Training the unstable client

I began training Amy* 8 years ago. She came to me because she wanted to build strength and prevent her osteoporosis from getting any worse. I was a much greener trainer at that point, and did my best to challenge Amy with heavier weight, dynamic movements, and body weight exercises. This didn’t go so well, and it became obvious that Amy was unable to support heavier weights, particularly in her upper body. Her shoulders were sloppy, and she didn’t have the ability to perform the movements in a technically proficient way. She also had some instability in her hips, and would occasionally get hip pain. 

My first three years with her was a lot of trial and error to figure out what wouldn’t bother her shoulders and her hips, but would still give her strength (some of my clients are amazingly patient people. Why she stuck with me, I will never know). It wasn’t until I began studying joint position and mechanics and actually understanding how that impacted function that I was able to help her. Instability is rampant in the yoga world; to be good at many of the advanced postures requires quite a bit of mobility. While this should be balanced with an equal amount of strength, it is not unusual for people that already possess a large amount of mobility to gravitate towards the practice. Unless they spend time focusing on finding strength in each asana, this can be detrimental and lead to a lack of cohesive movement. The body will move in a way that lacks underlying support- it’s like removing the foundation of the house and hoping that the beams are strong enough to hold up the roof.

To understand the importance of joint stability, it is important to have a brief understanding of how the nervous system works. When we want to lift our arm, for example, the brain sends information via motor neurons to the appropriate muscles required to both stabilize the body for the action and to the muscles that lift the arm. Inside the joints are sensory nerve fibers that provide information to the brain about forces exerted on the joint tissues, joint position, and whether or not the joint is moving (Grubb, 2004). The nerve fibers that provide this information are called proprioceptors, and are located in the joint ligaments. This poses a problem when a person has joint laxity, or ligaments that are overstretched. In the shoulder, for instance, it is believed dynamic ligament tension is involved in signaling how much force the rotator cuff muscles need to exert on the humeral head (Kelly, 2002). If the ligaments lack tension, this would alter the activity of the 4 muscles of the rotator cuff, as well as decrease the stability of the joint simply because the ligaments aren’t doing a very good job keeping the shoulder in the socket. In a healthy joint, full range of motion should be pain free, the person should know where his arm (or hip, or ankle) is in relation to his body, and there should not be a fear that something is going to “slip” or “fall out,” common descriptors when you work with hyper mobile clients. It has been my experience that when someone falls into the category of hyper-mobility, it is important to change the training strategy to give stability on the deepest level.

In the case of Amy, she returned one summer from travel with shoulders that were not in a very good position. They were painful, her neck was overactive, and she said she couldn’t figure out “where they [the shoulders] are supposed to be.” At this point, I suggested we back off the weights for a while and try and a different approach. She agreed, and while it was frustrating at times, (“why is this so hard? I am not doing anything”), we progressed slowly and steadily. I gave her things to be aware of when she wasn’t with me, such as how to move from the scapula rather than the shoulder to reach for things. We worked on other things as well, such as breathing and improving her thorax/pelvis integration, and eventually we got back to weights, though I don’t have her go very heavy (she is 64, and I find it is better to train smart with older clients, rather than harder). She said to me last week, “thank you. My shoulders haven’t given me trouble in a very long time, and I feel way more stable.” Sometimes, people need mobility, sometimes they need strength, and often they need a combination of the two. We tend to avoid the things we aren’t good at; these are frequently the things we need the most. Having a little patience and an overall plan can go a long way in improving function and well-being.

Yours in health and wellness,

Jenn

P.S.- For a glimpse of some of the things I use to enhance shoulder stability, view the link here: https://www.youtube.com/watch?v=pmY8J2EVxuM

Grubb, B.D., (2004). Activation of sensory neurons in the arthritic joint. Novartic Found Symposium, 260, pp. 28-36.

Kelly, I. The Loose Shoulder, Maitrise Orthopedique, 111.

The Integrated Systems Model, and evidence based practice

I recently listened to Diane Lee's lecture on the Integrated Systems Model, which she uses to classify her treatment strategy (more information can be found on her website here: http://dianelee.ca/the-classroom.php). I am quite fond of her presentation style- she has a good sense of humor, doesn't seem to take herself too seriously, and is passionate about her subject matter. If she allowed personal trainers to take her courses, I would figure out a way to get up to Canada and attend one of her 4 day workshops. She made a number of points in this particular lecture that resonated with me, and one thing she discussed rather extensively was evidence based practice.

Evidence based practice (EBP) has become a bit of a buzz word in the last 5 years. Practitioners want credibility, so they search out evidence (i.e., research) that demonstrates they are on the right path, while consumers want proof that what they are doing will help them become healthier/fitter/stronger/better. This is fair; the profession of exercise or movement science is quite young, and for every person that claims exercise helped, another says that exercise caused pain. It is muddy, and unclear, and everyone has an opinion. The term "evidence based medicine" was coined by Dr. David Sackett in 1996. He wrote, "...evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients," (http://en.wikipedia.org/wiki/Evidence-based_medicine). According to Ms. Lee, there are 3 components associated with this. The first (and the one most people attach to) is the research. For the research to be high quality, it should be a random control trial. Here is the thing with research when it comes to exercise- you can find a study supporting almost any view you want to take. In graduate school, I noticed over and over again during class discussions that people could take completely opposing views on something and there would be research to support both sides. By the time I was in my second year, I began to realize that sample sizes of things I was interested in were typically extremely small, the studies weren't always designed in a way that mimicked actual performance (who runs solely on a treadmill?), and not very much research on functional exercise or performance actually existed. I read through several studies last weekend examining deep core stabilization and how the intrinsic muscles of the core affect function. What I found was dismal. Saunders, Roth, and Hodges state, "despite the importance of the deep intrinsic spinal muscles for core control, few studies have investigated their activity during human locomotion or how this may change with speed and more of locomotion." This was in 2004, and not much has been done in the last decade to improve upon this.

The next component to the evidence based model is expertise. Experience comes from learning the material, practicing the material, and figuring out how to apply it. In the ISM, having a variety of tools is encouraged; the key is knowing when to apply those tools. It took me a while, but I eventually realized I am happiest in my career when I am learning. I find that what works best for me is learning a system fairly well, integrating it fully into my own workout/movement practice, and then using it with my clients. At this point, my tool box is diverse, and I feel comfortable using what I know. When I first learn something, I tend to use it on everyone; as the material becomes less foreign to me, I am able to more readily identify which tools fit best with each client. This is the final component to an evidence based model. The sample size that ultimately matters is when n=1. Not every modality works for every person. Some people respond really well to certain things, while others need a completely different approach. Working solely in an exercise setting, I can genuinely say I have experienced situations where 90 percent of clients do really well with one particular movement, while for the other 10 percent, that movement doesn't work at all. Experience comes largely into play, and over the years, I find I am able to figure out the best course of action with people a little more quickly.

Another note about EBP is a lot of the techniques that are out there are seriously lacking in research. Anecdotally, people will tell you "system x/y/z changed my life." Again, the sample size of n=1 is what matters. The beauty of this is that there is something out there that will work for everyone. It might take a while to find it, but patience and an open mind are key. From a consumer's perspective, I recommend trying something 4-6 times. This is enough time to let you know whether you a) hate it, b) don't really mind it, but aren't sure it's doing something for you, c) notice a little bit of difference, but maybe that's attributed to the 5 other things you changed at the same time or d) you know in your heart this is it. It's changing your life. As a practitioner, it is extremely important to learn things that resonate with you on some level. Maybe it's the material, maybe it's the teacher, but whatever it is, it needs to move you to learn it well and apply it in a manner that your passion for the material can be conveyed. This means that maybe not every workshop you go to will work for you, and maybe some things will work for you for a while, but then you might stumble upon something else that works a little better. Or maybe one specific system is your thing and you want to study that intensively for years. Find what works for you. Personally, I find that each system/teacher has strengths (and obviously, I haven't studied every system that is out there); the flip side, is they all have weaknesses. This is why I immerse my body into whatever it is I am learning about. I try it on, see how it fits, see how it makes me feel. Studying anatomy and physiology and reading a bit about the brain also allows me to better understand why things work (and I am very much a "why" person). Keeping an open mind when it comes to movement techniques and searching out quality, passionate instructors will help individuals find movement that they both enjoy and enhances their lives.

Yours in health and wellness,
Jenn

Some quick notes on the importance of the pelvic floor and why the body's second diaphragm should be addressed during movement

Over the last 8 months, I have become fascinated by the role pelvic position plays on the body's stability. More accurately, I discovered the importance of the pelvic floor on all things low back oriented. I train many people that suffer from low back pain. some of whom have had surgery, others that are trying to avoid surgery. While many of them have positional similarities, the most striking similarity I have found (now that I know to look for it), is the inability to maintain pelvic position with activation of muscles that work in the transverse plane, such as the transverse abdominis and internal rotators of the hip. Once this is cued correctly and the person knows how to "find" the proper engagement, stability increases dramatically (and people feel their "core." It's pretty amazing). While there are often other things that need to be addressed in these clients to improve function, this is an incredible starting point. The senior yoga people have been trying to explain this to me for years; however, rather than explain the anatomy, they use mystical terms such as mola bandha. I think many of the advanced pilates/gyrotonics people might know this, but I have never been fully immersed in that world, so I can't speak for sure.

The pelvic floor is often considered the body's second diaphragm. When there is a physiological change in the diaphragm, either during inhalation, exhalation, or coughing, there is a symmetrical change in the pelvic floor activation (Bordoni and Zanier, 2013). In order for proper intra-abdominal pressure to be maintained during respiration, support from the pelvic floor is required. This ensures trunk stability, and corresponds to activity in the transverse abdominis and internal obliques- therefore, if your pelvic floor isn't working properly, your deep abdominal muscles probably aren't working properly, causing an alternative (and less efficient) stabilizing strategy.

How does this relate to pelvis position? It is worthwhile to note that the pelvis is required to move in all three planes (sagittal, frontal, and transverse) during the gait cycle (Lee & Lee, 2011).  The sacrum, which attaches to the pelvis at the sacroiliac joint, needs to nutate and counter-nutate during various movements. For the purpose of this blog, think of the sacrum as something that moves slightly to handle load dispersal. If the sacrum is unable to move because the pelvis isn't able to move in all three planes, load will not travel well up the spine. If, for instance, someone remains in an extended posture most of the time, the anterior inlet spills forward and abducts, and the posterior inlet moves backward and adducts (see picture below). Think of what happens to the sacrum if the pelvis is stuck in this position- it can't move and the muscles on the back of the pelvis (specifically the piriformis) are going to be "gripping" to keep a person upright. Further, the muscles in the pelvic floor are long and loose- they aren't able to provide the support needed for the bottom of the canister to co-contract and provide stability. This is going to lead to movement inefficiencies (and possibly SI joint "tightness" or pain). In this example, to move the pelvis to neutral, we need to inhibit the piriformis by activating the internal rotators of the hip, activate the hamstrings to pull the pelvis down in the back, and activate the transverse abdominis and internal obliques to pull the pelvis up in front. In a sense, we are mobilizing the pelvis so it can move more freely during the gait cycle. (For some ideas on how to work with someone in an extension pattern on co-activation of the muscles in the pelvic floor, see the video: http://youtu.be/UtJnY0MhIPA).

(The anterior pelvic inlet is labeled in the picture above. You can see how when the pelvis tips forward, it will give the appearance that the top portion of that circle is widening. Conversely, the posterior pelvic inlet, which would be the view from the back and can be seen in the picture below, will appear to narrow when the pelvis is tipped forward. If you look at where the SI joint is located, you will notice that if you tilt the pelvis forward, the sacrum won't have much room to move).

As I have mentioned before, I view my job as a movement professional to help people move as efficiently as possible. This is directly related to the body's ability to stabilize on the deepest level, and really, it means having an understanding of what is required for the body to do that. If the pelvic floor and the engagement of the deep abdominal muscles is ignored, performance will be hindered. The crazy thing is I have watched efficiency (and movement quality) improve dramatically in yoga practitioners, golfers, and triathletes by simply improving the function of the deep stabilizing system. I have also seen grandparents pick up their grandchildren without pain, and low back pain lessen. Anatomy and physiology in the absence of disease is consistent- understanding how the body works dynamically is the most valuable tool a movement professional can have.

Your in health and wellness,
Jenn

P.S.- If you find this topic interesting and would like to study it further, I highly recommend Diane Lee's work (her website can be found at http://dianelee.ca/index.php) and/or the Postural Restoration Pelvis course (either home study or live).

Bordoni, B., & Zanier, E., (2013). Anatomic connections of the diaphragm: influence of respiration on the body system. Journal of Multidisciplinary Healthcare, 6, pp. 281-291.
Lee, D., (2011). The Pelvic Girdle, Fourth Edition. Churchill Livingston Elsevier: Toronto.

The problem with SMART goals, pincha mayurasana, and why it's okay tofail

I read a lot of blogs. And research articles. And non-fiction books (I was interviewed recently about the personal training industry. I told the journalist I had a continuing education problem, but perhaps it's more of a curiosity problem). I always enjoy the writings this time of year because they tend to be reflective and/or hopeful, focusing on what was accomplished or where the author wants to go. An acronym that is thrown around frequently when people talk about resolutions is SMART goal setting. I wrote a blog on this years ago, when I was in the midst of a Wellcoach training program and convinced SMART goal setting was the only way. Needless to say, my views have changed a bit, although I think setting goals that are specific, measurable, attainable, realistic and timely are great for people that have daunting tasks ahead of them ("I will lose 5 pounds this month" is a much better goal for someone with 100 pounds to lose than "I will lose 50 pounds in 4 months." The person needs something within his grasp to experience success, rather than a seemingly insurmountable task). For some, the word "attainable" is synonymous with "safety," and this is where I think the acronym shouldn't always apply.

I have written before about the fact that I am stuck in PSP (primary series purgatory). This happens to individuals that are relatively inflexible Ashtanga yoga practitioners with limited access to a teacher. These individuals never get progressed because they aren't technically proficient at, say, supta kurmasana, so they remain in PSP for years. This leads to boredom and eventual exploration of other poses. I decided to work towards arm balances, because they look cool, and posed a physical challenge that I didn't think was impossible. I suppose it could be argued that this fact makes my goal attainable, but I never set a time limit on it, or even really had any other aspiration other than to do pincha mayurasana in the middle of the room. I started working on this two years ago (yes, you read that right. As I said, no time goals). My first attempt (done after several youtube tutorials and some floundering attempts against the wall), resulted in my falling. So did my second. And third. And when I tried again a couple of days later, I fell. I fell over, and over, and over again until one day, my legs were over my head and I was balancing on my forearms, almost certainly with a bowed back because I didn't have good shoulder girdle strength at the time (I know now), but the point was, I was up. I was able to repeat this pretty regularly, not always on my first attempt, but usually on my second or third attempt, until I felt like I could safely say I could sort of do the posture. Over the last year, I have rebuilt my practice with a neutral spinal position, the ability to engage my bandhas (it turns out, if you ask someone in an extended spine position to engage the bandhas, it's pretty close to impossible, but that is another blog), and a much better integration of the shoulder stabilizers. As a result, pincha mayurasana continued to feel steadier until one day, 4 weeks ago, when I kicked up with a fair amount of control and fell over. "No big deal," I thought, "I will try it again." And I did, 7,8,12 times until my arms were shaking, deep frustration had filled me, and I finally recognized my mind and body weren't going to cooperate, so I let it go and finished my practice.

This, of course, is the beauty of any sort of challenging, mindful movement practice. It teaches you to fail, walk away, and know that you can attempt it again tomorrow. It is also the reason we have to remember to set goals that are slightly out of our reach, maybe not attainable on the first try. When I was going through the process of opening my studio last summer, I found myself thinking at one point, "what if this doesn't work?" I had run numbers, looked at business trends, and consulted with someone I trust, but there is no way of knowing for sure whether or not a new business is going to fail. Opening my own space had been a long term goal of mine for years, and similar to my goal of forearm balance, I never set a timeline for myself. I simply put it out there as something I wanted to do (it was written on my regrigerator), and when the opportunity arose, I jumped with both feet. Rather than dwell on my negative thoughts, I acknowledged it, let it go, and instead directed that nervous energy at becoming an even better professional. Recently, while working with a client, coaching, cueing, and guiding, I realized, "I finally get it." All of those concepts I have struggled with over the last 13 years, watching people move, reading, listening to experts in various movement fields explain "how" to help someone move better, the systems that I have studied, all came together in this crazy way. This isn't to say I don't have more to learn, or that I know it all; I have only scratched the surface, but all of the time spent learning challenging concepts is allowing me to do my job better than I ever have before.

When I returned to my yoga practice a couple of days later, I lifted up into pincha mayurasana with ease. Each time I have practiced it since, I feel stronger and steadier than I ever have before. I have read about this with skill acquisition; often there is regression before there is progression. While I expect I will still fall, I am confident it will happen less and less. When setting New Year's resolutions, remember It's okay to fall, and it's okay to fail, as long as you pick yourself up and try again tomorrow. You will be better for it.

Wishing everyone a healthy, happy 2014.

Yours in health and wellness,
Jenn

The little muscle that could, or why the serratus anterior is important for stabilization

I have come to the realization that I don't like the way anatomy is traditionally taught.  During my undergrad, we went to the medical school at UC Davis, looked at prosections, and learned the muscles of each section- their actions, their origins, and their insertions.  We never looked at how the body as a whole functioned to move, or approached anatomy the way I like to think of it now- these chains of muscles provide postural stability, these chains of muscles provide the strength necessary for movement, and here is how they interact (more anatomy trains-esque, although I am finding that understanding how to walk well is key to athletic performance.  If you aren't walking efficiently, you aren't going to move efficiently during basketball, yoga, Crossfit, or whatever athletic endeavor you pursue).  Prior to starting my graduate studies, I spent a weekend studying yoga with Kino MacGregor.  She talked about "filling in the space between the shoulder blades" and activating the "serratus anterior." I was intrigued, both because it changed the way my plank felt and because it was a muscle I had heard of, but never given much thought to.

Fast forward four years: I have learned the serratus anterior is both critical for walking well, important for shoulder girdle stability, and begins the chain of muscles that stabilizes the core.  The serratus anterior has attachment points on the front side wall of ribs 1-8 and the front surface of the scapula (http://www.anatomyexpert.com/structure_detail/5505/151/).  It shares attachment points with the diaphragm, which has attachments at the xiphoid process, ribs, and lumbar spine.  The diaphragm crura blends with the crura from the transverse abdominis; the diaphragm fascia also intertwines with the fascia from the psoas (Hatley, 2006).  The serratus anterior (SA) protracts the shoulder blades and stabilizes the shoulder girdle and, like the transverse abdominimis, fires before you move to provide stability.  The diaphragm is a muscle of inspiration and aids in postural stabilization.  Its ability to properly dome up is based on the position of the rib cage (Hruska, 2005). This ultimately affects the ability of other muscles of the core to properly function, specifically the internal obliques and transverse abdominus. The transversus abdominus (TrA) is essentially the SA of the lumbar spine.  It creates intraabdominal pressure and provides stability before movement, acting on a feed forward loop.  The psoas flexes the hip and provides lumbar stability. Anteriorly and from a stability perspective, this links the shoulder to the hip in four steps.  The interesting thing about all of these muscles is their ability to properly stabilize is position dependent.  If you have scapula that are retracted in a resting position, your SA isn't in a good position.  This is going to limit the ability of both the diaphragm and the TrA to properly function.  If the scapulae are retracted, chances are high that during rest, the rib cage is in an inspiratory position, which will affect pelvis position.  The ability of the deep stabilizers to work together is necessary for efficient movement mechanics, so while this started as a discussion of the oft forgotten serratus anterior, it's really a discussion of one piece of the deep stabilizing system.

Diaphragm Image

So how do we make sure it is working and why do we care?  We care because if it's not stabilizing the shoulder girdle, something else has to, and usually that something else is the latissimus dorsi, rhomboids, and upper fibers of the trapezius.  These muscles affect resting position of the scapulae, which is problematic if you raise your arms overhead for any reason.  They also affect resting position of the pelvis, with an overactive latissimus tilting the pelvis anteriorly. This can also lead to a "pain in the neck," quite literally.  Breathing should not take place with the shoulders elevating each inhale; when this happens, the upper trapezius and scalenes are going to be working overtime, which can cause overuse.  This also means the diaphragm isn't working properly, which means the lumbar spine isn't being properly stabilized, which means the pelvic girdle isn't in an optimal position.  In order to improve efficiency, the SA needs to be addressed.

The next question is how?  First, we have to inhibit the overactive muscles and improve position, so the SA in a better position to do its job.  If the scapulae are pulling away from the back, the scapulae retractors are working in over time.  To stretch them, we are going to protract the scapulae and bring the rib cage back to meet the shoulder blades. Protraction also fires the SA, so we are killing two birds with one stone.  Once the thoracic spine is less locked up and the scapulae are resting on the back, we can work on position.  The medial borders of the scapula should be parallel to the spine at the level of T2-T7 and flush against the thorax (Osar, 2012).  I use a tactile cue, which is demonstrated in the video below, but the key is to get the sense that the upper back is broad and the scapulae are gently being pulled down and around the back. This will inhibit the upper trapezius and activate both SA and the lower fibers of the trapezius, which relaxes the overactive muscles in the neck in people that are neck breathers.  This needs to be done in order; skipping directly to lower trapezius/SA stability won't fix faulty shoulder position.  The goal of all movement direction and cueing should be efficiency- how can we get the body to move well with the least amount of effort?  This doesn't mean there won't be work; it simply means the body will work more cohesively, and ultimately perform better.

A quick side note- I find it is helpful to remember the shoulder girdle functions like the hip girdle.  If we can relate the function of the muscles in the shoulder girdle to those in the hips, it sometimes makes things a little less foreign.  I will be discussing this in an upcoming post.

Yours in health and wellness,
Jenn

Video link: http://youtu.be/KEqv3V9-htc

Hatley, S., (2006).  Anatomy and Asana: Preventing Yoga Injuries.  Eastland Press: Seattle
Hruska, R., (2005).  ZOA position & mechanical function. Postural Restoration Institute, viii-xi (http://www.posturalrestoration.com/resources/dyn/files/1051512z69443dbe/_fn/ZOA.pdf)
Osar, E., (2012).  Corrective Exercise Solutions to Common Hip and Shoulder Dysfunction.  On Target Publications: Aptos.

Four examples of how I use PRI and DNS during training sessions, plus a plank variation...

I often get asked by other fitness professionals that are studying neuromuscular techniques or are thinking about studying neuromuscular techniques if I use it.  "Yes," I always reply, "all of the time." The inevitable follow up question is how?  How is it implemented into sessions that are supposed to be strength and mobility based?  How do you find the time to test/re-test and actually use some of the correctives when really, our job as trainers is to get people strong? Below are four examples of clients that I use the techniques with often.  The principles of DNS/PRI are utilized in every session I perform; the depth to which I use it depends on both the client's goals and how the client wants to use the session.  I should caveat this with a little about my clientele.  I do not have individuals walk into my studio that have absolutely nothing wrong.  This just doesn't happen.  Even if the person says he has no musculoskeletal issues, after 30 minutes it isn't unusual for there to be references to car accidents, shoulder surgeries, migraines, and my favorite, open heart surgery (while not a musculoskeletal injury, it still seems something worth mentioning to your trainer at the initial intake, but apparently not everyone shares that sentiment).  And, despite what some might think, I do train people under the age of 60.  They have things going on as well (degenerative disc disease at 40?  I am totally your girl).  The take home message is many of my clients have tried traditional exercise programs and have either been injured or had the feeling they were going to get injured if they continued on that path.  And so they end up in my studio, looking to me for guidance, for a safe program that will make them strong and able to do the things they enjoy in the real world.

Kate* is a 70 year old former professional dancer.  She has had chronic neck pain for the last year (diagnosed OA), suffered from a bout of spondololythesis about 16 months ago, and wants to gain functional fitness. She walks regularly and has participated in a variety of fitness programs over the years (her dance career ended in her late 20s).  She is also missing something structural in each foot (fairly certain it is a bone, but not 100 percent).  As a result, she has never been stable standing on one foot.  The very first session, I used DNS techniques to activate her SA (supine and prone 3 month model).  I also taught her how to bring her ribs to her shoulder blades, drop her ribs down, and activate her IOs and TA using PRI breathing techniques.  I did run her through some of the PRI tests, and she has instability issues in her hips.  After we worked on those things, I taught her how to stabilize standing, using her "center." She was able to stand on one foot for the first time in decades without pain or unsteadiness.  We have since progressed to dynamic balance using stepping sequences.  We discussed breathing and I showed her a handful of breathing techniques to help shut off her neck.  I have learned the hard way not to load an overactive upper trapezius.  Bad things happen.  Fast forward 6 weeks.  She walked in for her weekly appointment and said to me, "before we start, I have to understand what we are doing."  "What do you mean?" I asked.  "For the first time in a year, my neck pain has subsided.  You haven't touched my neck.  What are you doing?" This is the power of beginning to understand reciprocal inhibition and facilitation, coupled with the client having the awareness to notice breathing patterns.  She has also told me repeatedly how excited she is to stand on one leg.  It's empowering to be able to do something that has alluded you for most of your life.  We are slowly progressing to a more strength based routine with an emphasis on proper alignment and breathing.

Pete* is a 58 year old executive.  He has been active his entire life and has a bit of a type A personality.  He had low back surgery 16 months ago (disc repair), and, unfortunately, a negative physical therapy experience.  He began seeing me 12 months ago to regain fitness and get back to the activities he enjoys.  We started with working on DNS principles of getting the rib cage more neutral and engaging the SA.  We also worked on the external rotators of the hips and on the integration of the foot and hip using DNS techniques.  We got a bit stuck (he was plateauing, and I wasn't really sure where to go), so a PRI physical therapist assessed him and gave me some ideas.  We had one more set back, involving a very bad adductor drop test that I didn't address at the end of the session and a back spasm the next day (pretty sure it was related to moving furniture, but I didn't tend to my details when I should have, so I placed much of the blame on myself), and are now working towards neutrality by testing at the beginning of the session, repositioning, emphasizing breathing during the core work between the circuits, and re-testing at the end.  He also has breathing homework that he might be doing sometimes (I am not really sure how often, but I know that he is at least more aware of his breathing and knows how to get his ribs down).  He began playing golf 4-6 months after we started working together, walks regularly, and says he is the most fit he has ever been.  He made an interesting comment recently.  He has been working out with trainers off and on for the last 30 years, and he said he noticed that while he got older and his needs changed, the techniques the trainers used stayed the same.  I am the first trainer he has had that approaches things differently.  While I think more and more trainers that are serious about training as a profession are starting to use different techniques, I thought it was a fascinating glimpse into an industry that is slow to adopt new ideas. I am hopeful that in the next 4 months I will be able to help Pete move even more efficiently and enable him to continue doing the things he enjoys.**

Jess* is a 33 year old professional.  She is extremely active and movement keeps her sane.  I have worked her off and on for about 5 years.  We have always done more traditional strength training sessions, using primarily body weight, suspension trainers, and some weights.  She e-mailed me 4 months ago before one of our sessions to ask if we could just spend the hour stretching.  She was experiencing a lot of pain in her mid back, her hips were killing her, and she was sure she was going to have to give up running, which was making her sad.  When she arrived the next morning, I told her I was happy to spend the hour stretching if she thought that's what she needed, but I suggested we try some other, out of the box, things first.  She said that would be okay, so I ran her through some of the PRI tests (which made it pretty apparent why her mid back was bothering her), and we spent the next hour working thoracic mobility with breathing, engaging her IOs and TA, and helping her shut off some the things that were in a state of overactivity.  I told her to not make any declarations regarding running yet; rather, see if she felt better after our session, and see how things went.  She e-mailed to say she felt much better, and over the next 4 months we worked on activation with breath and have recently begun working on balancing out her frontal plane.  She is feeling much better, her mid back pain is gone, her hips only bother her when she does too much and throws herself back into an extension pattern, and she is running pain free (not everyday, but every other day).  We are back to devoting most of our session to strength and mobility work, but spend time in the warm-up on activation/inhibition techniques, and I make sure position is encouraged throughout our workout.

Jenn is a 33 year old personal trainer.  She loves all things movement, and has been active for as long as she can remember.  She runs and bikes (often), swims (a little), practices yoga, and spends some time in the weight room working primarily on body weight drills with a little bit of kettlebell work thrown in.  She pulled her hamstring in the gym 5 years ago and while the pain went away, she never really addressed the root of the problem.  She re-injured it a year ago during a daily yoga regimen that wasn't really that mindful and coincided with running a trail 1/2 marathon.  She began implementing some of the DNS positioning techniques and also began using a regular DNS flow as part of her daily warm-up.  It began to heal, and she noticed things were feeling a little bit better, but than she got a bit stuck.  She began learning PRI and it became obvious that she needed to address some major extension issues if she wanted to continue playing hard.  She began doing PRI every day with DNS as part of her warm-up (about 10 minutes) and implemented some of the PRI exercises during her 3 days/week gym routine.  She utilized the philosophies of both DNS and PRI in her yoga practice, and noticed a change in how she moved and how she felt.  One day, while running herself through some self PRI tests, she discovered she was actually in a state of neutrality.  This made her want to jump for joy, but instead she used it as an opportunity to progress to learning some of the PRI standing exercises.  Her low back no longer feels any sense of compression in back bends, her shoulder blades don't feel a sense of "tightness," and her hamstring feels wonderful.  She strongly believes DNS and PRI together are powerful tools.

Below is a link to a plank sequence I use when I want to activate IOs and TA.  It emphasizes breath to activate the abdominals and focuses on the ribs being in a state of exhalation.
https://www.youtube.com/watch?v=BMqbT_Q2B9k

*All names have been changed except for the last one.  Jenn, as you probably guessed, is me.
**Two days after I published this blog, I received a phone call from Pete's doctor.  He was impressed by Pete's mobility, strength, and overall fitness, and was wondering if he could refer people to me.  He has been looking for a fitness professional that "gets it" and is able to work with more difficult conditions for some time.  I am grateful I found methodologies that make sense to me and have such a profound affect on people's wellbeing.

Yours in health and wellness,
Jenn

Lakshmi, PRI re-positioning, and the brilliance of DNS positions

I was at a yoga workshop last weekend where the teacher discussed some of the Hindu goddesses.  One of the goddesses, Lakshmi, is the goddess of wealth, both internal and external.  As the teacher explained Lakshmi's influence over fortune, she said that part of Lakshmi's power is that she tends to the details.  Tending to the details allows wealth to grow and will result in good fortune, not necessarily in the form of money, but in an internal sense.  It was one of those stories that stayed with me for the week and made me wish I had more patience for the Indian texts (I failed miserably at my one and only attempt at reading the Bhagahavad Gita.  I lasted half a page).

Fast forward 5 days.  I was training a lovely endurance athlete yesterday who has gone from pretty much bullet proof to having some things crop up.  This, unfortunately, happens to endurance athletes, and if they don't get a handle on the root of the problem, they end up spending the next 10 years of their careers "chasing pain" so they can participate in their respective sport.  I have worked with her off and on for a long time (4 years), and I decided yesterday to run her through some of the PRI tests to see what was going on and to give her a more directed, therapeutic program for the off season.  There was only one glaring issue (left AIC), so off to work we went.  After 10 minutes of re-positioning work, I re-tested her, tending to my details, found she was in a much better position, and we moved on with our session.  While we worked on the normal strength training stuff for her upper body, I used several DNS positions for her lower body to try and improve some of her firing patterns.  Her main issue seems to stem from an old ankle injury and her right glute max is taking a pretty intense vacation.  I started her in DNS side lying, couldn't really get any activity there, moved to 3 month supine mode, where I had much better success, and then skipped forward to tripod sit, which is far more developmentally advanced.  She is a crazy endurance athlete after all; I figured I should be able to get some activity going and add some challenge.

While I was moving her through the DNS positions, it occurred to me how brilliant the system really is.  The goal of PRI is reciprocal, alternating movement; DNS addresses movement dysfunction via developmental positions.  The goal of the baby ultimately is walking which is reciprocal, alternating movement.  The higher developmental positions do a wonderful job with pelvic orientation and  addressing strength and mobility needs specific to various stages in the gait cycle.  In many ways, it makes the job of the movement professional easier- make people walk well.  Only then are they going to be able to perform well athletically.  Tend to your details.

At the end of the session, I put her back on the table to re-test her position.  I do this with people when I begin working on improving position.  I want to make sure I am on the right track.  Her left leg didn't drop.  At all.  I had undone her position.  This has never happened to me before- my sessions always address the needs of the individual and I pay attention when there are significant imbalances.  But I had skipped steps.  When she couldn't activate in side lying, I moved her backwards, only to jump forward again.  The neurology wasn't ready for that.  I didn't tend to my details and instead of taking the proper steps, I tried to skip ahead.  I promptly re-positioned her using PRI techniques, re-tested, and she was back to the position I had attained at the beginning of the session.  The take away message: don't rush the process.  Systems exist for a reason and you cannot cheat the system when it is based on neurology.  And don't forget to tend to your details.

Yours in health and wellness,
Jenn