Author: aiannarino3

Is there an “correct” solution to a movement problem? Opinions from movements professionals seem to live on a spectrum between two polarized opinions. On one end is the biomechanical purist who would deviate towards the belief that movements need to be precise and align with biomechanical models of efficiency. The extreme end of this argument would posit that there are only a few ways to correctly complete a task and deviation from this will come at a cost. At the other end of this argument are the movement optimists. This side would argue that the human will be able to self organize into “correct” solutions or that repeated exposure to any stimulus will allow for adaptation and tolerance to that position. 

Human as precise machine vs human as adaptable movement amoebas. 

What if both are right? 

The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.

F Scott Fitzgerald

Context is King

This argument is really pointless without defining the conditions.  “Correct” lives on a continuum. This means there are times when I should and shouldn’t care about the minutia. Biomechanics may not matter AND may be the limiting factor to enhancing performance and managing risk. 

When Should I Care: The Movement Wedge
There are many correct solutions, until there is just one.  Look at the figure below. The thick end of the wedge is the task at its most simple. Low intensity, low volume. The area inside is the options for a “correct” solution. The narrow end is the task at its most demanding. High intensity, high volume. There are very few correct options. 

A simple example here is picking up an object from the floor and getting it overhead. The task of picking up a feather off the floor and putting it on a shelf lives on the far left side of the wedge. With the lack of demand, there are a multitude of options available for the individual to choose from. Variation here is welcome and desirable. Now change the feather to Lasha Talakhadze performing his world record 220kg snatch. This lives at the extreme right tip of the wedge. Not only must his body perfectly coordinate himself around the rapidly rising mass, he must be specifically built for this task. The solution to this movement problem is the product of nature (specialized anthropometrics) and nurture (years of very specific training) to match the demands defined by physics. 

Now picture the transition from walking to jogging to sprinting. With walking, the forces on the body are relatively low. We are at the thick end of the wedge. The human can get away with more deviation in walking gait over time with less risk of negative repercussions. But now try to run a sub 9.58s 100m. With this amount of intensity, a half of degree of knee extension could be the difference between a world record and a hamstring strain. We must also consider volume. A 5 mile training week may live at the left end of the wedge for many while an 80 mile week lives on the far right. Again, we have come the very edge of the wedge.

The Mechanical Wall

Most of human movements does not live in these polarized ends. We often find ourselves in working in the gray zone in the middle of the wedge. Let’s create a theoretical scenario of two twin runners (Andy and Randy) going through the same training program. Every step and running velocity has been perfectly matched throughout their entire life.  Andy always gets through training perfectly healthy, but year after year, Randy breaks down 2 months into the training cycle with a right tibial stress reaction. You note that Randy seems to have a stiff landing on his right leg and a more supinated right foot compared to his left. When does this matter? 

At a certain point when intensity and volume rise we may meet the mechanical wall. This is the theoretical point where his mechanics matter. Randy could theoretically run 39.9 miles/week at an 7:00 pace for the rest of his life but the transition to 40 miles or a 6:59 pace may tip him over the edge. He has reached the end of his adaptability within the limitations of his mechanics. Prior to this, his deviation was a “correct” solution to his movement demands, but as the demand rises, it is no longer sustainable. The cost of doing business has now exceeded his physiological capacity. The deviation away from our “biomechanical optimum” has potentially limited his ability to adapt beyond this level.

This is the point in my opinion, which biomechanics truly matter. When the stakes rise there is less room for error. And our trends over time with this athlete allow us to understand his physiological limitations. We can couple this n=1 data with our large scale understanding that a stiffer ground contact may predispose a runner to increased tibial stress. We can now run the experiment of decreasing total workload to stay behind this mechanical wall while we invest time in altering mechanics. Once the changes have been made, volume and intensity can again progress to assess how Randy does when approaching this wall. 

“ We can reduce the effect of our biases by combining a large scale understanding of averages with the long term lens of a single athlete”

Sophia Nymphius

Of course, our real world scenarios are never this clean. We will rarely be able to define a precise workload in which the individual consistently breaks down. However, our trends over time coupled with an evaluation of how far away from a biomechanically defined “optimum” their mechanics are may give us some insight into when the juice of changing mechanics is truly worth the squeeze. Practically, the management of a first time injury to a runner with an asymmetrical gait pattern who ramped their volume up 50% over the last month and a chronically injured runner with the same gait deviation following a logical training progression should be viewed  and managed differently.  When making the decision of how to proceed , ask yourself: 

• What are the injury trends of this individual over time? 
• How logical has their training progression been? 
• How far do their mechanics shift away from a biomechanical “optimum”?
• How much effort will this take for the individual to change their mechanics? 

Arguments over the importance of biomechanics and self organization versus coaching rage on in our profession. But the argument is really pointless without defining the conditions.  Correct lives on a continuum. This means there are times when I should and shouldn’t care about the minutia. Biomechanics don’t matter AND are the most vital element to performance and managing risk. Context is key. Knowing when is the art. 

-Anthony 

Managing running workloads can be challenging. Ask any runner pushing their volume or intensity, this is a complex and deeply individual jigsaw puzzle. Adding in the element of injury recovery can make this process even more noisy. There are a number of factors to consider with a weaving web of interplay that will effect our return to run decision making, timeline, and the risk of re-injury upon return.

“Running experience and injury threshold seem to play a role in the relationship between training characteristics and development of injuries, while volume, duration, intensity, and frequency seem to have a complex interaction with each other which is not accounted for in the majority of the included studies” 

Nielsen et. al (2012)

With the inherent complexity of these modifiable and non-modifiable factors, we must simplify the problem to make sense of the issue and find a starting point for intervention. To do this, we can take a three step approach:

I. Identify Opportunity and Risk

Throughout the return to run process there will be varying levels of re-injury risk. Is it is our job keep this risk as low as possible while preparing the individual to return to their prior level of function or beyond. Too much focal stress and we re-exacerbate the issue. Too little and we leave the runner vulnerable to re-injury upon return to normal training load. This is often a tricky balance to strike.

Nassim Taleb’s Barbell Strategy is a nice framework to help make sense of situations such as this and identify how to maximize opportunity while mitigating risk. Taleb’s barbell suggests that the bulk of investments should be made to either the general (low risk/low reward) “protect from the downside” buckets or the specific (high risk/high reward) “invest in the upside” buckets. Care should be taken to avoid the trap of the middle ground (moderate risk/moderate reward)  (*cough cough slow jogging) between these. 

In the return to run process, this model helps us to make sense of how to protect against downside while making calculated investments into specialized qualities that can pay dividends later on. For example, during a return to run recovery for a patellar tendinopathy, our primary focus must be in protecting from the downside (too much tendinous stress). During this time, the variety and our training methods should be relatively high and evenly distributed between general physical qualities (strength, endurance, ROM, elasticity,power etc..). This will help to maintain and improve base levels of fitness to “protect from the downside” of de-training. Concurrently, we can use a smaller amount of our resources on specificity. This can be a focus on a specific qualities to “invest in the upside”. This may include stiff contact pogo hopping to increase foot ankle stiffness or low volumes of sprint work while we are still developing tolerance to normal running speeds and volumes. Early introduction of these more specific, higher intensity, qualities early on gives us a starting point to gauge tolerance while managing risk by slowly progressing dosage and choosing the stimulus wisely.

II. Categorization 
Similar to how I simplified running injuries into stiffness or compliance in a previous post, we can simplify injuries into either intensity/magnitude or volume related issues. These certainly have a degree of overlap, however, based on the likely primary driver of the injury, we can ascertain which stimuli need to be avoided to protect against the “downside” and where we can more safely begin to intervene.

Intensity/Magnitude 
An example of a magnitude based injury would be a hamstring strain. The rate of force applied to the hamstring through a swing cycle created a tissue over-stretch and subsequent level of tearing of muscle fibers. Though there is likely an accumulation effect leading to the tissue vulnerability, for all intents and purposes the mechanism of injury is one of high force during one stride cycle. For a magnitude related issue, such as a strain, our primary concern is with the magnitude of force applied to the tissue. Specifically, the rate of loading of the hamstring as it lengths. Our manipulatable variables here will be centered around changing the range of motion of the activity and decreasing the angular velocity of the movement to decrease eccentric stress. We will need to be more cautious with the application of certain intensities but have more freedom to train a higher volumes. 

An example of an upside investment opportunity in hamstring rehab is the accumulation of high volumes of sub maximal accelerations. Often, we are able to accumulate as much as 3 sets of 10, 10 meter accelerations. This is a high volume of work that will help to maintain sprint patterning and general tissue preparedness without stressing the vulnerable tissue since the rate of loading of a hamstring is quite low in the first 10 meters of acceleration. This leads us into a window of opportunity for a more volume based entry point for return to run. 

Volume 
For a volume related issue such as a shin splints, while the intensity is certainly a consideration, our main determinants of tolerance will likely be more volume based. Within this categorization our primary controls will be modulating training volume, and changing the surface and speeds to manipulate impact forces. In the initial stages for example, the runner may be able to tolerate high intensity jumping or sprinting at low volumes. The leaves us with a more intensity biased program as an entry point into return to run.

III. How to Dose? 
These categorizations can simply provide a suggested starting point. I find this useful but it is certainly imperfect. The power in this process is the permission to train harder, earlier, and more safely through finding the tolerable opportunities. Ultimately, any intervention delivered must be gradually increased in volume and intensity and anchored to subjective and objective measurements of tolerance for the individual runner. Simply put, we must pick a starting dosage and slowly titrate this while gauging tolerance. 

Sets and Reps
There is no magic recipe for the number of sets, reps, or total distance the runner should be able to tolerate at any given stage. The best method is to simply start with a very conservative dose and titrate from there. I will typically make a best guess at what volume I expect the runner to be able to tolerate based on their previous training volumes, current level of impairment, and subjective pain experience. I then decrease this by ~10% and start there. Once we find a tolerable baseline level we can slowly titrate up from there typically with session to session changes no greater than 10-20%. 

Anchors
Subjective pain experience in most circumstances is the best measure to glean tolerance. Setting a max acceptable pain threshold for the runner (i.e no greater than 3/10) is a good way to monitor this and give the runner ownership over the daily training decision making. Another avenue to track tolerance for certain issues is repeated range of motion measures. For instance, in hamstring strain rehab, the use of a Max Hip Flexion Active Knee Extension (MHFAKE) assessment can be a decent indicator of how volumes and intensities are being tolerated. Throughout the recovery process, you should see an increase in the range of motion. If at any time you see a regression, this may be a sign that the hamstring is protectively “tightening” due to intolerance of dosage.   For an ankle or lower leg injury, weight bearing ankle dorsiflexion (posterior tissue injury) or plantaflexion (anterior tissue injury) may be a good repeat test. 

Wrapping up

Return to run is an imperfect process. A pre-fabricated plan with pre-set progression is far inferior to agile planning with room to adjust. By categorizing the issue, identifying risks and opportunities, and anchoring dosage to indicators, we can maximize opportunities while having guardrails to keep us from driving off of the road.

-Anthony

References:

1. Nielsen RO, Bertelsen ML, Møller M, et al. Training load and structure-specific load: applications for sport injury causality and data analyses. Br J Sports Med. 2018;52(16):1016-1017.
2. Taleb NN. Antifragile: Things That Gain from Disorder. 1st edition. Penguin; 2012.
3. Credit: Jovanović M. Strength Training Manual: The Agile Periodization Approach.

Running requires a balance of loading and unloading. Give and take. Yielding and unyielding. Stiffness and compliance.

A simple model that I find useful for return to run decision making is defining mechanical issues and/or mechanisms of injury as either an excessive stiffness or over compliance issue. While this way of looking at the problem is overly simplified, like it any model, it can be a useful guide despite its limitations. Stiffness lives on a spectrum. Knowing which end of this spectrum the recovering running deviates towards and the end of the spectrum that the injury occurred can serve as an entry point for early return to run interventions to both prime for mechanical improvements and protect vulnerable tissues.

The concept of stiffness in rooted in physics. It is a the amount of force required to move a deformable object, like a spring, a certain distance. For athletic performance and running, stiffness can be a super power. It is our ability to store and release energy. Increased leg stiffness is related to increased running speeds, decreased stride lengths, and decreased energy requirements. With stiff leg contacts we see decreased joint ranges of motion and an increased contribution from the ankle rather than the hip or knee. With a decreased joint excursion, we will rely more heavily on the lengthening and shortening of non-contractile tissue (tendon/fascia) to store and release passive energy rather than the active contribution from contractile tissue (muscle).

However, just like any good thing too much can be a problem. Excessive stiffness can lead to increased peak forces and loading rates due to reduced joint excursions. Think of a boxer taking a punch to the face. If the boxer rides with the punch, the forces are dispersed over a longer time. If the boxer takes it square to the jaw, the rate of impact is very high. In these situations, the force will be distributed to a smaller number of tissues, thus more focal shock. Williams et. al (2001 & 2003) demonstrated that runners with higher arches (greater leg stiffness and vertical loading rates) had a higher incidence of bony stress injuries compared to low arch runners.

On the flip side of the coin, too little stiffness increases joint excursion putting more of the force demand on contractile tissue. Williams et. all (2001 & 2003) found that runners with lower arches (decreased leg stiffness and lower rates of loading) had higher rates of soft tissue related injuries. With increased joint excursion, more lengthening is required from contractile tissue. Repeated eccentric stress can lead to micro-trauma and may predispose the runner to either an accumulated stress issue or a magnitude related issue (muscle strain).

So how does this guide our decision making for return to run following an injury? As mentioned in a previous post, a common mistake seen is treating jogging at the main entry point back into running. For most people, jogging is playing to the middle ground of stiffness and compliance. Forces are relatively high and joint excursions are as well.  We need preparation to handle these forces. We can start on the opposite end of the stiffness or compliance stress from where our issue is classified or from where our vulnerable tissue is most compromised. If we had a stiffness related issues (i.e stress fracture) we can start with our compliance bucket of drills. Starting with longer ground contacts and larger joint excursion will help to distribute the forces to a larger area. We are allowing the runner to ride with the punch thus reducing loading rates and focal shock to the recovering tissue. These include activities such as longer contact time plyometrics, box step downs to a soft landing, and slow tempo strength training.

For a compliance related issues, we will prioritize activities more biased towards decreased joint excursion to limit the lengthening stress of a vulnerable tissue. The menu here features short contact plyometrics, box step down with a stiffer landing, dibble drills, and isometrics.

Using these categorizations, we can make more calculated decisions to create the best path forward for a recovering runner or field sport athlete. Manipulating the stiffness and compliance of an activity should allow the runner to maintain the highest possible training volume to maintain desirable qualities (endurance, mechanical competency, neurological preparedness) while decreasing the risk of adverse effects during injury recovery.

Resources:

1) Butler RJ, Crowell HP, Davis IM. Lower extremity stiffness: implications for performance and injury. Clin Biomech (Bristol, Avon). 2003;18(6):511-517.

2) Williams, D.S., McClay Davis, I., Scholz, J.P., Hamill J., Buchanan, T.S., 2003. Lower extremity stiffness in runners with different foot types. Gait and Posture, in press.

3) Williams, D.S., McClay, I.S., Hamill, J., 2001. Arch structure and injury patterns in runners. Clin. Biomech. 16, 341–347.

-Anthony

As an entry point for return to running after an injury, slow jogging is a terrible option. 

There I said it.

Slow jogging or as the literature often refers to it “slogging” (Ugh, its even just terrible to say-  “Slogging)  is underwhelmingly un-athletic. It’s often lazy and lumbering. It’s lukewarm. Sport is dynamic. It is hot and then cold. On and then off. And slow jogging  is the professor that drones on about nothing of relevance to simply check a box that ultimately is left unchecked. 

What did slow jogging ever do to me you ask? It became a catch all for return to run after injury. It became a pre-requisite to sprinting and change of direction. It became the calling card of the un-calculated “just go slow and ease back in to it” approach. Running is a skilled athletic movement. It requires foundational levels of strength, elasticity, power, and endurance. Slow jogging is a dead end to returning these qualities back, and in most circumstances, is exposing the recovering runner to GREATER forces than other seemingly more intense methods would be. Not only are we slogging in circles chasing our tail, but we are potentially creating technical and tolerance issues while we do it. If this is not enough for you to join my vendetta against slogging (ugh) then please keep reading. 

Running issues (and the associate qualities that need to be built back up during rehab to mitigate injury risk) can be over simplified into two major inefficiencies:

• excess stiffness problems -too much force dispersed over to small an area (i.e bony stress)

and 

• over compliance issues – too large an excursion of ROM creating increased load in areas that may not be as equipped for repetitive forces (knee/hip) and creating increased joint excursions thus increased eccentric stress (achilles and patellar tendon) and potential accumulation of musculotendinous micro-trauma.

For many injuries, slow jogging is not the graded re-introduction to loading that we think it is. For an issues that is either related to stiffness or compliance it is in the middle ground. Ground forces are surprisingly high and joint excursions are as well due to longer ground contact times. A 2019 paper by Hunter et. al demonstrated that lower than normal running speeds actually had higher estimated cumulative tibial loads than normal selected or fast speeds of running. Slogging often predisposes runners to a more lumbering gait style in which there is a slower cadence, higher vertical oscillation, and harder ground contacts. These characteristics are associated with higher vertical ground contact forces and a faster vertical loading rate both of the elements we are trying to shield the recovering athlete from. Additionally, these qualities are not serving as preparation for the faster more elastic running that the athlete will need to progress to in order to sprint and perform specific sporting tasks. The initial return to run progression should serve as a bridge. Slogging is a dead end. It is unproductive at best. 

I will not send slow jogging out to pasture without providing alternative options. If we reverse engineer the process and look at the end goal (high quality running and sprinting) we can pick out the qualities needed to achieve success. These include the ability to produce and tolerate stiff ground contacts buffered by elastic qualities of the muscle and tendon. While slow jogging fails to train either of these qualities, progressions of drills such as rudiment hops, dribbles, skips, and bounding fit the bill. All of these interventions can be scaled and titrated with progressive volumes and intensities over time to match and progress the capabilities of the rehabbing athlete.  

For return to sport rehab, just say no to slogging. There are much better options to protect the vulnerabilities of the reconditioning process while appropriately scaling stress and promoting athletic qualities. 

-Anthony

Hunter JG, Garcia GL, Shim JK, Miller RH. Fast Running Does Not Contribute More to Cumulative Load than Slow Running. Medicine and Science in Sports and Exercise. 2019 Jun;51(6):1178-1185. DOI: 10.1249/mss.0000000000001888.

In over 10,000 NCAA 1-A Football games, the home team won 59.97% of the time. From body paint to crude taunts, teams and fan bases will go a long way to create any sort of edge to increase their probability of success. In 1979, the head coach of Iowa football, Hayden Fry went as far as painting the visiting locker room pink in attempt to create a psychological hindrance to the opposing team. 

Are we providing a home field advantage for our clients?

In our client interactions, there is an internal and external component to home field advantage. These factors live outside of the x’s and o’s but these less considered factors can have a strong impact on whether you and your client achieve your collective goals or if no show’s, decreased adherence, or frustration derail a process. They ultimately can determine the clients readiness for the interventions you are throwing at them.

⁠⁠External “Home Field Advantage”

This is the environment that the client finds them self in. Do they feel welcomed, secure, and safe to learn? Does the environment create an impression of where the process intends to take them? Do they enjoy being here for 30-90 min 1-3x/week? ⁠Picture a geriatric client  walking in for a first training session with no weight training experience. They are nervous and unsure if this is going to be appropriate for them. They have been goaded into giving it a shot by their kids but are very concerned about the potential for injury. Imagine them walking into a musty gym with death metal and dropping barbells shaking the walls. Is this person inclined to double down on their fears or jump in to the experience with both feet? This environment will likely create an extreme “away game” experience. This is not to say it cannot eventually become a home game, however, the initial resistance will likely be high. 

Of course, a home field advantage for some is an away game for others. We must curate our experience as best we can to fit the clientele we serve. Home field advantage is more than the color of the walls or music playing. It’s a timely reply to a phone call. The tone of voice and a smile. Allowing the person to feel heard. And ideally, making this a place they look forward to coming to. Our initial encounter should be centered around optimizing this environmental perception for the client. It will set the stage for the process to come, and just like with a sporting event, increase your probability of success. 

Internal “Home Field Advantage” ⁠⠀

This is the persons physical and mental state. Is the body ready to spare resources for adaptation? If the kitchen is on fire, this may not be the best time to build that new sun room. For many pain problems in our clients, the rate limiting step may be general levels of fitness. We may be unable to create the adaptations needed because they simply cannot yet tolerate the work it will take to do so. Their internal environment is always an “away game” any time the stimulus is applied. The threatened body rejects it like a gas station hot dog. We need to first create an internal environment that is ready to handle adaptation. We need to produce a “home field advantage”. 

From the perspective of motor learning, we can prime a home field advantage through aerobic training. It has been shown that as little as 10 minutes of aerobic exercise before or after a learning stimulus increases the amount of brain derived neurotrophic factor (BDNF) in the brain. BDNF is like fertilizer for sprouting new neural connection. BDNF thus, increases the potential for motor learning in an individual increasing your probability of success. Now how’s that for a home field advantage? 

Addressing these variables as needed and modifying or even stepping away from the rehab/training process temporarily to create an internal and external environment conducive to make the desired changes can sometimes be the best call. ⁠We must adapt the environment to the person in front of us and be their biggest fan. No body paint required.⁠⠀

-Anthony

We want what we want and we want it now. A microwave meal is done fast but at the sacrifice of quality. Speed often leaves us with a pizza roll that is “destroy your mouth” hot on the outside and frozen solid on the inside. Positive adaptations take time. It takes patience and the right dosage to cultivate a favorable outcome. 
 

From the time we were born, our bodies are being shaped. Muscles pulling on tendons, tendons pulling on bone, and bone shaping itself to best align with these forces. We are being constantly reshaped into more efficient versions of ourselves. Our tubercles, tuberosities, processes, and epicondyles are all products of the muscle and tendon repeatedly pulling on this area of bone. When we come across pain in one of these boney projections, or the associated tendon, in an otherwise healthy youth athlete we can assume that an adaptation is occurring too quickly. The immature skeleton cannot handle the volume or magnitude of forces it is being succumb too. This skeleton needs time to mature with a properly dosed amount of stress to guide the bodies architecture itself to handle more and more of this type of stress. 

What do Osgood Schlatter’s disease, Sever’s disease, and Little League shoulder all have in common? They are positive adaptations that are occurring way too quickly. The result of the microwave method of athletic development. 

What is the difference in a little leaguers humerus from a mature 24 year old pitcher? The bone changes in length and bone density, and the vulnerable growth plate will close. On top of this, the bone will actually twist to create a shape more conducive to throwing. The anatomy shifts to make the task more efficient. If this twist happens too fast, we call it little league shoulder (or elbow).

What is the difference between an elite basketball players tibia and that of a 13 year old? Again, besides density changes, length changes, and closure of the growth plate, the pull of the patellar tendon over time on the tibial tubercle will create an increased anterior projection. This will increase leverage of the musculotendinous attachment, thus providing increased torque producing capabilities. If this positive change happens to quickly we call it Osgood Schlatter’s disease. 

What is the difference between an elite sprinter’s calcaneus and that of a 13 year old? The posterior projection of the calcaneus will be greater creating greater leverage for the achilles tendon and the gastroc-soleus complex. If this positive adaptation occurs too quickly we call it Sever’s Disease. 

When it comes to athletic development, forgo the microwave for the crockpot. Adaptation takes time. Be patient, don’t burn your mouth. 

Flour. Water .Salt

These foundational elements combined together at the right time, given the right temperature, and combined with the bakers hand and exposure to the natural elements in the air can create something truly magnificent. The skill in making bread is not in the ingredients, it is in the process. It is in the synergy of simple elements given the time and space to work together. Its about the baker not rushing and not overly interjecting him or herself into the reaction. Be there when you need to be there and only to the extent that you are needed. The minimum effective dose of interaction. 

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• 

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The baker must know the signs of progress. Air bubbles, texture, rate of change. This takes experimentation and failure. It takes lessons learned and pattern recognition from missteps and suboptimal outcomes. A recipe is a starting point, but the skill is in the subtle adjustments.The slightly longer fermentation time if the environment is a bit colder yielded a slower reaction. It is knowing when to do nothing and just let things occur. 

Flour, water, salt all combined with the synergy of the bakers hand and time. The wisdom to know what need be changed and what is best left alone. 

As coaches and therapists, our foundational elements are education and stress. Just like with bread, these must be titrated to the context of the situation. Knowing when and how to apply these foundational elements, when to intervene, and when to stay out of the way is the magic in the process.

As coaches and therapists our job is to be a catalyst for change. We provide inputs to the persons life or suggest helpful edits. But in the process of finding the most helpful changes, we often make a mess. Our job has no protocol or script that works every time. We are often going through the closet trying on clothes to see what fits our client best. Once we find the pair of jeans that works we are often left with a room strewn with litter. 

What mess are we leaving behind in our course of care and client interactions? Is it a list of exercises a mile long that the client thinks they will need to do forever? Is it a narrative that is not useful? We have all seen the resulting effects on client who has held on to this clutter. Perhaps it is a belief about having to sit upright with their shoulders back from comments about poor posture as a child. Or a fear of weight training from a bad experience or ill fated story. Perhaps it’s an accumulation of junk that has led to feelings of fragility. Our interactions must be finalized with clean up. Well intentioned comments are often misinterpreted.

Unwrap and review the process.

Pick up the garbage and try to make your process as junk free as possible. 

Clean up after yourself. Don’t litter. 

– Anthony

Be agile. Rigid plans and programs are handcuffs. Shorter iterative plans allow us to make decisions based on the most recent data. They allow us to course correct in real time. Know where you are heading and establish checkpoints to make sure you are going in the right direction. But allow flexibility in how you get there. This is coaching. This is patient centered care.

How to Establish an Agile Plan:

It can be very useful to frame any process as a series of short sprints. Think of this as akin to software going from version 1.0 to 1.1 to 1.2. We can focus on making the next small change with the vision of 2.0 in our mind. These sprints need to lead to an imbedded test to allow us to know whether we have truly reached the next version and if we are still on track as originally planned. These short sprints allow us to quickly shift gears as needed. In patient care or coaching, this is a way to quickly calibrate based on response to a stimulus. This can be organized using a tool called a PDCA loop. PDCA stands for Plan, Do, Check, Act. I will break these four components down.

Plan:

Based on my assessment, what is the first step towards the goal. What is the “rate limiting step” in the equation that will allow the rest of the process to continue with less resistance.

“Based on my evaluation, we are going to start with isometric loading to bring some additional blood flow to the tendon, desensitize the area, and gauge tolerance to conservative loads.”

Do:

Carry out the plan. Initiate your first step. Apply the first stimulus.

“Begin with 4x45s single leg heel raise iso holds 3x/day”

Check:

Assess progress towards the desired outcome. Collect the relevant data and identify positives and unanticipated issues.

“Patient reported that isometric holds were 2/10 painful for the first 2 days and then reduced to 0/10 on the 3rd and 4th days”

Act:

Adjust based on feedback from this first loop. The overall process can be revised and updated during this step. Are we still headed in the right direction? Is there a faster route? Do we need more information?

This of course, is followed up with our next planning phase and the loop continues until the desired outcome is met. Rigid plans do not work with human beings. Too many variables change day by day. There is too much information we do not know when creating these plans. We need to respect the emergence of new information that will ultimately allow us to be more accurate tomorrow than I am today. Start with a system that optimizes for this. PDCA.

– Anthony

One major role of a coach and therapist is to align expectations to reality. It is our job to be a more objective lens. An experienced guide that can see past the clients limitations in perception.

At time this is the role of the hype man/woman. Building confidence to allow them to see their potential. Showing them that they truly are resilient and adaptable. Allowing their perception to match their innate or trainable capabilities. Here we must put them in situations to succeed.

At other times, we must show them failure. We must take them safely to the task that they cannot yet manage. We must show them that despite their perception, they are just not quite there yet. 

It is our job to titrate the experience. To align expectations to reality. To keep it real. 

– Anthony