this, there are many other possible asymmetries and different morphologies due to genetics/ontogenetics.Not only are our bodies asymmetrical, but we live in a very asymmetrical world.  Everyday activities are asymmetrical; you push the car pedals with your right foot, grab your wallet out of the same pocket, open doors with your right hand, use the computer mouse on the same side.  Sporting activities are asymmetrical; you shoot with your right hand, kick with your right leg, swing a golf club to the same direction everytime.  And then there is just plain handedness.These asymmetries are normal and usually not a problem.  However, sometimes these asymmetries become too significant.  The imbalances become too much for the body to handle.This asymmetrical problem is taken to the next level when you add a symmetrical load to the system.  Symmetrically loading an asymmetrical system is the formula for injuries.  And this is one of the biggest mistakes Crossfitters make.While this applies to the entire body, it is critical in shoulders.  There are two reasons why:

1) You have a much more prominent handedness than footedness

2) Your legs benefit from some unilateral weight bearing activities everyday (walking, stairs)

Therefore, your upper extremity asymmetry is accelerated much faster compared to the lower extremity.  In other words, a right handed person can pretty much go all day without using their left arm at all.Fast forward to this person going from not using their non-dominant arm for most of their life (or past few years) and then throw a barbell at them.  It’s not going to go well.  The symmetrical external load (barbell) won’t be met with a symmetrical internal force (muscles).  Bringing a symmetrical exercise to an asymmetry is a recipe for disaster.Look at your car for an analogy.  If you car alignment is off, it’s going to cause some big problems.  Not only is most of the load going to be dumped onto one side, but it will also prevent a smooth straight path.  With the alignment off, the car will naturally want to veer from straight.  But it is being driven in a straight path, so the car has to pull (compensate) to maintain the desired direction.The same thing happens at your shoulders with barbell exercises.  One shoulder will get too much of the load, the other has to compensate to keep it straight, and it becomes an internal tug-of-war to keep the all important straight bar path.  Therefore, if you have a shoulder asymmetry, then the whole time you are cleaning, pressing, or snatching your shoulders will be compensating against each other.As mentioned in Part I, over time compensations lead to decreased performance and injuries.So what do you do about this?  Start brushing your teeth with your non-dominant arm?  Do barbell cleans with one arm?  Walk on your hands?

A Suggestion

The best thing you can do is incorporate some single arm (unilateral) strengthening into your weekly workouts.  This will not only prevent injuries, but it can also be used as an assessment.  If you can strict press 70# with your right arm, but only 50# with your left, then what do you think is happening when you strict press with a barbell?There are many different ways to work on unilateral strengthening, but in my opinion kettlebells are the best equipment to accomplish this.  They allow for the same metabolic burn, similar technique work, multi-joint strengthening, and most importantly - unilateral strengthening.  Pavel said it best "Your body has to adapt to the barbell while the kettlebell works with your body."Here’s a list of some unilateral shoulder exercises that can be done with just a kettlebell and some space:

Armbars, Bear Crawls, Quadruped T's, TGU, Single Arm Push Ups, Half/Tall-Kneeling/Standing KB Strict Press, Farmers Walks (overhead, rack, suitcase), Single Arm KB: Swing, Squat, Clean, Clean & Squat, Clean & Strict Press, Clean & Push Press, Snatch, Unilateral Suitcase Deadlift, Plank KB Pull Through

There are plenty of great coaches that can probably come up with some amazing unilateral upper extremity WODs.  There’s not just one right way to do it.  As long as you are training unilaterally and exposing weakness you will be decreasing your risk of injury and improving performance.For clinicians there is this Clinical Pearl

• If someone comes in with dominant side shoulder pain from bilateral/symmetrical training, the fix may be to strengthen the non-dominant side

Bottom Line

Like anything that becomes popular or trendy, there quickly becomes a group of people that jump on the bandwagon and a group of people that protest against it.  But this isn’t EDM, this isn’t Instagram, this isn’t the new iPhone.  This is simply another opportunity to help people stay active and exercise.  It’s not for everyone, but it’s not for no one.Medical professionals need to focus on ways to reduce injury and improve the activity rather than just pointing out what we don’t like.  Crossfit coaches need to focus on what’s best for the athletes health rather than what will give them the best workout.  And the Crossfit athletes need to be educated on the risk of lifting with poor technique and/or with a significant asymmetry.

References

Strength is a Good Thing1) Preethi Srikanthan, Arun S. Karlamangla. “Muscle Mass Index as a Predictor of Longevity in Older-Adults.” The American Journal of Medicine (2014) 2) Lauersen JB, Bertelsen DM, Andersen LB.  The effectiveness of exercise interventions to prevent sports injuries: a systematic reviewand meta-analysis of randomised controlled trials.  Br J Sports Med. (2014) Jun;48(11):871-7.3) Harridge, Stephen D.r., Ann Kryger, and Anders Stensgaard. "Knee Extensor Strength, Activation, and Size in Very Elderly People following Strength Training." Muscle & Nerve 22.7 (1999): 831-39.4) Suetta, C., S. P. Magnusson, N. Beyer, and M. Kjaer. "Effect of Strength Training on Muscle Function in Elderly Hospitalized Patients."Scandinavian Journal of Medicine & Science in Sports 17.5 (2007)5) Askling, C., J. Karlsson, and A. Thorstensson. "Hamstring Injury Occurrence in Elite Soccer Players after Preseason Strength Training with Eccentric Overload." Scandinavian Journal of Medicine and Science in Sports 13.4 (2003): 244-506) Nadler, Scott F., Gerard A. Malanga, Melissa Deprince, Todd P. Stitik, and Joseph H. Feinberg. "The Relationship Between Lower Extremity Injury, Low Back Pain, and Hip Muscle Strength in Male and Female Collegiate Athletes." Clinical Journal of Sport Medicine 10.2 (2000): 89-97.7) Peate, Wf, Gerry Bates, Karen Lunda, Smitha Francis, and Kristen Bellamy. "Core Strength: A New Model for Injury Prediction and Prevention."Journal of Occupational Medicine and Toxicology 2.1 (2007)8) Orchard, J., J. Marsden, S. Lord, and D. Garlick. "Preseason Hamstring Muscle Weakness Associated with Hamstring Muscle Injury in Australian Footballers." The American Journal of Sports Medicine25.1 (1997): 81-859) Jankowski, C.m. "The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial."Yearbook of Sports Medicine 2012 (2012): 65-66.10) Willson JD, Dougherty CP, Ireland ML, et al. “Core stability and its relationship to lower extremity function and injury.  J Am Acad Orthop Surg. (2005) Sep;13(5):316-25.11) Hewett TE, Lindenfeld TN, Riccobene JV, et al. “The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study.” Am J Sports Med. (1999) Nov-Dec;27(6):699-706.Movement Based Exercise vs. Isolated Exercise12) Gentil, Paulo, Saulo Rodrigo Sampaio Soares, Maria Claúdia Pereira, et al. "Effect of Adding Single-joint Exercises to a Multi-joint Exercise Resistance-training Program on Strength and Hypertrophy in Untrained Subjects." Applied Physiology, Nutrition, and Metabolism 38.3 (2013): 341-4413) Gottschall, Jinger S., Jackie Mills, and Bryce Hastings. "Integration Core Exercises Elicit Greater Muscle Activation Than Isolation Exercises."Journal of Strength and Conditioning Research 27.3 (2013): 590-96Exercising in Fatigued State14) Cortes, Nelson, Eric Greska, Roger Kollock, Jatin Ambegaonkar, and James A. Onate. "Changes in Lower Extremity Biomechanics Due to a Short-Term Fatigue Protocol." Journal of Athletic Training 48.3 (2013): 306-13.15) Santamaria, Luke J., and Kate E. Webster. "The Effect of Fatigue on Lower-Limb Biomechanics During Single-Limb Landings: A Systematic Review." Journal of Orthopaedic & Sports Physical Therapy 40.8 (2010): 464-73.16) Barnett S Frank, Christine M Gilsdorf, Benjamin M Goerger, et al.  “Neuromuscular fatigue alters postural control and sagittal plane hip biomechanics in active females with anterior cruciate ligament reconstruction.” Sports Health (2014) Jul;6(4):301-817) Quammen D, Cortes N, Van Lunen BL, et al. “Two different fatigue protocols and lower extremity motion patterns during a stop-jump task.” J Athl Train. (2012) Jan-Feb;47(1):32-41.18) Pau M, Ibba G, Attene G. “Fatigue-induced balance impairment in young soccer players.” J Athl Train. (2014) Jul-Aug;49(4):454-61.Imbalances Are Bad19) Knapik, J. J., C. L. Bauman, B. H. Jones, J. Mca. Harris, and L. Vaughan. "Preseason Strength and Flexibility Imbalances Associated with Athletic Injuries in Female Collegiate Athletes." The American Journal of Sports Medicine 19.1 (1991): 76-8120) Baumhauer, J. F., D. M. Alosa, P. A. F. H. Renstrom, S. Trevino, and B. Beynnon. "A Prospective Study of Ankle Injury Risk Factors." The American Journal of Sports Medicine 23.5 (1995): 564-70.21) Common Sense & Conventional Wisdom (>6 million years BC)Motor Learning22) Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. Print.23) Schmidt, Richard A., and Craig A. Wrisberg. Motor Learning and Performance: A Problem-based Learning Approach. Champaign,IL: Human Kinetics, 2004.24) Williams, L. R., McEwan, E. A., Watkins, C. D., Gillespie, L., & Boyd, H. (1979). Motor learning and performance and physical fatigue and the specificity principle. Canadian Journal of Applied Sport Sciences, 4, 302-308.

“The body does not have the capacity to learn movement patterns when highly stressed/fatigued. This factor is not related to the specificity of training principle associated with overload adaptation in energy systems. The specificity principle of physiological adaptation does not apply to motor learning. To learn skilled movement patterns that are to be executed under fatigued conditions, that learning has to occur in non-fatigued states” — Williams 1979

 --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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