Vaulting: Using Unconventional Movements to Enhance Strength, Mobility, and Well-Being


One of my favorite post-rehabilitative exercises is vaulting. Yes, you read that right, as in figuring out ways to navigate objects that are off the ground. Or, more accurately, the steps towards tripod vaulting or the butt roll vault or any other variation that involves weight bearing on a hand while navigating an obstacle with the torso and legs.

Now, it’s true that most of the shapes made while vaulting can be made on the floor. It’s also true that most people won’t feel the need to use a tripod vault to deal with a tree that has fallen down or to jump a fence because a) the obvious solution to a downed tree is to go around it b) if a fence is prohibiting you from accessing a specific place, the fence is probably there for a reason and the legality of jumping the fence is probably questionable and c) unless you practice vaulting, you don’t realize it’s even an option to vault over the tree or over the prohibitive fence. Learning to trust the limbs to coordinate and support you while you manipulate your body over objects has benefits that extend beyond accessing questionable locations and can improve proprioception, strength, and mobility in joint positions that aren’t often used in most people’s daily lives.


The Benefits of Novelty and Variability:

Let’s start with the most obvious reason to learn how to navigate over objects: it’s interesting. One of the best ways to get someone into their body is by giving them an activity that requires focus. There is a meditation technique that easily transition into the movement world called focused attention, which at its most basic level means paying attention to what you are doing.

When you teach someone a skill where there is a manageable challenge (if hands aren’t planted just so or you don’t lift your leg high enough to clear the obstacle, you may fall), they pay attention to the task at hand instead of their phone or the never-ending script in their heads. This external focus of attention may contribute to positive performance states, such as the state of flow. Additionally, external focus of attention during the performance of motor tasks, like vaulting, may lead to more efficient and effective movements than focusing on the body movements themselves. I find it much easier to teach the coordination of flexion, abduction, and external rotation of the hip using a vaulting preparation task like the first one demonstrated in the video below than isolating out each individual piece. That’s not to say there isn’t a time and a place for isolating movements. There is, and I teach that, too, it’s just that the task based work is often more mentally stimulating and frequently accomplishes the same results in a shorter amount of time.

Because vaulting can be done over a variety of objects, at differing heights, the movement pattern is challenged in a variable way, creating a novel experience for the nervous system every single time the student performs the skill. The brain thrives on novelty, and researchers speculate exploring novel options is an essential aspect to our ability to make adaptive decisions. Novelty is intrinsically motivating, which leads to exploration. When someone becomes interested or curious in a movement or skill, they are more likely to practice the movement or skill outside of the gym, resulting in faster skill acquisition and more opportunities for unstructured physical activity, which is good for health and well-being. The movement of vaulting, then, never feels rote, and the movement pattern isn’t ever performed in exactly the same way. This is a rewarding experience for the central nervous system, and results in associating a movement skill with a positive experience.

These slight movement variations are also good for proprioception and joint health. Joint position sense, an aspect of proprioception, is reliant on several factors, including the forces that are acting upon the joint (i.e., muscular tension), and how a joint is regularly used.

When joints are used in positions that are slightly varied to meet the demands of the task, this translates to varied amounts of force and muscular tension through the limbs that are resisting gravity. In the case of vaulting, that is largely the upper extremity. Put more simply, the act of vaulting on different objects leads to more strength and mobility in the shoulder joint, as well as more accurate joint position sense.

Researchers suggest elite soccer players allocate less energy processing proprioceptive information regarding the movements required to dribble and pass the ball because they have spent so much time practicing and refining their skills that the neural circuits devoted to ankle proprioception are well developed. Because these circuits are fast and efficient, players can devote more attention to locating team mates and monitoring opponents. Honing proprioception in a complex movement task will likely translate to the ability to use the joint in more varied ways in every day life—the more confident you are in your body’s ability to support you, the more likely you are to use your body on a daily basis.

Enriched Environments and Anxiety:

Creating task based obstacles and giving people movement puzzles that require thought may also be good for emotional well-being. Animal studies consistently show enriched environments improve working memory and decrease the effects of chronic stress on anxiety behavior.

While humans are obviously different than rats, a compelling case study utilized an enriched environment on a war torture survivor as an intervention for PTSD. Modified sports, dance, games, restorative movement (such as breath work), and movement tasks were all used to emphasize training, learning, and experiencing. The subject reported positive affective states associated with the training, including feelings of mastery and accomplishment, and focused attention on playing. He also reported having fewer depressive moods, being more active, and feeling more motivated to live, suggesting an environment that emphasized movement and learning had a positive impact on his overall mental state.

A recent study performed by Faro et.al, found that when compared to traditional resistance training, functional resistance training led to higher acute positive psychological states, higher levels of enjoyment, and more energy expended (). While the study was small (34 subjects), hopefully more research will be done to explore whether strength based movements that are done in an environmentally interesting context positively impact psychological well-being.

This small study is consistent with what I have observed with clients: people who are scared to lift a 35 pound kettlebell off the floor repetitiously have no problem walking a 45 pound plate back to the rack to help me put things away, or moving a medicine ball from one side of the room to the other while avoiding obstacles. In fact, it takes on a different meaning and becomes interesting in a way that traditional strength based work sometimes isn’t. People get interested when there is a purpose and end up doing more even though it feels like they are working less.

Incorporating vaulting into a movement practice:

“This is all fine and dandy,” you may be thinking, “but how can vaulting be incorporated into a physical practice?” When you are pondering where to place a specific skill, like vaulting, there are there main factors to take into account:

  • What mobility is required to do the skill?

  • What stability is required to do the skill?

  • How exhausting is the skill?

The progressions to the tripod vault I demonstrate in the video require hip flexion, abduction, and external rotation, wrist extension, and straight arm pressing strength. Ideally, unless you are working with a client who moves around all day, tripod vaulting would be placed after mobility work for the hips and wrists.

The stability required to perform the tripod vault are shoulder stability/integration between the hand and the shoulder and the ability to control the pelvis when the leg moves into hip flexion/abduction/external rotation. As a result, tripod vaulting should be taught after shoulder and hip/pelvis pre-requisites have been established. If I am planning on having the client perform variations of a tripod vault in the day’s practice, I will incorporate loading of the shoulder in different positions, cueing hand to shoulder integration, and moving the femur independently of the pelvis in the warm-up. I find particularly with the first progression demonstrated in the video that people naturally orient the pelvis towards the obstacle they are lifting their leg on to, limiting pelvis rotation and excessive hiking, making it great for active hip mobility work

Unless you are performing the skill at a high speed or as part of a circuit, this particular skill isn’t overly taxing, which means performing it early or towards the middle of the practice won’t exhaust the client. This skill does require focus and coordination, so performing it after a taxing physical task may result in neuromuscular fatigue/difficulty focusing and coordinating the arm and the leg. Set and rep schemes vary based on how you are integrating the movement into the practice, but for teaching purposes, I often begin with 4-6 repetitions per side for two to three sets as part of a three exercise circuit (which is frequently how I set up sessions), but there are no hard and fast rules. Just remember that if you want to teach a skill, repeated exposure to the task grooves the motor pattern and moves the student from the cognitive stage to the associative phase of learning more quickly.

Any movement can be corrective if it’s taught thoughtfully and with the appropriate progressions. Skills that look advanced can often be useful for almost anyone if they are broken down into manageable pieces and cued in a thoughtful way. Incorporating the environment into movement focuses attention, stimulates curiosity, and makes the physical practice feel less like work and more like play. Gaining strength and mobility doesn’t necessarily have to be miserable to be effective; introducing skills like vaulting can be a fun way to enhance strength and mobility, all while improving proprioception and kinesthetic awareness. Plus, it makes people feel empowered when they realize they have moved their body in a way that they haven’t in years, and who doesn’t like feeling empowered?

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Eggs, Eyes, and Creating Long Term Change

I went to the eye doctor recently for my annual exam (which happens more like every 14 months), so I could renew my contact lens subscription. I first learned I needed corrective eye assistance when I was in middle school. The nurse came to science class and tested everyone’s vision and hearing. I remember realizing I wasn’t acing the eye exam, as well as the embarrassment that accompanied the fact my peers that were in line behind me were privy to the fact I wasn’t acing my eye exam. “Step back a bit,” she instructed the other 12- and 13- year olds as she had me try one more time to read the letters on the screen.

I was a bookworm as a child, though not inactive. When I wasn’t reading or listening to music, I enjoyed playing outside, usually alone, occasionally teaching myself gymnastics moves. With the exception of softball, sports weren’t encouraged, and since Youtube didn’t exist yet, I was left to my imagination when it came to athletic endeavors. I didn’t spend time developing my vision, and it could be argued I inherited a propensity for weak eyes from both sides of my family—my dad and my mom’s brothers were all bespectacled, so between the hours (and hours) spent reading and my genes, my diagnosis of near sightedness wasn’t exactly surprising.

My vision got progressively worse through my late teens, stabilizing as I entered adulthood. A few years ago, after I had successfully improved my feet and dramatically reduced the size of my bunions, I wondered if corrective lenses were a bit like orthotics—necessary for the short term, but with the right intervention, perhaps the dependency on them could lessen. I began incorporating eye exercises into my training and practicing looking out into the distance, curious if practicing the skill of focusing on objects far away could make a difference.

Consistency:

I regularly have conversations with clients who struggle to maintain consistency. They want to do more, but don’t know how or where to start. Despite my regular reminders that they don’t have to do forty minutes of exercise to make a change in their physical abilities, “just three to five minutes a day,” I tell them, “will make a difference in how you feel and your body awareness throughout the day,” people struggle, unable to commit or prioritize their time to make room for extra movement.

On the other end of the spectrum are my clients with very real conditions, the ones with MS or undiagnosed connective tissue disorders, or who have depression/anxiety/trauma, who are committed to living. Part of living, they understand, is being able to use their bodies to their fullest capacities, and so exercise/fitness/movement becomes part of their daily lives, even though it’s hard and uncomfortable. These individuals are the silent inspirations, the ones who celebrate when they do a perfect squat and who are excited when they have the grip strength to open a water bottle. While they aren’t celebrated on Instagram as “fitspo,” their dedication to being as strong and capable as possible despite their circumstances is an inspiration.

What makes people commit to consistency? Obviously, there needs to be some sort of reward for the behavior that keeps people engaged enough to want to perform the behavior again, whether the reward is emotional or physical. “I feel amazing while performing 100 kettlebell swings,” said no one, ever, but people do notice they feel calmer or stronger or more present after the hard work of swinging a kettlebell is done. This could be thought of as a delayed response to a strong stimulus. For some clients, the response is more immediate. They ache or feel discomfort in some place. By focusing attention and providing a stimulus that deflects their focus from the area that aches or is painful, the pain disappears. Movement, both in the form of aerobic exercise and in the form of muscular force have an analgesic effect. The absence of pain is positive feedback, and is often enough to get people to perform movement snacks or homework that lasts 5-10 minutes a day, at least for a little while, until the pain goes away.

Making Long Term Change:

I was vegetarian for a few years in my late twenties, and at 29, went fully vegan. The benefits of cutting out dairy were profound. I recovered faster from my workouts, was less sore, and experienced a significant reduction in symptoms related to inflammation. I felt like I had stumbled upon an eating routine that could sustain me for the rest of my life.

Until I began reading about the effects of omega 3s on brain health. Omega 3s are polyunsaturated fatty acids that have neuroprotective properties, specifically against neurodegenerative and neurological disorders. They are found primarily in fish, and while there are other foods that have them (namely chia seeds and flax seeds), I don’t always remember to put chia seeds and flax seeds in everything. Another food that has decent amounts of omega 3s is eggs.

Why did I suddenly care about omega 3s and the brain? Parkinson’s runs in my family (my maternal grandmother died from it and my maternal great-grandmother had dementia), and I care about my ability to learn and remember things throughout my lifetime. I use my brain as much as I use my body, and my long term goal is to be able to use both until I (hopefully) drop dead. Diets low in omega 3s are linked to memory deficiency and difficulty learning. Since I have never cared for fish, I added eggs back in my diet, hopeful that consuming eggs 3-4 times a week would be enough to keep my brain healthy.

*It’s worthwhile to note sleep also appears to play a role in memory retention. Sleep deprivation is associated with reduced clearance of beta-amyloid, a waste product that accumulates in the brain’s interstitial fluid; some scientists believe the accumulation of beta-amyloid is the primary cause of Alzheimer’s disease.

Clarifying your Why:

My why is clear to me. I take a lot of pleasure out of life. I prioritize learning, enjoying the environment around me, and my independence. These things are made possible by my brain and my body. My desire to climb steep hills and frolic on rocks down at the beach is the reason it’s not difficult for me to motivate myself to lift heavy weights and jump on top of boxes. My love of movement as a way to express myself makes it easy to do mobility work, even though it’s uncomfortable sometimes, and my curiosity about how I can move more efficiently and remain injury free enables me to slow down, focus, and feel regularly.

Because my long term brain health is such an instrumental part of my life’s why, I was willing to make a change in my diet to include a food I don’t really like, but I also don’t have a strong aversion to. I plan on being around for a while, and I want to make the most of the time I have while I am here, so cultivating a diet that may reduce the risk of dementia and assists in my ability to establish new neural connections benefits me over the course of my life time.

What if you or your clients struggle with committing to long term change even though the desired behavior is “better” or “healthier"?

There are number of things that fall into this category, not just exercising more or altering eating habits. Long term changes that impact a person’s life can include things like making space for self care, spending time in nature, reading more, decreasing screen time, and slowing down.

One way to approach committing to change is clarifying both long term goals and the underlying reason for those goals. Do you have a pen and paper handy? If so, set a timer for five minutes. Write down a long term goal and explain, in detail, why you want to do it.

When the timer goes off, read what you wrote out loud to yourself. Does it stir something up in you by making you excited, passionate, or ready to commit in some way? If so, you are on the right track. Fold that piece of paper up and place it somewhere that’s easily accessible, like your wallet or your laptop bag. On a separate piece of paper, make two circles at the top of the page. In one of the circles, write your goal. In the other circle, write down your current state.

For instance, before I made a change in my diet, one circle might have been “omega 3s for brain health.” The second circle might have been, “vegan diet.” Once you have established the two top circles, make one more circle below the top two circles and between them. It will look something like the graphic below.

IMG_3099.jpg


In the lower circle, write “behaviors.” This simply reflects your actions. These actions will either move you towards your goal or towards your current state.

Between the “behavior” circle and the “goal” circle, draw an arrow. Label that arrow “towards.” This represents the changes you make that move you towards your goal.

Between the “behavior” circle and the “current state” circle draw an arrow. This represents behavior that keeps you moving towards your current state.

Spend some time thinking (and writing) about what actions you currently do that keep you moving towards your current behavior. What actions would you have to do to work towards your desired goal? Are they in line with your why? And even though the new actions might be challenging, is your why worth it?

Self reflection:

There is a body of research that suggests self reflection is a powerful tool for learning. Taking time to reflect on your current state, your current actions, where you want to go, and the steps needed to get there is a way to shift your perspective and mindset towards the desired behavior. Change is hard. There will be set backs along the way, and that’s okay. As long as you remember (and occasionally re-read) your why and continue making steps towards your long term goals, acknowledge the set backs and move on. If the set backs are beginning to happen more frequently and no matter how often you read your why, you can’t seem to muster the enthusiasm or passion to implement a change in behavior, it’s possible you need to re-evaluate your why. Again, this isn’t necessarily a bad thing. Life changes or perspective changes result in a shift in what’s important. If this happens, spend time re-writing your why and see what comes up for you.

Eggs and Eyes:

What does any of this have to do with eyes, you might be wondering? During my annual eye exam, after assessing the image of my eye and telling me that my cholesterol, blood pressure, and eyes were extremely healthy, the doctor looked at me and said, “your curvature has changed.” When you are nearsighted, either the shape of the cornea is too curved for the length of the eyeball or the eyeball is too long. My myopia is related to a curvy cornea; altering the shape of the cornea means it’s less curved in relation to the length of the eye ball. “I don’t know what you are eating or doing, but whatever it is, keep doing it.”

I mentioned earlier that I implemented eye exercises a few years ago, which has helped with my ability to focus more quickly. However, the biggest change since my last eye exam was the consistent consumption of eggs, a food that not only has the omega 3s needed for brain health and cognitive function, but also contains a carotenoid called lutein. Research suggests consumption of lutein is associated with a number of beneficial effects, especially for eye health. Lutein is available in an array of foods, including fruits and vegetables, as well as egg yolk, so eating eggs isn’t the only way to get more lutein in your diet. However, since improving my vision wasn’t the reason I changed my diet, the reduction in my prescription was a pleasant additional benefit.

That, perhaps, is one of the biggest benefits to having a why that is clear and has a deeper, intrinsic meaning—the change in behavior required to accomplish the desired goal often improves other areas of your life, accidentally. These improvements, whether they are emotional, physical, or a combination of both, are reminders that the “new” behavior is worthwhile. This establishes a positive feedback loop, making the new behavior easier and easier to do, until eventually, it becomes habit.

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The Anatomy of a Movement Practice


I was recently contacted by a concierge service to train an out of town visitor. I thought about it before calling her back, since it meant I wouldn’t have any days off from training and I had things I needed to do, like format the book/film/complete online training for my government job, but since my week had been slower than normal and training is more interesting than formatting/filming/clicking through online trainings, I called back and said yes, I would do it.

It’s been a long time (i.e. years) since I have worked with someone who wasn’t a direct referral with some idea of what I do. I wasn’t even sure I knew how to deliver a standard, run of the mill personal training session any more.

It turns out, I don’t. It also turned out it didn’t matter—I provided an experience that differed from the client’s regular, periodized program. “I feel like I just did something really good for myself that I don’t do in my every day life, so thank you,” he said, halfway through our workout the second day.

As I drove home after our last session, I found myself reflecting on what, actually, makes a good movement practice? What do people require to say, “this feels really good,” or “I feel really good?”

The Value of Awareness and Joint Mobility:

There are a lot of things I do that I take for granted. I assume every personal trainer/movement professional is consistent with cueing and takes into account the reference points of the body. I also assume every personal trainer/movement professional watches someone move and identifies the blind spots, the joint ranges that are ignored, impairing body schema and proprioception. When joints are healthy, placing people in positions that tap into these blind spots provides afferent feedback to the central nervous system, waking the brain—and the body—up. This awakening leads to a recognition of a more complete physical body and feels satisfying.

Awareness is created positionally and through afferent feedback. This can be done in either an open chain or closed chain manner, dependent on the client and whether they have any restrictions. Awareness and joint mobility can be an entire session or a small piece, depending on the client’s needs. Eventually, awareness can be sprinkled throughout the session with effective cueing and joint mobility can be used as a warm-up, a cool-down, or as a way to rest between exercises. My sessions never look the same, and classes and workshops don’t look like my client sessions. The components are important, but how they are mixed together depends on the teacher, the environment, and the context. Awareness can also be used to teach connections, which generally enhance more complex movements and can be used as a neuromuscular warm-up before a specific skill, establishing integration and motor control.

Strength and Conditioning:

Everyone benefits from strength. Basic strength, which doesn’t have to be fancy to be effective, decreases anxiety, improves feelings of stability (), and can reduce symptoms related to chronic pain (which is correlated with anxiety and depression. Funny how that all works together). We are designed to lift heavy things occasionally, but daily, modern life doesn’t require that from us very often; the solution, then, is sets and reps with iron (or bodyweight, or some other form of outside resistance), in a gym.

Here’s the thing with strength and conditioning: as long as resistance/load/time under tension is added gradually, people will get stronger. The keys to effective strength and conditioning programming in the absence of specific goals are:

  • Use compound movements

  • Develop pushing and pulling strength

  • Lunge/squat/hinge/carry

  • Perform movements slowly

  • Performing movements quickly

  • Consistency

It doesn’t really need to be more complicated than that if you have a balanced movement practice.

Some people love strength and conditioning work. They begin salivating at the idea of kettlebells and barbells, and the thought of adding plates makes them gleeful. I am not that person. That isn’t to say I don’t like feeling strong or watching my clients get strong (I do), and it’s not that I don’t like weightlifting; deadlifts make me happy, and I love a good pull-up (or four). But given the option between iron and bodyweight, left to my own devices I will choose bodyweight.

However, the benefits of thoughtfully placed external load really can’t be ignored and regular conditioning plays an important role in a well-rounded movement practice. The external load used doesn’t have to be in the form of iron and steel if that isn’t your thing; some of the strongest people I know lift other people on a regular basis and since other humans are heavy, they provide enough load to elicit strength and stability.

Play, skill, and adaptable movement:

Being able to adapt and interact with the physical world makes life more playful. People who find the world interesting are engaged with the world around them and are more willing to explore. The physical world is not predictable or uniform; as a result, if the goal of a movement practice is to enhance a person’s life, the practice should contain elements of adaptable, fluid movement that’s not predetermined. Introducing an element of play or skill training into the movement practice is a way to nurture adaptability and responsiveness.

Play and skill work both require focused attention. They differ in that learning a skill requires specific sets to attain the skill; however, good teachers use drills that examine the same skill many ways, approaching it in a less linear manner.

Play, of course, isn’t linear. Unlike skill training, play doesn’t have a specific outcome. It’s an opportunity to explore a task with a set of constraints and see what happens. It’s like creating your own game or movement puzzle.

Both play and skill training turn movement into something more than work. It changes a person’s relationship with their body as they begin to realize what they are capable of doing with the right intention. The types of play and skill training used depend on the person’s interests—a person who dislikes ball skills probably won’t enjoy a movement session centered around throwing games. However, that same person may enjoy balance activities and may find obstacle courses and balance challenges interesting.

Restorative movement and floor work:

Restorative movement and floor work are opportunities to slow things down. It becomes less about work and effort and more about ease and softness. Restorative movement can be introduced simply as breath work or gentle, somatic based movements that are performed slowly and attentively. Restorative movement is a wonderful opportunity to practice open monitoring, the act of observing without judging, as people connect to how their physical body responds to various positions and/or movements.

Floor work can be used in a variety of ways, but for the purposes of this article, let’s think of floor work as a way to learn how to respond to the floor. This responsiveness down-regulates the nervous system, increases kinesthetic awareness, and acts like a self massage, applying pressure to the skin as you move over it. Tools like foam rollers have an analgesic effect, so if you place pressure on your left anterior thigh with either a foam roller or the floor and you notice sensitivity, the sensitivity throughout the body decreases. For people who tend towards less flexibility, this decreased sensitivity temporarily increases mobility. Floor work is also a time for inquiry, where people can ask, “what happens if…” The floor teaches softness as people learn how to adapt to the pressure the floor applies. It teaches people how to gently transition from various positions, moving from supine to prone, from prone to seated, or from seated to supine.

Self reflection:
The final aspect to a movement practice is self reflection. This can be interspersed throughout a movement practice (how did it feel when you used your foot? Was it different to press your right hand into the ground? How can you make it over the obstacle in a more fluid way? What can you do differently when you transfer weight into your hands?)

It can also be performed at the end of the practice, allowing the practitioner to reflect on the experience. Self reflection is a component of learning, a way to establish what worked and what didn’t. It also gives people an opportunity to observe the impact the practice has on the self as a whole, making the practice about more than just a physical act of doing.

These elements don’t have to be separate. They can blend together, since skill work can certainly be strengthening, strengthening work can mobilize joints (so can game play and floor work), awareness can be used during strength work or restorative work, and self reflection can be practiced during the warm-up, after an exercise, or after the practice has concluded. But it is these components that begin to make exercise more mindful and less about simply doing to do.

On the second day of working with the client who sparked this article, I purposely had him do a wrist mobility drill and shoulder band drill during the warm-up that I knew would provide interesting feedback for him. “Oh my God,” he said. “Where has this been all of my life?”

Later, during a weighted clubbell exercise that is performed in a circular manner, he said, “this feels really good. Hard, like I’m doing something, but really good on my back.”

At the end of the session, after he had carried heavy things, practiced getting up from the ground, rolled, performed plank-ups, and a myriad of other exercises and drills, I had him lie down on a foam roller length-wise. I cued the breath, brought awareness to his middle back, and watched as his entire system relaxed. I was reminded in that moment that I don’t have to try to be a traditional personal training session. I believe in movement as a vehicle for learning, and I think it can be taught in a way that is more than periodized strength and mobility.

Getting people strong isn’t actually hard. Neither is getting people more flexible. Both of these aspects of physical function are important and there are many people out there who teach this part of fitness better than I do. But the other parts, the part where the person becomes more interested in their body and how they move, the part where the person feels the connections between different parts of the body and the sensation of work in new places, the part where the person feels like they have just had a massage, except no one has touched them, those are the parts I am interested in. Those are the parts that begin to chip away at the centuries old idea that the mind and the body are separate and that the body is fragile, incapable of healing or not worthy of being celebrated for what it can do. Once this shift begins to happen, it seeps into other parts of a person’s life, from their nutrition, to their sleep, to their emotional responsiveness to the world—and the people—around them.

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Biological Learning and Control: Thoughts on Motor Control and its Applications to Movement



I recently finished the textbook, “Biological Learning and Control: How the Brain Builds Representations, Predicts Events, and Makes Decisions,” by Reza Shadmehr and Sandro Mussa-Ivaldi. It was a fascinating, but dense, exploration of how the brain interprets the signals from the environment and makes movement decisions. Though I skimmed most of the mathematical equations, the explanations behind the theories and its application to movement was more than interesting. I highlighted some of my favorite concepts, with thoughts on their relevancy to a movement setting.

  1. “Prediction is due to internal models that describe what should happen. Measurements are due to reports from a sensory system that describes what actually did happen. Perception is a combination of the two, describing our belief about what happened.”



    The authors make this statement on page one, in the introduction, as they lay out the fundamentals of human movement and motor control. When you are working in a predictable environment, this particular model is dependable, with perception accurately representing your prediction and your measurement reflecting what you expected to happen.

    

An example of this is squatting down to pick up a 15 pound kettlebell. If you have worked with kettlebells for a while, you can predict what the kettlebell is going to feel like and how much effort it will take to lift the kettlebell from the floor based on your previous experience using the same lifting strategy. If the kettlebell leaves the floor in the way you expected, you can measure whether your prediction about how it would feel and whether you would be successful was accurate. Your perception will be informed by what happened versus what you expected to happen. 

This hypothetical example is pretty cut and dry. Kettlebells are a familiar tool, the surface you are standing on is likely hard and consistent, and you have previous experience to draw upon, informing your movement pattern as you lift the kettlebell.

    

Let’s look instead at a commonly issued cue that is less easy to interpret. Let’s pretend you are told to stand up tall. What happens then?

    

Your prediction of how to perform the task is based on what you think it means to stand up tall, either because of pictures you have seen or previous instruction you have received. You will change your position to conform to what you believe is right. You will receive feedback from your sensory system that you have, indeed, changed your position. Your perception will reflect what you believe to be a position of standing up tall, but are you actually standing up tall, or are you arching your back, or sticking your chin out or throwing your ribs out? How are you accomplishing the task and is your internal representation (i.e., perception) of how you accomplish the task accurate? 


  2. “Biomechanics are indeed important, but consider the fact that our movements change from the teenage years to young adulthood, and they continue to change as we grow older. Our movements change because of maladies such as Parkinson’s disease, schizophrenia, and depression.”



    Is there a perfect form, a perfect way to squat, hinge, get down on the floor, or get out of bed? If our movements are a reflection of our thoughts, our emotional state, and our maturity, should we try to make an 8 year old swing a baseball bat like a 30 year old? Should we assume the clinically depressed war veteran should squat with the same form as a 25 year old ballet dancer? Are the movement ideals we insist upon in the weight room or the yoga room appropriate for every person? Or should there be more room for exploration and individual expression within a set of constraints? Maybe constraints can provide the framework for which a person can be given permission to explore? I realize I provided no answers, but I do think these questions are worth asking

  3. .
“Properties of our muscles change due to a variety of disturbances, such as fatigue, disease, exercise, and development…Therefore, when the nervous system observes an error in performance, it faces a credit assignment problem…That is, adaptation to things that are likely to be permanent (fast states) should be remembered, while adaptation in response to things that appear transient (fast states) should be forgotten.”

    

If properties of our muscles change for a variety of reasons, it stands to reason our experience of our muscles working will also change. Two examples I see regularly are the sensation of joint cracking and the random zinger.



    Clients will occasionally experience the sensation of joints cracking. The noise may not be audible to me, but it is audible to them. When they are asked to load the area differently, usually through a series of low grade isometrics, the sensation almost always goes away. Why? 

I don’t actually know, but maybe it has something to do with the nervous system detecting a change in performance, creating the feeling of stability. Regardless of the mechanism, what’s important is the client realizes the feeling they were experiencing is transient, a temporary blip that can be experienced differently with a novel input.

    

The random zinger occurs when someone moves a specific way and gets shooting nerve discomfort down the extremity. When someone has chronic pain and/or has not exercised in many years, the random zinger happens with new movements. In my experience, it resolves 99% of the time through approaching the same movement a different way, or simply doing something else for a little while before coming back to the same movement. Determining whether movements are potentially harmful is one of the jobs of the nervous system; every time you try a new movement, the nervous system has to make sure the movement is safe and worth repeating. If you don’t have very many movements in your movement toolbox because of inactivity, new movements pose an interesting problem. Your ability to predict what should happen is based on fewer past experiences, which affects how you perceive (and execute) the movement. Trying the movement again and not having any discomfort creates an opportunity for the movement task to be successful, making the painful response to the movement task temporary.


  4. “Suppose that the objective of any movement is to place our body in a state that is more rewarding…we get a natural balance between effortful behavior and maximizing reward: the movement that we perform is one that maximizes reward while minimizing effort.”

    

Why is so much of our brain devoted to movement? It could be argued we evolved to move so we could survive; survival is predicated on a number of factors; all of which involve some form of a reward, whether it’s food, water, sex, or not getting eaten by the predator. When you think about moving as a way to move to a place that is more rewarding, the relationship to movement changes.

    

It also creates an interesting disconnect between the current prescriptive view of exercise and the authors’ theory that movement should maximize reward while minimizing effort. “Do 8-10 exercises, 1-3 sets, of every major muscle group at least two times per week, for muscle health.” It’s no wonder adherence to weight lifting is low—nothing about the current exercise prescription appeals to a sense of reward (and curiously, drop out rates in exercise programs among people with depression is often high, despite the fact exercise tends to improve depression symptoms).

    Perhaps this is why people are being drawn to movements modalities that invoke a sense of flow—there is something inherently rewarding about trying to get from point a to point b to point c in an interesting way. In today’s world, building strength is necessary (we are missing the foundational strength that was required hundreds of years ago just to get through the day), but we also seem to have forgotten that movement can be rewarding and that building efficiency through coordination makes the experience more pleasurable. This could also be an argument for more task based movement—figuring out how to lunge down to pick up a series of objects or picking up a heavy object and moving it across the room, setting it down somewhere else are meaningful objectives with a measurable outcome. You are designed to figure out how to maximize reward (successful completion), while minimizing effort. Tissues will adapt and get stronger, more motor units will be recruited with subsequent attempts, and you will become more capable with meaningful practice.


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Breathwork: An interview with Valerie Moselle


“Our movements become more fluid, and we can access a state where we are connected to our inner rhythm…and the natural, organic pulsing movements that I believe we would do regularly if they weren’t conditioned out of us in childhood. Breath helps us ‘tune in’ to our inner experience. But if a student is detached from that experience, they don’t naturally come into it with ease…you have to ask them to do it, to remember it again and again.” ~Valerie Moselle, on breath.

I began studying breath work in 2011, when one of my graduate school professors recommended Charlie Weingroff’s DVD set “Training equals Rehab.” In it, Weingroff laid out the foundations for stability, beginning with the breath. I was immediately curious, and what ensued was an all encompassing quest to understand how breathing works, both physically and emotionally, and why (and how) to teach it.

Fast forward eight years later, and teaching breath work is a regular part of my practice. It finds its way into workshops and I almost always end up teaching breath to all of my clients at some point as a way to support their physical practices.

I recently interviewed Valerie Moselle, founder of Luma Yoga in Santa Cruz and author of the upcoming book, “Breathwork: A 3-Week Breathing Program to Gain Clarity, Calm, and Better Health” on her thoughts on all things movement related. Below is her story. I hope you enjoy it as much as I do.

How did you become interested in yoga/movement?

“I was a dancer…started when I was 3. So crafted movement was part of my life from the time I was very little. I have a BFA in Dance from a small art college in Seattle called Cornish, and though I took my first yoga classes with my mom in the late 70’s, I started taking classes in Seattle in my early 20s as a supplement to dance training. I was struck by the suggestion of movement for movement’s sake, rather than performance…and the absence of mirrors (an invitation to experience movement internally, rather than to be observed…or in competition…as in sports.)

In the early days I took Iyengar. The focus on perfecting alignment was familiar as this is what you do all day as a dancer. I found Bikram in SF. This was before his ‘explosion’ of popularity. Bikram had started this tiny studio in North Beach. I didn’t take class with him because he had recently moved to LA to open his studio there. There was no such thing as “hot yoga” at that time. I was drawn to the heat and the intensity of it. I think it spoke to me as a dancer. There were 2 excellent teachers there. Kind, careful people. I think Bikram developed the ego and allowed his abusive tendencies to flourish later, as he became famous and people started flocking to him. These two teachers in his studio eventually were replaced by other teachers, didn’t have such depth. It started to feel scripted and the movements too repetitive (only so much you can do with 26 postures), so I moved onto Ashtanga Yoga at Larry Schultz’s studio. Ashtanga spoke to me as a dancer because of the kinetic ‘flow’ of the Suryanamaskaras. I remember I used to think it looked like people were flying. From there, yoga started to explode. Studios were opening everywhere, and ‘flow’ yoga was starting to appear. I took all kinds of classes all over town, and my first teacher training was Iyengar with Lisa Walford.

When I moved to LA, I took an Ashtanga-based training at Yoga Works, before Maty and Chuck sold the studio and the first corporate yoga entity was born. But I fell in love with Max Strom’s studio and wound up being more engaged in that community, The Sacred Movement Center for Yoga and Healing. His classes were breath focused, moderately paced, and welcoming. A little less ‘culty’ than the practices I was into before, a little more permissive, and less radical. I found this environment more healing and less dogmatic. I began teaching there. As I rubbed shoulders with LA’s yoga elites I got to see a lot of the ugliness behind the scenes. Competitiveness, lack of integrity, ugly displays of ego, etc… I decided that integrity in a teacher was super important to me. I still work with Max, and that is one of the reasons why.

In 2006 my husband and I went to India with our 8-month old daughter and set up a household for a 6-month work opportunity my husband had. I found a teacher there. He taught me what we would refer to in the West as Ayurveda…holistic lifestyle management…seeing-treating the whole person, rather than trying to perfect asana specifically. We spent most of our time there in practice on pranayama and philosophy. He has been a great inspiration.

In 2007 my friend Denise Kaufman encouraged me to study with Paul Grilley…and my eyes were opened to variation and morphology. At the time yoga was all alignment and rules. We were gobsmacked. Whaaaaat? There is no ‘right’ way to do a pose? This kind of thinking is more out now, but at the time it was a complete deviation. Breaking the rules has been my favorite thing ever since. Why? Why are we doing this. Let’s look at it again. Why? Yoga teachers really need to be asking this. We have inherited a plethora of mythology that is based on very little…and we have perpetuated it.

As for my life’s path, in SF before LA and India I started subbing yoga classes. I was teaching at a little dance studio in Berkeley, and had been for about a year…It made sense to teach yoga…because I had before been teaching dance. I started subbing at Yoga Tree in SF…which was brand new then. I remember teaching this class and this thing happened (which I would now call a state of flow) where I felt I was channeling. I had led an experience…not a lesson. I see this now as one possibility of what our job is as yoga teachers…to get someone into that zone…that state of flow. It’s a form of meditation. I felt completely at home, and solid…even though I was a new teacher, nervous and inexperienced. Later, a work colleague who had come to that very class at my invitation expressed to me that she felt something special happen in that class. She told me she and her boyfriend had a new saying between them, “like Valerie teaching yoga.” Meaning…you’re in the groove, you’re “on the jazz.” I’ve only recently been able to reflect on that moment from the perspective of that being a moment where I became deeply intrigued and inspired to keep digging into the practice.”

How has your idea of yoga/movement changed in the last decade? How have you evolved as a teacher?

“It depends on which day you ask me. There is a way in which I’m very much a purist. The practices of yoga (asana and breath) have brought me deeper into my experience of Self. I feel I have learned so much from the perspective of my organism and how it is in relationship to the forces around me. I try to embody the thoughts and ideas of interconnection…opening myself in practice, musings, imagination, human interactions and play to the idea of being able to tap into that more original energy, flow, current that is present both within us and all around us. That IS us and everything around us. Visiting that place is deeply nourishing. The philosophy behind it is fascinating, and also provides a structure or construct that I find useful for making sense of my world. So in the last decade I have dug into these aspects intellectually, and viscerally…actually trying to feel, through my body, that sense of integration and connection.

Separately I have become fascinated by the paradox that is yoga. On the one hand, yoga (historically especially) asks us to transcend the body. On the other hand, yoga claims therapeutic properties. What we (Modern Postural Yoga Teachers) who have been at it for a while are discovering is that these two ideals are sometimes at odds. Here is an example. In meditation when the body starts to complain, in many philosophical schools that have personal transcendence as a goal of meditation, you train yourself to ignore the needs of the body. Your goal is to transcend physical reality, and connect to the underlying energetic structure. These schools teach the body is to be sacrificed. This is the root of austerities. It shows up in the forest yogis of the Mughal era, in Buddhist monasteries all over the world, and even in Christianity in the form of self flagellation. This might be a path for a certain kind of devotee seeking a certain kind of revelation. But it’s not necessarily physically therapeutic.

However, we have sold yoga in the West as healing to the mind-body continuum. If yoga’s going to heal the mind-body, from the perspective of the body we have to understand the biomechanics of tissue adaptation, the neurological aspects of pain, and the relationship between physical practice and the nervous system. We have to be educated in exercise science, but then take it a step further and make space for our psychology. This is a tall order. Most yoga teachers are not equipped to do this. But this is where yoga is going. But it probably won’t be called yoga…because what the layperson thinks of now when they think of yoga is basically that hot, physically exhausting thing you do in gyms and fancy studios in special pants. A great (if not sound) hot, sweaty workout with an endorphin high that is conflated with shallow promises of transformational bliss and inner peace. (Yes…I’m bitter and disappointed).”

What role does breath work play in your teaching? What about in your personal practice?

I teach breath in the way Max taught me to teach it. I instruct it constantly, until I feel like a broken record. There are times to be more intuitive and elegant with the breath…and often…in my own practice the breath is less scripted than I invite students to do. But what I have noticed is that first you have to break the ‘breath barrier’…a student won’t free the breath on their own. They hold onto it, like they’re bracing for a car accident. Once you get the breath flowing, you can back off of it and let it come more naturally. When we breathe deeply and consciously we detach from the ‘busy mind’ and instantly come into a more visceral moment-to-moment awareness experience. Our movements become more fluid, and we can access a state where we are connected to our inner rhythm…and the natural, organic pulsing movements that I believe we would do regularly if they weren’t conditioned out of us in childhood. Breath helps us ‘tune in’ to our inner experience. But if a student is detached from that experience, they don’t naturally come into it with ease…you have to ask them to do it, to remember it again and again.

I go through phases, I sometimes teach more formal pranayama in the beginning of class, I sometimes arrange whole classes around scripted breaths with lots of standing breathing exercises. I sometimes get infatuated with breath-initiated movement, and then sometimes I just get bored of hearing myself talk about it and I let it go for a while. When I do this, my students stop breathing. They look more anxious and stiff. I think it’s important to insist on it as a teacher. To constantly remind us to pay attention. There is something in us that releases when we replicate the kinds of breaths we would take if our lives were more kinetically varied and less sedentary. We return to our bodies.”

Speaking of personal practices, what does your current practice look like? How has it changed in the last ten years?

“Ugg…honestly, a few years ago I took a meditation class for women with Camille Maureen where she suggested that practice could be what it needed to be in the moment. You could roll around and growl, you could sit in meditation, you could eat chocolate. I took that as an invitation to listen to my internal ecosystem and do whatever it was calling for. This released me from all the ‘shoulds’ that made practice a chore. Again. permission…liberating. I’ve been teaching yoga for a long time. What I teach is entirely different from what I spend time doing in ‘practice’. So for my physical body I lift weights. Maybe take a dance class. Go for a walk. In my room on my bedroom floor practice looks a lot like rolling around on the floor until my body feels a little less creaky…maybe doing a few strength inquiries which could sometimes be postures…and could be push ups or squats or burpees until I’m a little worn out..I usually resolve with stillness. I love to sit and make micro movements with my spine and see what emotions come up. I sometimes focus on a pain I have in my body and try to figure it out, does it have an emotional component, which muscles are those. I often listen to the birds or sit quietly in the dark and become so still I can feel my heartbeat rocking my spine. I let the breath ripple through my spine…I call it the ‘breath wave’. Sometimes I don’t practice for a long time because I’m too exhausted or busy. Middle age with family is work to dinner to putting kids to bed to showering and preparing for work again…This too is a practice…or an excuse…but probably both! Right now I’m into handstands. I gave up learning to balance them when I got pregnant the first time 14 years ago. Now I want that skill. Attachment, Desire. Sometimes for usually short periods, some number of months, I commit to getting up every morning and sitting…that is usually not sustainable in the long run, sleep always wins. So I let it go, and then reinvest in it again later. I’ve noticed a seasonal relationship to my ability to sustain early morning meditation practice. I’m curious to see how my practice changes as my kids get older and more self sufficient. I don’t really enjoy taking classes much anymore…I’m too busy paying attention to the teacher…I don’t like the pacing…I want to listen to my body. How’s that for all over the place? I try not to be too hard on myself.”

What do you see as the biggest obstacle to the health and well-being of the general population in the US?

“Sedentary living and a feeling of separateness from the earth and from one-another.”

What role (if any) do yoga and movement professionals play in making movement, breath, and mobility a larger part of people’s lives?

“We provide opportunities for people to regularly engage in the experience of flow, to systematically stress (just enough, not too much) different physical, neurological, and psychological systems promoting integration between the different structures and aspects of ourselves, AND in group settings, we provide opportunities to experience community…to move and breathe together.”

Is there anything else you would like to add?

“What great questions! Thank you!”

To pre-order Valerie’s new book, please click here.


Exercise, Anxiety, and PTSD: Part II

When I originally planned to write a follow-up piece on fear, anxiety, and kinesiophobia, I had a different plan, one that would establish clear solutions and would help people struggling with anxiety thrive.

But as I dug into the research, I realized my plan was being thwarted with the reality of what people with anxiety or PTSD experience and how poorly equipped the traditional fitness industry is to help these individuals. To be clear, exercise isn’t a magic pill that immediately works on every single person with anxiety or PTSD. In fact, exercise can be the source of the anxiety, becoming compulsory and feeding into a cycle of obsession. However, what the numbers show is people with anxiety or PTSD who are not currently physically active would benefit from the physiological effects of exercise. Specific types of exercise regulate hormones, give individuals a sense of purpose, and create more emotional and physical balance in a person’s life. Traditional fitness is focused on numbers: how much, how long, and how often; much of the narrative in the fitness industry centers around which “type” of approach or modality is the best approach for gaining strength, flexibility, endurance, or mindfulness.

As you will see, it’s not about the best type of exercise, or even the most effective. To truly help individuals who have generalized anxiety, a specific form of anxiety, or PTSD requires listening and providing individualized programming. It requires not judging or having a rigid agenda, a challenge for an industry that tends to follow a specific plan or sequence of exercises based on what science says is best for strength and flexibility, rather than focusing on what resonates most with the person. The ability to be fluid and offer suggestions to create a more adaptable environment for the student or client isn’t something I have ever been taught—it’s a skill I have learned, and it’s a component to working with people in an individualized setting that I think many trainers could benefit from learning, particularly those working with clients struggling with mental health disorders.

Characteristics of Anxiety and PTSD:

Generalized anxiety disorder is defined by the National Institute of Mental Health as excessive anxiety or worry on most days, lasting six months or more (1). Symptoms associated with generalized anxiety disorder include feelings of restlessness, fatigue, difficulty concentrating, irritability, excessive muscle tension, feelings of worry, and difficulty sleeping. Other types of anxiety disorders include panic disorder, phobia-related disorders, and social anxiety disorder.

Post traumatic stress disorder (PTSD) is no longer considered an anxiety disorder by the Diagnostic and Statistical Manual of Mental Disorders, largely because PTSD is specifically related to trauma while anxiety is not. Exposure to a traumatic event, which is defined as “actual or threatened death, serious injury, or sexual violence,” is the first criterion for the diagnosis of PTSD, though exposure to trauma doesn’t guarantee PTSD will be present (2). There are four qualifying types of exposure: personal exposure to the trauma, witnessing the trauma of others, indirect exposure through a family member’s trauma, or repeated exposure to aversive details of a traumatic event, which happens in professions like forensic child abuse investigators or military mortuary workers.

Over the course of a person’s lifetime, three out of every ten people will experience an anxiety disorder; in any given year, 19.1% of adults in the US are suffering from an anxiety disorder. (The number is higher for women, with 23.4% of women and 14.3% of men experiencing a form of an anxiety disorder annually) (3). In adolescents, the numbers are higher: 31.9% of adolescents annually have an anxiety disorder; again, the percentage is higher for females, with 38% of females and 26.1% of males experiencing an anxiety disorder annually.

Post traumatic stress disorder (PTSD) affects 8-12% of adults at some point in their lives, and 13-31% of military veterans will experience PTSD. PTSD is characterized by unwanted memories or flashbacks, avoidance of trauma reminders, negative changes in mood and changes in arousal, such as hypervigilance (4). Hypervigilance is characterized by an attentional bias towards detecting and reacting to threat-related stimuli (5). In addition to PTSD, hypervigilance exists in a range of anxiety disorders and affects cognition, physiology, and behavior.

Physical Activity and Anxiety and PTSD:

Less than 75% of the US population meets the minimum weekly recommendations for aerobic and strength training activity (6). Obviously, not everyone who isn’t exercising has anxiety or PTSD, but anxiety or PTSD can prevent a person from beginning an exercise program because of the way exercise makes a person feel.

Anxiety sensitivity, which is characterized by focusing on negative outcomes and often results in the misinterpretation of bodily sensations, can make people with anxiety reluctant to begin an exercise program because the physiological effects of exercise, such as increased heart rate, increased respiration rate, and burning muscles, mimic the physiological symptoms of anxiety (7, 8). On the flip side, when people with anxiety undertake an exercise program, they experience an increase in self-efficacy as they realize that they are strong enough to cope with the physical experience of exercise. Curiously, high intensity regimens are more effective than lower intensity regimens for lowering anxiety levels, but drop out rates in high intensity exercise programs are higher than in lower intensity exercise programs among this population.

It makes sense that drop out rates are higher—people with anxiety can be hyperaware of what they are experiencing physically, and anyone who has ever done high intensity training can attest that it doesn’t exactly feel comfortable in the moment. There is also a strong co-occurrence of anxiety and chronic pain; a study from 2003 that examined the correlation of anxiety and chronic pain found the strongest associations between chronic pain and panic disorder and PTSD (9, 10). Chronic pain and heightened sensitivity can make exercise difficult—if it hurts, it’s hard to muster up the desire to want to do more of it. The conundrum lies in the research—high intensity exercise is good, but people are less likely to stick with it. Where does this leave professionals working with anxiety and/or chronic pain and anxiety?

Here is where traditionally trained fitness professionals are ill-equipped. If you are working with people in an individualized setting and you are focused on teaching a specific set of exercises or movements in a specific way, the attachment to the program probably isn’t going to work if sensitization or fear is present. A meta-analysis from 2017 concluded resistance training significantly improves symptoms associated with anxiety, so getting people strong is important, but if someone is fearful of injury or of making pain worse, it needs to be done in a way that takes into account the individual’s concerns by not progressing too quickly and starting off with fewer sets/reps/exercises than is usually prescribed (11). Once the client trusts you and sees that you are willing to work slowly, he or she will be willing to do a little more and try things that perhaps were originally off limits because of injury concerns.

I train a man in his 70s I will call James. James has had multiple shoulder surgeries and chronic back pain. He is extremely intelligent and well-read on a variety of topics, including pain science. He also has anxiety—he has been to the ER at least once for heart palpitations that were anxiety related and when he began seeing me, he was quick to tell me what would be bad for his shoulders and what wouldn’t. Things like lifting anything heavier than six pounds and performing any sort of push-up position, he told me, was bad for his shoulders.

His first few sessions were extremely gentle. I worked on having him do simple, basic movements and asked for lots of feedback. Slowly, I began incorporating things he had originally been fearful of—one set of eight pound biceps curls, four times. One round of walking ten feet with a fifteen kettlebell in his right arm. One ten second plank hold at the wall.

Gradually, the volume increased to two sets, and as he gained confidence, the wall plank turned into a wall push-up and he was walking across the room with twenty pounds in each hand instead of fifteen pounds in one. He still has low back pain, but he feels stronger and more capable than he has in a long time. (Added bonus: his wife tells me he’s in a better mood, which I hope means he feels more positive about life.) Will he ever deadlift a hundred pounds or do three sets of twelve push-ups on the floor? Probably not, and that’s okay. That’s not what he wants, but I will continue to do my best to incrementally make him feel stronger and more confident. His workouts aren’t about my ideas of fitness, they are about his goals and concerns, requiring open communication and not being attached to specific movements or skills, something which is difficult when we are taught everyone needs to do three sets of eight to ten repetitions of every exercise to maximize strength benefits. What if instead of this idea that everyone needs to accomplish a specific amount of strength, we were all okay with trying to be a little bit stronger next week than we are today? Does the speed at which we attain strength and mobility really matter if exercise is something that creates fear surrounding pain and injury?

What about mind body modalities?

Individuals with PTSD seem particularly responsive to low/moderate exercise as a way to elevate mood and decrease anxiety, specifically mind/body interventions such as Qigong, yoga, and Tai Chi. (4). In fact, a growing body of evidence suggests mind-body interventions have a positive impact on quality of life, stress reduction, and improvement of health outcomes in individuals with PTSD.

Mind-body interventions can be defined as interventions with components of interaction among mind, body, and behavior; the intention of mind-body interventions is to integrate these three components to improve physical function, as well as mental and physical health (12). Modalities that require paying attention to the task and/or observing how a specific task happens without judging the outcome integrate the mind and body.

Though modalities such as yoga, and Tai Chi are traditionally associated as mind-body interventions, it could be argued anything related to movement that requires focus and attention is a mind-body discipline. The act of slowing down and learning a skill, or figuring out how to interact with the environment or another person in a way that requires focus and problem solving blurs the line between traditional fitness and mind-body disciplines.

Research on alternative modes of mind-body disciplines and their impact on mental health is lacking, but that doesn’t mean it should be discounted. Rock climbing, a hobby the requires focusing on how to navigate the body up a rock require being in the moment and could be argued that it fits the definition of integrating mind, body, and behavior. Nick Carpenter, a US Navy veteran who has struggled with PTSD, writes about rock climbing, “Climbing has saved me from a downward spiral that would have resulted in me taking my own life or drinking myself to death,” (13).

Dance and movement therapies are consistently used during the treatment of PTSD, but the evidence for its effectiveness comes from case studies rather than empirical studies with large sample sizes (14). Other modalities, such as MovNat and Parkour, require high degrees of attention and observation, both of the self and the environment, but aren’t mainstream enough for the potential therapeutic benefits to be studied. One journalist who has generalized anxiety disorder and uses circus art training as one aspect of her treatment writes, “But for 90 minutes I could focus only on my body. I had to, or I could get hurt. Though I got frustrated—a lot—I never cried…These activities have helped boost my confidence and quiet my fears and anxiety towards the unknown, or of being “bad” at something before I’ve given it a chance,” (15).

Anxiety and Balance:

Anxiety disorders can be associated with symptoms related to vestibular symptoms, such as vertigo, dizziness, and unsteadiness. When children with anxiety underwent a balance training intervention, their anxiety symptoms improved as their balance improved (16). Mice who are born with a balance deficit exhibit anxious behavior; when they are raised in acrobatic cages, their balance improves and their anxiety decreases, suggesting balance training can decrease symptoms related to anxiety (17).

Balance training requires paying attention to what you are doing, which makes it mentally engaging. It also requires figuring out how to use the entire body to prevent falling in a contextual way—if you are walking across an elevated surface, or you need to get over an obstacle without hitting it, you are problem solving with your body. Balance training also demands that you, so you can figure out how to perform the task in a way that is safe and minimizes risk of injury. The modalities I mentioned above all require high degrees of dynamic balance, creating mind-body connections by posing challenges that go beyond simply following directions and trying to re-create a movement or skill. Researchers Fetzner and Asmundson point out attentional focus can be directed inwards using body awareness and mindfulness, or outwards, away from bodily sensations. Both, they conclude are possible in treatment, but they encourage investigating the role physical activity can play in creating “a sense of accomplishment” and providing a reprieve from daily anxiety (18).

One of the first things I noticed about James, the client I discussed earlier. was he wasn’t steady on his feet. I regularly implemented exercises that involved tossing a ball while moving, walking backwards over obstacles, and finding footing on slightly elevated, narrow surfaces. He finds these tasks interesting. They challenge him, and while he isn’t always successful, he will try, repeatedly, until the balance and coordination begins to click in a relatively consistent way.

Using activities that are interesting, challenging, and physically and mentally engaging can be beneficial for the participant. When someone is asked to move or interact with the environment (or a person) in a way that is new or viewed as novel, the brain is activated to seek a reward by figuring out the task (19). Several areas of the brain are activated during the process of learning, keeping the individual stimulated (20). What one person finds interesting enough to figure out, another may not, requiring the fitness professional to pay attention to how the client is responding and re-routing if necessary.

Exercise Recommendations:

Aerobic activity: Though I didn’t discuss it, research does show moderate aerobic activity, such as going for a walk outside, is effective at decreasing symptoms for individuals with PTSD. Since people with PTSD and anxiety sensitivity may be less likely to exercise or fearful of the effects of exercise, a gentle walking program may be a good place to start (21).

Strength: Resistance training builds resilience, improves self confidence, and improves self efficacy. Start small, build slowly, and be willing to take a less is more approach so people have a chance to adapt and build trust in their bodies—and you.

Mindful movement: Mindful movement focuses attention and can create internal and external awareness. If someone isn’t receptive to traditional mind-body modalities, don’t be afraid to think outside of the box and suggest alternative modalities such as rock climbing, dance, or Parkour. Any movement task can be mindful depending on how it’s taught, and activities such as martial arts or MovNat classes have the added benefit of having a social component, something which can be extremely beneficial for individuals struggling with anxiety or PTSD.

Play: Incorporating activities that are challenging and interesting can make an individual feel present and elicit a learning response. Pay attention to how the person responds to the task, and don’t be afraid to try something different if your original plan isn’t working.

Helping people with anxiety and PTSD feel stronger and more physically capable may require an individualized approach. The physical sensations that arise during exercise or physical movement can be scary; having empathy, building a strong foundation, and understanding how to use focal points to create balance and security can be instrumental in the client’s success.

Exercise is only one piece to treatment for mental illness; making it rewarding and enjoyable can improve adherence and make a huge impact in a person’s life.

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References:

  1. The National Institute of Mental Health, (2018). Anxiety Disorders. https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml.

  2. Pai, A., Suris, A.M., & North, C.S., (2017). Posttraumatic stress disorder in the DSM-5: Controversy, change, and conceptual considerations. Behavioral Sciences, 7(1), 7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5371751/

  3. The National institute of Mental Health, (2017). Any Anxiety Disorder. https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder.shtml

  4. Hwan Kim, L.S., Kravitz, L., & Schneider, S. PTSD & Exercise: What every exercise professional should know. https://www.unm.edu/~lkravitz/Article%20folder/PTSD.html

  5. Kimble, M.O., Fleming, K., & Bennion, K.A., (2013). Contributors to hypervigilance in a military and civilan sample. Journal of Interpersonal Violence, 28(8), 1672-1692.

  6. Centers for Disease Control and Prevention. Exercise or Physical Activity. https://www.cdc.gov/nchs/fastats/exercise.htm

  7. Wearne, T.A., Lucien, A., Trimmer, E.M., Logan, J.A., Rushby, J., Wilson E., Filicikova, M., & McDonald, S. (2019). Anxiety sensitivity moderates the subjective experience but not the physiological responses to psychosocial stress. International Journal of Psychophysiology, https://www.ncbi.nlm.nih.gov/pubmed/31054275.

  8. Aylett, E., Small, N., & Bower, P., (2018). Exercise in the treatment of clinical anxiety in general practice—a systematic review and meta-analysis. BMC Health Services Research, 18, 559. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6048763/.

  9. Asmundson, G.J., & Katz, J., (2009). Understanding the co-occurrence of anxiety disorders and chronic pain: state-of-the-art. Depression and Anxiety, 26(10), 888-901.

  10. McWilliams, L.A., Cox, B.J., & Enns, M.W., (2003). Mood and anxiety disorders associated with chronic pain: an examination in a nationally representative sample. Pain, 106(1-2), 127-133.

  11. Gordon, B.R., McDowell, C.P., Lyons, M., Herring, M.P., (2017), the effects of resistance exercise training on anxiety: a meta-analysis and meta-regression analysis of randomized controlled trials. Sports Medicine, 47(12), 2521-2532.

  12. Hwan Kim, S., Schneider, S.M., Kravitz, L., Mermier, C., & Burge, M.R., (2013). Mind-body practices for post traumatic stress disorder. Journal of Investigative Medicine, 61(5), 827-834. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3668544/.

  13. Carpenter, N., (2015). Rock climbing saved my life: a veteran’s struggle with PTSD. Rock and Ice: The Climber’s Magazine, https://rockandice.com/climbing-news/rock-climbing-saved-my-life-a-veterans-struggle-with-ptsd/.

  14. Steinberg-Oren, S.L., Krasnova, M., Krasnov, I.S., Baker, M.R., & Ames, D., (2016). Let’s dance: a holistic approach to treating veterans with posttraumatic stress disorder. Federal Practice, 33(7), 44-49, https://www.mdedge.com/fedprac/article/110095/mental-health/lets-dance-holistic-approach-treating-veterans-posttraumatic.

  15. Emily, L., (2019). How circus training helped me deal with my anxiety disorder. Self Magazine, https://www.self.com/story/how-circus-training-helps-me-deal-with-anxiety.

  16. Bart, O., Bar-Haim, Y., Weizman, E., Levin, M., Sadeh, A., & Mintz, M., (2009). Balance treatment ameliorates anxiety and increases self-esteem in children with anxiety and balance disorder. Research in Development and Disability, 30(3), 486-495.

  17. Shefer, S., Gordon, C., Avraham, K.B., & Mintz, M., (2014). Balance deficit enhances anxiety and balance training decreases anxiety in vestibular mutant mice. Behavioural Brain Research, http://kbalab.com/wp-content/uploads/2012/05/Shefer-et-al_2014.pdf.

  18. Ley, C., Barrio, M.R., & Koch, A., (2018). “In the Sport I am Here”: therapeutic processes and health effect of sport and exercise on PTSD. Qualitative Health Research, 28(3), 491-507.

  19. Cell Press. "Pure Novelty Spurs The Brain." ScienceDaily. ScienceDaily, 27 August 2006. https://www.sciencedaily.com/releases/2006/08/060826180547.htm

  20. Censor, N., Sagi, D., & Cohen, L.G., (2012). Common mechanisms of human perceptual and motor learning. Nature Review Neuroscience, 13(9), 658-664.

  21. Hegberg, N.J., Hayes, J.P., & Hayes, S.M., (2019). Exercise intervention in PTSD: a narrative review and rational for implementation. Frontiers in Psychiatry, 10(133), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6437073/.

The pelvis and low back pain part I: mobility exercises to improve awareness and mobility

Your pelvis, the bowl shaped structure that hangs from the bottom of the spine, is comprised of muscles on the inside that help maintain intra abdominal pressure and muscles on the outside that transmit forces from the leg to the torso during walking and running and also control movement of the leg at the hip socket. (Intra abdominal pressure refers to the co-contraction of several torso muscles to keep the spinal segments stable).

The pelvis moves when you walk, rotating in an oscillating fashion up, down, laterally, forwards, and backwards. When the pelvis is coordinated with the rest of the body, the movement looks fluid, not stilted. When people try to alter the movement at the pelvis, either consciously or unconsciously because they don’t want to be perceived a certain way, they are trying to transmit a certain status or posture, they experienced trauma that has disconnected them from how the area moves, or they have been given instructions in group exercise classes about how to move (or not move) the pelvis, they are doing their entire body a disservice. When the pelvis isn’t integrating with the rest of the joints for efficient movement, other joints will move more or move less to create the mobility/stability the body needs to propel itself forward or accomplish a specific movement goal.

Let’s pretend your pelvis only knows how to rotate back, tucking under when you stand and tucking under more when you do things like lift your leg. The muscles that support posterior pelvic tilting (which is the term of a pelvis that’s rotated back), will be good at that movement, but they won’t be good at moving the pelvis forward or rotating the pelvis. Or maybe you have a pelvis that moves up and to the right really well, but doesn’t know how to move up and to the left, so you experience a constant ache on the right side of your low back. The muscles that tilt the pelvis up and to the right are good at that movement, and the muscles that move the left side of the pelvis down are good at that skill, but to create more balance, the muscles on the left need to learn to move the pelvis up and to the left and the muscles on the right need to learn to move the right side of the pelvis down.

There are a number of ways to gain better control of the pelvis. Let’s start with looking at how to feel whether the pelvis is moving or not. Learning to feel and consciously control movement in the pelvis is a great way to restore mobility and coordination and take a load off your spine because you can’t change what you can’t feel.

Exercise 1:

Pelvic tilts, three ways

Lie down on your back, with your knees bent and your feet flat on the floor. Take a moment to feel your pelvis on the ground. What does it look like? If you were to draw a picture of how it rests on the floor, which parts would be heaviest? Which would be lightest?

Roll your pelvis so your low back comes closer to the floor. Make the movement small and go slowly, not going to the point of discomfort. Now, roll the pelvis the other way, so the low back arches away from the floor. Go back and forth between these two movements four to six times.

Come into a seated position, either on a chair if the floor isn’t comfortable, or on the floor. Feel the sitting bones, the two bony knobs at the bottom of the pelvis, against the surface on which you are sitting. Roll behind your sitting bones. Make the movement small and don’t go to a place of discomfort. What happens to your low back? Now, roll in front of your sitting bones. Again, observe what happens in your low back. Go back and forth between the two positions four to six times.

Come into a hands and knees position. Imagine you have a tail. Move your tail slowly between your legs. Move your tail up towards the ceiling. What does your pelvis do when you move the tail between your legs? What about up towards the ceiling? Go back and forth between the two positions four to six times.

Lie on your back again. Take a moment to observe your sense of the pelvis against the floor. How does it feel now?



Exercise 2:

Tilting the pelvis sideways, three ways

Lie down on your back with your legs long and your arms overhead on the floor. If your arms don’t rest comfortably overhead on the floor, raise them up by your sides as high as you can, keeping the entire length of the arm supported against the floor.

Slide the legs to the right, keeping them long. What happens to the right side of the pelvis? What about the left side?

Bring the legs back to center and slide the legs to the left, again, keeping them long. What happens to the left side of the pelvis?

Go back and forth between the two positions four to six times. Make sure you are breathing, and remember to make the motion small, staying in a pain-free range.

Come into a hands and knees position. Pretend like you have a tail. Wag your tail to the right. Bring it back to center. Wag your tail to the left. Go back and forth between the two positions four to six times. How does that feel?

Come into a standing position, placing your hands on your hips. Keeping your legs straight, press your right foot into the ground, lifting your left foot the ground about an inch. What happens to the pelvis beneath your hands?

Return to center and press your left foot into the ground, lifting the right foot off the ground about an inch. What happens to the pelvis beneath your hands?

Go back and forth between the two positions four to six times.


Exercise 3:

Pelvis rotation, three ways

Lie down on your back, with your feet flat and your hands resting on your hips. Tilt the knees to the right. Let the weight of the knees tilt the pelvis. Keep the movement small, and make sure you can return the legs to the starting position. When you return to the starting position, tilt the knees to the left, letting the weight of the legs rotate the pelvis. Go back and forth between the two positions, four to six times.

What happened underneath your hands? Was one side more challenging than the other?

Come on to a hands and knees position. Reach your right knee into the ground. Lift your left knee half and inch off of the ground. Pause for a moment and lower the left knee back down. Reach your left knee into the ground, lifting your right knee half an inch off of the ground. Go back and forth between the two positions, four to six times.

What happens in your pelvis? Were you able to keep the rest of the torso still, not shifting weight from side to side?

Come into a standing position. Place your hands on the hips and step the right foot forward about 18 inches. Both feet will be on the floor.

Rotate the left hip forward as the right hip rotates back. You will feel the left hand coming forward and the right hand moving back. Bring the hips back to the starting position, but keep the feet staggered. Perform four to six, and then switch sides, stepping the left foot forward about 18 inches, keeping both feet on the floor, and rotating the right hip forward as the left hip rotates back. Perform four to six, and then relax with your feet together.


These simple awareness drills can be used as a warm-up before your workout or as a way to relax before bed. If one was particularly challenging for you, practice it four to five times a week for about a month. As it gets easier, notice if you feel any more movement in your pelvis when you are walking or any more control in your pelvis when you are exercising. Feeling how your pelvis moves makes it easier to prevent the pelvis from moving, which can be beneficial for improving hip strength and mobility, and core strength and mobility. Part II in this series will focus on learning how to improve the sense of stability through the pelvis through exercises that use the muscles in the core to keep the pelvis still.

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Fear, Anxiety, and Kinesiophobia: Part I


Fear:

What scares you? It’s an interesting question, isn’t it, because we are all scared of something, whether it’s the monsters under the bed, snakes, awkward social situations, or something deeper, fear is part of the human condition, which isn’t a bad thing. The sensation of fear exists to alert us when danger is present; in fact, fear circuits are present in other mammals, and even single celled organisms have the ability to detect and respond to significant events (1).

Individuals with high risk tolerance, i.e., higher thresholds before the fear response kicks in, stay calm under pressure longer than someone who has a lower threshold for fear. These individuals may also take higher risks than the average person. Alex Hannold, the world renowned free climber who soloed half dome is an example of someone who, according to brain imaging, has an unusually high threshold for fear (2). The lack of activity in his amygdala, the part of the brain that triggers the physiological responses associated with fear and sends information to higher processing parts of the brain that say, “hey. This is scary. Maybe this isn’t such a good idea,” might explain part of his success. His lack of response may allow him to do things like stay calm longer while climbing up the face of a rock without ropes, thousands of feet above the ground. Many would argue that his hobby/career/life’s purpose is, indeed, a high risk behavior, though he pursues it in an analytical, calculated way designed to minimize errors.

You can deal with fear a number of ways, including

  • Ignoring it and doing the thing that scares you anyway. This is often referred to as facing your fear. When you do something that scares you and nothing bad happens, it reinforces the fact that maybe the thing that brings you fear isn’t as harmful as you think. This works best in situations where the fear may be blown out of proportion and the situation is generally safe, such as walking into a room full of people you don’t know, flying in an airplane, or giving a public talk. It should also be done on a small scale first—don’t walk into a room of one hundred people you don’t know, walk into a room of ten people you don’t know and see how it goes.

  • Preparing for the thing that scares you to maximize your chance of success. Alex Hannold uses preparation to maximize his chance of scaling a rock face, sans ropes, without falling. He prepares in the fullest way possible through repetition, visualization, and physical conditioning. Most of us don’t aspire to free solo huge rock faces, but all of us can learn from his commitment to preparedness. If you have fear of balancing on rails that are three feet off of the ground, start with a rail that’s two inches off of the ground. If you are giving a talk to 50 professionals, spend time researching, putting together the presentation, and then practice. Practice so much you barely need to look at your slides because you know the material and what you want to say. Gain confidence through preparation.

  • Create small steps towards facing your fear. Rather than ignoring your fear, this mindset requires acknowledging that you are scared and finding small opportunities that allow you to take steps towards your fears without creating an anxiety provoking feeling that causes you to freeze, disconnect, or flee. If talking in front of groups gives you anxiety, the next time you are in a group, introduce yourself to one person you don’t know and offer a piece of information about yourself. Or, if you are afraid of heights, if there is a footbridge near your house that gives you trepidation, take two steps across it and then return to the starting position. Maybe the next time you approach the bridge, you can take three steps, but begin with one step at a time.

Kinesiophobia:

What does any of this have to do with exercise and fitness, you may be wondering? Often fear prevents people from exploring movement and developing strength and flexibility. It may even stop people from beginning an exercise program. Fear in an exercise setting can be specific, (“I’m scared of placing weight on my hands so I’m not going to do anything that places weight on my hands,”), or it can be more general.

Kinesiophobia, or excessive fear of movement, occurs when people feel vulnerable to injuring themselves during movement because of a previous injury (3). Kinesiophobia contributes to pain becoming a chronic condition—individuals believe that physical activity will result in more pain/re-injury, leading to avoidance of physical activity, disuse, and depression.

Fear of injury can come from many sources. If someone reads in an interview with a postural expert that bending over is bad for the back and this individual has experienced back pain, he may avoid bending over at all costs. His spine will become stiff as he protects the back from injury because an expert said it was potentially harmful, leading to muscle guarding, altered body perception, and, ultimately, more pain.

Patellofemoral pain (PFP) is the experience of nerve sensitivity in the soft tissues and bones around the kneecap. The sensitivity can become chronic, despite the fact the ligaments and menisci supporting the knee are intact. It affects 23% of the general population and long term prognosis is poor—two thirds of individuals diagnosed with PFP still have knee persistent knee pain one year after the initial diagnosis (4).

You probably know someone with “bad knees.” It’s the person who makes off handed comments while watching you squat and crawl around on the floor that her knee could never do that, or who tells you that her right knee is bad and that’s why she avoids walking downhill. She feels most things that require knee bending, actually, are going to injure her right knee and make it hurt worse than it already does.

Here is the crazy thing about interventions for chronic pain: a number of studies show temporarily aggravating symptoms using exercise therapies actually leads to an overall decrease in pain. It’s as though exposing the body to the very thing it’s become fearful of reduces sensitivity.

So, the person with a chronically painful right knee with no structural damage would benefit from walking downhill, or squatting with weight, or maybe even performing single leg squats on a regular basis. The short bouts of discomfort lead to stronger tissues (i.e., the muscles, ligaments, and bones get stronger), and a shift in mindset—exercise is no longer viewed as something to be avoided because it will injure the joint more.

Anxiety:

Fear and anxiety are similar. Anxiety is defined as constant worry, and worry is fear of actual or potential problems. (Interestingly, dictionary.com also defines worry as a verb specific to carnivorous animals. It means to tear at or gnaw on, like what a dog does with a bone.) Fear is the sensation that arises when you are unsure of a situation’s outcome, so a state of anxiety could be thought of as being fearful of what could happen in most situations.

Fear, which occurs when a potential threat has been identified, can result in passive or active responses. There may be an initial freeze response, while the severity of the threat is determined. If the threat is life-threatening and there is no obvious escape route, the heart rate may slow, blood pressure may drop, and the animal may “play dead” until the threat passes (5). If the animal moves into a fight or flight response, heart rate increases. Respiration rate increases. Breathing becomes shallow, and blood moves away from the digestive system to the global muscles, which tense.

The DSM-5, which is the decider of all psychological disorders, defines generalized anxiety disorder as symptoms that include: feeling restless, getting tired easily, having difficulty concentrating and sleeping, irritability, and muscle tension (6). The persistency of worry leads to chronic physiological responses, affecting an individual’s heart rate and respiration (7, 8).

It’s no surprise panic attacks are often mistaken for heart attacks—one prevailing hypothesis is that panic attacks (which result in anxiety), are provoked by misinterpretations of bodily sensations. If you don’t trust that your body is strong, things like elevated heart rate and shortness of breath suggest a potential weakness that could potentially be life threatening (9).

When you first begin an exercise program, your body responds by revving up, mimicking the same symptoms that a person may fear cause harm. The increase in heart rate and rapid breathing stops when exercise is over. This can be a teaching tool, similar to the way using the knee to perform strength based exercises is a teaching tool for the person with PFP. The realization that, “my heart was beating fast and for a short time, my breath was shorter, but I’m okay,” can help someone re-write the story they tell themselves about the fragility of their body.*

When you learn new physical skills, sensations arise. These sensations can be unpleasant while you figure out how to hold the limbs a specific way or coordinate the limbs to move in specific pattern. New movements require muscular work that feels foreign and the sensations can be overwhelming as your nervous system goes into overdrive, figuring out what it’s being asked to do and how many motor units should be sent to the muscles to accommodate the new position. The experience can be overwhelming and scary, and can be enough for a person who is concerned exercise may be a source of pain to decide it’s not a good idea to ever be in that particular position again. Interestingly, the second time you try the same new skill, it will feel less uncomfortable. Novelty is never as interesting the second time, and the neuromuscular system’s response to new positions is no exception.

New positions can also cause sensation in the joints, particularly if the joints aren’t used to dealing with specific types of load. The sensation in the joints can almost always be altered by focusing on the connection of the entire kinetic chain, so if you’re doing a wall sit position and you feel it in the knee, focusing on actions in the feet or pelvis will change what you are experiencing, usually for the better. This requires knowing how to alter focus, so unless someone suggests you change how you are supporting the movement, you may not realize there are less pain provoking ways to perform the skill, reinforcing fear of exercise and movement.

Finally, exposing the body to new positions can cause more noise in the nervous system while it struggles to understand the most efficient way to accomplish the task. These sensations are often quick, sharp, nerve-like sensations that disappear as the neuromuscular system figures out the best way to coordinate the movement. Have you ever had a sudden twinge when you reach for something, only to have the twinge disappear when you reach again? That’s noise. If the twinge persists with repeated exposure, then you should definitely get it checked out, but more often than not, it simply disappears.

If you struggle with anxiety, perhaps the most important thing you can do when you begin an exercise program is expose yourself gradually. The guidelines for exercise make it seem like the average person should be able to do 30 minutes of sustained cardiovascular activity and 3 sets of 10 repetitions on the first day after a long exercise hiatus. The reality is if you have been inactive for a long time or you have struggled to be successful in an exercise program, either because it caused discomfort or felt overwhelming, less is more. Begin with a seven or eight minute walk instead of a thirty minute walk. Do one set of squats, four times, instead of three sets of ten. If something hurts, take a break for a minute or two and then try the same move again. Give the body and nervous system a chance to adapt to what you are asking. Feel the different parts of the body interacting with the floor when you begin strength training so you feel a sense of security. Don’t focus on how much you think you should do, focus on what you can do. Gradual, repeated exposure is what will set you up for long term success and give you an opportunity to feel stronger, more capable, and more emotionally and physically resilient.

Thank you for reading part one. Part two will take a deeper look at other factors that can contribute to anxiety, such as traditional gym and class settings, what happens if you exercise and still experience anxiety, and the importance of self efficacy.

*This is a reference to Brene Brown’s Netflix special, “The Call to Courage.” If vulnerability interests you, you should watch it.

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References:

  1. LeDoux, J.E., (2012). Evolution of human emotion: a view through fear. Progressive Brain Research, 195 (431-442). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3600914/

  2. Mackinnon, J.B., (2016). The strange brain of the world’s greatest solo climber. Nautilus, 39 (https://nautil.us/issue/39/sport/the-strange-brain-of-the-worlds-greatest-solo-climber).

  3. Larsson, C., Hansson, E.E., Sundquist, K., & Jakobsson, U., (2016). Kinesiophobia and its relation to pain characteristics and cognitive affective variables in older adults with chronic pain. BioMed Central Geriatrics, 16, 128. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4936054/

  4. Smith, B.E., Hendrick, P., Bateman, M., Moffatt, F., Rathleff, M.S., Selfe, J., Smith, T.O., & Logan, P., (2019). A loaded self-managed exercise programme for patellofemoral pain: a mixed methods feasibility study. BMC Musculoskeletal Disorders, 20(129). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6438027/

  5. Steimer, T., (2002). The biology of fear- and anxiety-related behaviors. Dialoagues in Clinical Neuroscience, 4(3), 231-249. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181681/

  6. Patriquin, M.A., & Mathew, S.J., (2017). The neurobiological mechanisms of generalized anxiety disorder and chronic stress. Sage Journals, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181681/.

  7. Severino, P., Mariani, M.V., Maraone, A., Piro, A., Ceccacci, A., Tarsitani, L., Maestrini, V., Mancone, M., Lavalle, C., Pasqioni, M., & Fedele, F., (2019). Cariology Research and Practice, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6398072/.

  8. White paper: Anxiety and breathing difficulties. University Hospital Southhamptom, http://www.uhs.nhs.uk/Media/Controlleddocuments/Patientinformation/Stayinginhospital/Anxietyandbreathingdifficulties-patientinformation.pdf

  9. De Cort, K., Hermans, D., Noortman, D., Arends, W., Griez, E.J.L., & Schruers, K.R.J., (2013). The weight of cognitions in panic: the link between misinterpretations and panic attacks. PLoS One, 8(8), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3734098/.

Thoughts on pain, nociception, and sensation

I have been in the fitness industry for 18 years. I watch as pendulums swing regularly. It’s good—there is a desire of fitness and movement professionals to provide information to clients that helps them get stronger, feel more empowered, and get out of pain.

Random fact about me: throughout my 20s, I had chronic pain issues. I was wound tight, strong in a small range of motion, and busy trying to absorb all of the information about personal training I could. I ended up with inflammation in my elbows, a swollen left knee, and shoulders that felt like they belonged to an 80 year old.

So, at 24, I decided the solution was to start yoga. Yoga, it seemed, would make my body feel better by restoring some flexibility, something my young mind told me I needed.

At the time, plyometrics and stability ball workouts were all of the rage. Standing on BOSUs to improve balance and using stability balls for everything was encouraged, and creating situations for people to challenge their balance was sure to activate the deep abdominal muscles.. So were transverse abdominis isolation exercises using things like blood pressure cuffs and every variation of plank possible. Low back pain, we were told, was caused by a weak transverse abdominis, and squatting with your knees moving past your ankles was sure to cause your menisci to implode, causing permanent damage. Fitness and anything centered around the mind/body were completely separate disciplines. Yogis didn’t lift and personal trainers stretched, but didn’t do anything resembling Surya Namaskar A.

So, I began my yoga journey, but I still lifted weights because my professors said one of the most critical times for building a foundation for bone density is in your twenties (I was an exercise physiology major. My Even though I understood you could build bone density throughout your life, when professors use terms like, “critical time” and you’re a rule follower, you faithfully build your bone density using load, even though your yoga teachers tell you that is going to cause irreparable tightness).

Yoga made me feel marginally better, but it wasn’t the magic cure I thought it would be. Plus, even though I was good at focusing on me and the mat, I couldn’t help but notice how my lack of flexibility prevented me from progressing. My body was firmly stuck, no matter how many teachers tried to push me forward in forward bend, or how many days I practiced on my own.

I began studying alternate, “fringe” modalities, frustrated with both my nagging pain issues which ebbed and flowed throughout my twenties and the fact that, still, I felt something was missing. I also went back to graduate school so I could clarify a few things. I thought I wanted to specialize in working with runners, not realizing runners at the time lifted weights as often as yogis lifted weights. It worked out, though, because I became fascinated by gait mechanics and motor control.

I started to figure things out in my own practice. All of this self exploration led the elimination of my chronic pain, an improvement in flexibility, and clients who were also feeling better. It would still be a few years before I was able to put everything fully together, but I was on the right path.

Nociception is sensation caused by nociceptors, unspecialized nerve cell endings that send information to the brain. They act on fast or slow nerve pathways, depending on the type of axons the nociceptors as associated with (think of axons like the highways carrying the nociceptor information as rapidly as possible up the spinal cord).

If you pick up a steaming hot pan you drop it before you realize the pan is burning you. You can thank your mechanothermal nociceptors for letting you know the temperature of your skin is dangerously high and there is potential harm. Your motor nervous system respond by spontaneously dropping the pan.

Pain is defined as a somatic sensation. It’s complex, a myriad of sensory, emotional, and cognitive experience. Nociception generally occurs when there is an extreme change in pressure or temperature that could be potentially harmful and/or toxic molecules and inflammatory mediators.

Let’s say you’re camping and your five year old wanders off, falling into a deep ditch. She hits her head and may have broken her leg. You hear her screaming, and while you are rushing down to get her, you gash your hand on a broken branch. The laceration is deep, but you need to get to your five year old. Do you feel pain?

Probably not in the moment. Stress can suppress the sensation of pain so you can make it through and survive whatever the situation is.

Conversely, anticipation can exacerbate pain. Have you ever reached for something and experienced a twinge, only to reach for the same thing a moment later and have no pain? Why did your nervous system anticipate pain in this situation? Maybe you had something else on your mind that was stressing you out, or maybe you were a little worried about how reaching would affect your shoulder because it’s been achy. Or maybe you were tired, or maybe you don’t normally reach at that angle, so you weren’t quite sure if the new position was okay. Whatever the reason, your nervous system anticipated the movement as being potentially harmful, even though it didn’t pose a threat to the musculoskeletal system.

We all have habitual movement patterns that get us through the day. I don’t have to think about which hand I use to brush my teeth (though it’s fun to try and brush your teeth with the opposite hand once in a while). This saves me time and makes me efficient at tooth brushing, freeing up energy for other things, like pondering nociception and learning Parkour. Habits create efficiency, which is a good thing.

Sometimes, our habits create sensitization. In the above scenario, reaching the arm towards an object caused a twinge, so hypothetical you waited a second and tried it again. There is a pretty good chance hypothetical you changed something slightly about how you were performing the movement, whether it was reaching at a slightly different angle or using less muscular tension or more muscular tension, or less bend in the elbow. One way to look at pain that is caused by a specific movement is it’s a teacher to let us know we should try doing something differently.

But what if when you reached it caused a dull ache in your elbow that you ignored? And every time you reached you felt this dull ache, but you kept reaching anyway because life required you to reach? And what if you were to spend an entire day paying attention to how you reach and you noticed you reached for everything by tensing your fingers and never fully extending the elbow? Is it possible your options for reaching have become so narrow you have created the perfect situation for irritation, whether it’s of the tissues or the nervous system?

A few months ago, I noticed a dull ache in my right lateral hip while I was sleeping. Like all good practitioners who become complacent about practicing what they preach, I ignored it. Soon, it morphed into a sensation of tightness through the front of my left thigh that was sort of electrical feeling, more like nerve sensation than muscle sensation.

I viewed it all curiously, and while it didn’t impact my life or my movement practice in any way, the sensations were annoyances. It didn’t occur to me to check in and see if I had developed a habit that was creating movement patterns that were sensitized, or ponder whether my current work pace was creating a hyper-vigilant loop, rooted in too much doing and not enough time being “off.”

In October, I thought it would be a good idea to add either writing or filming to my lunch breaks. By the time March rolled around, I was using every free moment between clients to write or film, and after work time was becoming consumed with added responsibilities that come along with a busy in person practice and a desire to grow professionally in a different way. Maybe, just maybe, I was embodying my hyper-vigilance and perfectionism, tendencies I am acutely aware of and spend a lot of time fighting.

A New York Times article came out earlier this year that told the story of a 71 year old woman who was born with a rare genetic mutation that prevents her feeling pain. She also has extremely low levels of anxiety. She scored zero out of twenty-one on an anxiety-disorder questionnaire and doesn’t remember every feeling depressed or scared. Perhaps anxiety and pain are related, suggesting our thoughts become our physical selves, or maybe our physical selves become our thoughts.

In late Match, I began filming a course on the pelvis. Two days after I began filming, I noticed the sensations in both hips had significantly decreased. The last weekend in March, I went to a workshop based largely in somatic techniques and centered around the pelvis. I suddenly realized in the midst of the workshop I had been clenching my glutes. All of the time. The tension I was carrying in my life and the pressure I was putting on myself were translating into my body.

The sensations completely decreased after the workshop. Periodically throughout the day, I still feel myself defaulting to tightening and clenching. When this happens, l relax and observe, my emotional self resisting, as though relaxation isn’t okay.

Currently, the prevailing thought making rounds in the movement and therapy worlds is if there is pain, you should load it. While this works well for people who aren’t strong and who need more strength, for those who are already loading the area and there is still sensation, finding an alternative solution through changing position or down-regulating the system may be a better solution.

A client came in recently who has been working with me once a week for almost five years. He lifts regularly on his own. He also has a high stress job and spends a lot of time working—I have never known him to take a vacation. He had tweaked his knee but, he told me, he was able to get rid of the discomfort if he subtly shifted his position. While it could be argued that shifting position shifts load (and I would agree that this is true), it also creates a connection with you and your body. How are you moving in this movement right now? Is it serving you or could you change something about it to make it more comfortable?

Earlier that same week, another client texted me to let me know her chronic pain had become less chronic. When she felt it come on, she breathed, shifted positions, and waited to see if it would pass. More often than not, it did.

Prior to seeing me she had tried working with various trainers. Her pain continued to get worse, until it was a deafening scream in her right upper gluteal region. MRIs revealed nothing, and she felt frustration with herself and a disconnect from her body. A combination of modalities, including improving kinesthetic awareness, learning how to perform movements in ways that didn’t hurt, and learning she had the power to change her experience through subtle, gentle shifts created a connection between her and her body; strength training in a pain free way reminded her she is strong. She needed strength, but that alone wasn’t breaking the pain cycle.

While there is absolutely value in creating strength and a sense of resilience, if you are loading your tissues and that isn’t working, don’t be afraid to try a different approach. We all have different definitions of what pain feels like, and everyone’s threshold for sensitivity is unique. Was what I experiencing in my hips pain? Probably to some, but I didn’t view it that way. However, what I experienced in my twenties was definitely what I would define as pain. I am, hopefully, a different person than I was fifteen years ago, so it’s possible just the act of growing up has changed my perspective on how I view sensation.

Enabling people to feel holding patterns and encouraging subtle shifts creates a sense of freedom; instead of feeling like the body controls the experience you, actually, have far more power than you realize. My sensations disappeared when I took the time to slow down and actually feel how I was holding myself. An old proverb says, “if you listen to your body when it whispers, you won’t have to hear it scream.” Getting stronger is one important piece to feeling better, but I don’t think it’s the only piece.

Swiss balls have come back into vogue; so has balancing on uneven surfaces. I have no doubt the pendulum will swing again, hopefully equally emphasizing the value of strength as well as the ability to feel.

To Tuck or Not to Tuck: Why always tucking the pelvis isn’t the best strategy for movement freedom

I will never forgot the first time I worked with someone who habitually tucked her pelvis. She was referred to me by an acupuncturist who was hopeful I could help her with the chronic low back pain she was experiencing. As soon as she walked in, I could tell her gait was stiff. As I watched her move, her pelvis remained tucked in every position. She explained she had done quite a bit of a specific movement modality that cued pelvis tucking in a lot of the exercises, so she made a conscious effort to tuck in order to keep her back stable. 


Your pelvis, the hollow bowl-like structure that connects to the spine and the lower extremity (specifically, your leg), is designed to move a variety of ways (1). Using the top of the pelvis as a reference point, you can tip the top of the pelvis forward. This would move the bottom of the pelvis back. (You can try this right now by coming into a tall kneeling position with your fingers on your two front pelvis bones where your pants normally sit. What happens to the bottom of the pelvis when you do this? Hopefully, it moves back. Otherwise, you have successfully invented a new dance move.)

When you perform the above movement, you are moving your pelvis anteriorly. Now, come into the same position, but move the two front pelvis bones away from your fingers. What happens to the bottom of the pelvis? It moves forward, right? This is tilting your pelvis posteriorly, aka as tucking your pelvis.

Go back and forth between the two positions a few times, bringing your pelvis bones forward into your fingers and back, away from your fingers. Once you’ve done six or eight, settle into a comfortable position. How does that feel?

Different movements require the pelvis to tilt one way or the other. In fact, certain movements coordinate with an anterior pelvic tilt and others coordinate with a posterior pelvic tilt. We have the ability for our pelvis to move both ways for a reason. What becomes problematic is when the pelvis becomes habitually held in one position.

The anatomy of the tuck:

What happens when you tuck your pelvis? Since the back wall of the pelvis is made up of the sacrum, which happens to be the five fused vertebrae that form the segment of the spine following the lumbar vertebrae, when you move your pelvis either forward or back, there will be echos of the movement throughout the base of the spine, meaning the lowest lumbar vertebrae will move into a little bit of flexion if you’re tucked, or extension if you’re in an anterior tilt. The lumbosacral joint is the meeting place of the lumbar spine and the sacrum. It’s designed to allow pelvic rotation during walking (2). If the pelvis is always tucked and what do you think that does to the rest of the spine when you walk?

It will limit movement, making your gait less efficient. Try this: sit long on the floor with your legs extended in front of you (if you can’t extend your legs long, you can do this with your legs bent). Roll in front of your sitting bones (the knobby bones at the bottom of the pelvis), and behind your sitting bones. Do this three or four times. Pause behind your sitting bones. This is the “tucked” position.

Try and walk your pelvis forward in the tucked position. How does that feel? Do you move very much?

Now, roll your pelvis forward and back a few more times and stop with yourself on your sitting bones or just in front of your sitting bones. Walk forward again. How does that feel?

(I tried this. I’m not winning any pelvis walking races in the tucked position: https://www.instagram.com/p/BvRSPdtB-hu/).

Probably a lot easier, right? That’s because your pelvis has room to rotate when it’s not tucked under; rotation is a motion that’s necessary for walking. If your pelvis doesn’t rotate, you will pick up the rotation from somewhere else so that you can propel yourself forward.

How much rotation/flexion/extension are you “supposed” to have, you may be wondering? It turns out, everyone is a little bit different, and how much your pelvis moves when you walk depends on things like whether you’re male or female and how old you are (3). There is no “gold standard” for how much a joint moves. What matters more is the sense of freedom you feel in the area.

The belly situation:

There are a number of muscles that attach to the pelvis, both from the torso/abdominal/back region and the hip region. If you habitually tuck your pelvis under, it’s going to impact how you feel work in your abdominals and how you feel work in your hips.

“But wait,” those of you who study movement might be thinking, “aren’t the abdominals the muscles used to tuck the pelvis? So if my pelvis is constantly tucked, I should feel work in my abdominals always, right?”

Yes, the rectus abdominis, your six pack muscles, attaches at the pelvis and plays a role in posteriorly tilting the spine (4). BUT (and this is a big but), in a standing position, your body will default to the position that requires the least amount of effort. If your tendency is to place your pelvis under your body, your weight in the center of the body is suddenly going forward. To counterbalance, you may adopt a number of strategies, not all of which place a large amount of load in the abdominals. In fact, one of the things I find most interesting about chronic tuckers is usually when I have them move their hips back in standing (which conveniently untucks the pelvis), they all comment on how much they suddenly feel their abdominals working.

If you are habitually tensing your abdominals to maintain a pelvic tilt, you are working your abdominals just not in a way that’s working for you. Muscles work best on the joints they move when they have the ability to move through a broad range of motion with the appropriate amount of tension required for the task. Do I need the same amount of abdominal tension to lay here and write this as I do to deadlift a heavy, wet log? Probably not. The neuromuscular system likes options with all things; muscle tone is no exception.

Research suggests that when you contract the pelvic floor muscles voluntarily, you also contract the abdominals (5). If you have a tendency to suck in your belly or you really try to keep your abs flexed because you feel like you “look” better this way, you may be doing your pelvic floor a disservice. Not only are you limiting movement at the spine and pelvis, if contracting your pelvic floor results in abdominal contraction, maybe contracting your abs causes a change in pelvic floor contraction. Creating tension in a variety of positions is important, but so is the ability to let the tension go. Does your dog have to suck in its belly to maintain stability? You didn’t evolve to suck in your gut or stay tense all of the time. Movement freedom is determined by tension AND ease.

What about the hips?

There are lots of muscles that attach on the outside of the pelvis. Many of them control rotation and movement at the hip joint. Try this: come into a standing position and tuck your pelvis. Pick up your right leg and try and make a circle at the hip joint as seen below (a hip CAR for those of you who study FRC). Try two or three circles. How does that feel?

Hip CAR: https://youtu.be/Sb5imZbEU7Q

Now, untuck yourself and try and make a hip circle (or two). How does that feel?

A LOT easier, right? So the whole tucked pelvis thing will impact your hip mobility, reducing it until your poor femur struggles to move freely in the joint.

You can feel this when you stand. As soon as you tuck your pelvis, your pelvis shifts forward and your weight in your feet shifts back. When you lift your leg in this position, it requires effort because your torso and hip are far away from each other. If you untuck your pelvis, your torso shifts forward and you are able to lift your leg much easier. (I totally just tried this for the first time. It was much harder than I expected. Now I see why my tucked clients all flex their hips by posteriorly tilting their pelvises! Lightbulb moment.)

Holding the pelvis so it stays in one position, all of the time, is disadvantageous for movement; it’s also disadvantageous for things like pelvic floor health.

Your pelvic floor is comprised of bone, muscles, and connective tissue (6). These muscles contract and relax throughout the day when you do things like breathe, go to the bathroom or have sexual intercourse.

When you breathe, your inhale moves the diaphragm down and the pelvic floor muscles relax. On your exhale, the pelvic floor contracts. The abdominal muscles, including the diaphragm, and the pelvic floor muscles work together to maintain pressure in the abdominal cavity (7). This is known as IAP and plays an important role in creating a sense of stability in the torso when you lift a heavy object or when you cough (I know, two seemingly unrelated things, but both cause force that needs to be dealt with. IAP is what nature came up with to keep the organs safe).

The muscles of the pelvic floor are designed to contract and relax. I mentioned earlier habitually holding in your stomach affects the pelvic floor muscles by contracting them, but what happens if you habitually tuck your pelvis and you aren’t sucking in your abs to do it? Would that affect your pelvic floor muscles?

Imagine you lived most of your time with your arms bent, holding a five pound medicine ball. Your arms stay in that position for sixteen hours a day, except when you eat and go to the bathroom. Let’s pretend you stayed in this position for five years. How easy would it be to straighten your arms at the end of that five years?

Hard, right? In fact, you probably wouldn’t have the strength to straighten your arms, let alone reach for anything behind you. Whenever you keep a joint locked in one position, the muscles that move the joint in different directions become weak even though they are strong in the one position they spend most of their time in.

What if instead of holding a five pound ball, you rested your elbows on a table for sixteen hours a day for the next five years? Not only would you have extreme difficulty straightening the elbows, you wouldn’t have strength to hold anything with your elbows bent, either. The muscles that support the joint can not only be stiff, but can also be weak, depending upon how you’ve been using your body. If you remain habitually tucked, the muscles in your pelvic floor won’t have strength throughout their full range of motion. If you’ve been holding the pelvis in one position with a lot of muscular effort, these muscles may be unable to relax; if you’ve been holding them with minimal muscular effort, they may be unable to contract. Either way, restoring mobility to the pelvis will improve overall function and health of the pelvic floor.

Try this:

Come into a seated position. Roll just in front of your sitting bones so your pelvis is barely tilting forward. Inhale. Try to breathe so the breath moves all of the way down into the pelvis, like you are moving the pelvic floor down with your breath. Exhale, see if you can feel the pelvic floor muscles move up as the air moves out. Do this for two or three breaths.

Now, roll slightly behind your sitting bones, so your pelvis is tucked. Perform the same breathing pattern, inhaling all of the way down to the pelvis so the pelvic floor moves down and exhale, feeling the pelvic floor move up as the breath moves out. Is that easier or harder to feel?

Harder, right? If you want to highlight the ability of the muscles to contract even more, try doing a Kegel with your pelvis tilted forward, with your pelvis tilted back, and with your pelvis in a more “neutral” position (for the purposes of this demonstration, neutral is when you are resting on the sitting bones). Which situation makes the contraction and the relaxation most clear?

There are other things that affect your pelvis and how the muscles in the pelvic floor are contracting, like where you place the weight in your feet. Changing the foot position has been shown to change pelvic floor muscle activity. It’s all connected, so if you have postural habits, just know it will affect the rest of you in some way (8).

So, should you tuck? You should certainly have the ability to tuck when the movement or condition calls for it, but holding yourself in one way, all of the time, reduces your options, as well as your strength and mobility. If you habitually tuck, ask yourself why? Often, postural tendencies arise because we’ve been told that’s the way we “should” move. Your pelvis is designed to move a variety of ways and should feel free when you walk, not stiff.

Another reason people develop habitual postural tendencies is because their systems, either consciously or unconsciously, don’t have the knowledge or ability to be in another position. This can happens for a variety of reasons, including a sense of weakness in a specific area or because there has been a trauma causing a loss of connection with the area. Free your pelvis and improve awareness through gentle, somatic movements and get strong in a variety of positions to feel more resilient. You deserve to feel—and use—all of the parts of you.

*I got so excited about pelvis stuff while writing this I began filming an online course designed specifically to restore awareness and movement to the pelvis. I am silly excited about it. Release date TBD.

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References:

  1. Wobser, A.M., & Wobser, R.W., (2018). Anatomy, abdomen and pelvis, bones (ilium, ischium, and pubis). StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK519524/ *This is really good. If you are interested in the anatomy of the pelvis, worth a read.

  2. Muscolino, J., (2017). Kinesiology—E-Book: The Skeletal System and Muscle Function. https://books.google.com/books

  3. Palastanga, N., Field, D., & Soames, R., (2006). Anatomy and Human Movement: Structure and Function, Volume 20056. Elsevier Health Sciences: New York.

  4. Lee, S-Y., (2015). Muscle activation of the rectus abdominis and rectus femoris and their ratio during leg raises performed by healthy adults. Journal of Physical Therapy Science, 27(3), 549-550.

  5. Madill, S.J., & McLean, L., (2008). Quantification of abdominal and pelvic floor muscle synergies in response to pelvic floor contractions. Journal of Electromyography & Kinesiology, 18(6), 955-964.

  6. Faublon, S.S., Shuster, L.T., & Bharucha, A.E., (2012). Recognition and management of non relaxing pelvic floor dysfunction. Mayo Clinic Proceedings, 87(2), 187-193.

  7. Park, H., & Han, D., (2015). The effect of the correlation between the contraction of the pelvic floor muscles and diaphragmatic motion during breathing. Journal of Physical Therapy, 27(7), 2113-2115.

  8. Halski, T., Slupska, L., Dymarek, R., Bartnicki, J., Halska, U., Krol, A., Paprocka-Borowicz, M., Dembowski, J., Zdrojowy, R., & Ptaszkowski, K., (2014). Evaluation of bioelectrical activity of pelvic floor muscles and synergistic muscles depending on orientation of pelvis in menopausal women with symptoms of stress urinary incontinence: a preliminary observational study. Biomedical Research International.

The fitness industry and what really matters

Last night, I watched BJ Miller’s TED talk on “what really matters at the end of life.” Miller is a palliative care physician who, when he was 19, was in an accident that resulted in the loss of both legs and an arm. He poignantly discusses what matters to his patients as life winds down and how people nearing death can be better supported. “…namely, we need to lift our sights, to set our sights to well-being, so that life and health and healthcare can be about making life more wonderful, rather than just less horrible. Beneficence.”

I often feel conflicted about the fitness/movement/wellness industry. It’s prescriptive in nature, just like healthcare is prescriptive. Step by step exercises are to be done to fix/strengthen/tone/improve. Perhaps the bigger issue is the fact the step by step exercises and the prescriptions are created with the people who already exercise and move in mind. That number is remarkably small—in the US, 23.5% of the population meets the weekly minimum recommended amount of physical leisure time activity. According to the World Health Organization, that’s 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous intensity aerobic physical activity per week and muscle strengthening activity involving major muscle groups on two or more days per week. This means 7.5 out of 10 people aren’t meeting these requirements..

Yet, the health and fitness industry is a 30 billion dollar industry that’s grown 3-4% annually for the last decade. There is a disconnect, somewhere, and it suggests the people who prioritize health and fitness are willing to spend money on it, likely because it’s a hobby and a lifestyle, while the people who aren’t participating in leisure time physical activity are left to flounder, confused by the information that exists, afraid of hurting themselves, tired of feeling bad about what they aren’t doing.

I fall into the movement is a lifestyle category, and I am grateful there are people willing to teach people like me how to writhe across the floor, arm balance, and vault. I find movement fascinating, I like to feel strong, I like to have endurance, and so it is a priority, but over the years I have worked with many people who don’t love exercise and would much rather be eating a frozen yogurt than feeling the sensation of their muscles working or focusing on how they are moving a specific body part.

I first became aware of the discrepancy between people who like to move and people who struggle with it in college. My junior year, one of my many jobs was in a laboratory, performing follow up interviews with women who had participated in a weight loss program the previous year. I questioned them about their physical activity, charting what their activity levels looked like over the course of a week.

I remember the first woman I interviewed. She had sad eyes, and looked away as I asked her if she had done any aerobic activity in the last ten days. “No,” she answered.

“What about spending time on your feet moving around?” I asked. “Did you park far away from the entrance the last time you went grocery shopping?” (I was trained to ask about all possible physical activity if they weren’t doing anything structured.)

“No,” she answered. “Wait—I take that back. I did vacuum for twenty minutes last weekend.”

By this time, she was clearly feeling uncomfortable and guilty, and I was surprised and unsure of how it was possible to not do anything physical with the exception of vacuuming. I was also 21, working 3 jobs, a full time college student, and I worked out at least five times a week. Exercise kept me calm, and so it was part of my routine, but, I was learning, that didn’t mean it was part of everyone’s day, nor did everyone want it to be.

There is an element of punishment that exists in traditional exercise settings. You work out, push hard, sweat, perform 3 sets of 10 or to failure, whichever comes first. And yes, it’s true, these things make you stronger, but if you look around a gym, people who are exercising by themselves don’t look like they are having fun. They have a look of determination, of “I will suffer through this and get it done,” a willpower that not everyone has and many don’t want.

After the lab project ended, I got a job at an obesity clinic. I still had my job teaching spin and personal training at a local gym, my job at a corporate facility helping teach group exercise and doing administrative work, and my waitressing job, but I was busy exploring career possibilities and figuring out what I wanted to do when I graduated in the spring.

The obesity clinic, like the lab project, was eye opening. It was run directly following the cardiovascular therapy program and overseen by a doctor who came in once a week. She met with patients to discuss options for weight loss, including pharmaceutical interventions. There were two of us present at any given time, monitoring blood pressure, guiding the aerobic exercise, and helping those who expressed interest with strength exercises. The patients were, for the most part, kind and motivated to move. It became clear to me early on that, unlike a traditional gym setting, most of the patients felt safe exercising there. No one judged them and no one cared what anyone’s pants size was.

I started around the same time as a patient I’ll call Greg. Greg weighed over 500 pounds and wore a garbage bag wrapped around his right knee because he couldn’t find a knee brace large enough to fit him. He was quiet, shy, and always looked away when he was having his blood pressure taken with the thigh cuff, because the regular arm cuff didn’t fit.

He began walking on the treadmill. It was extremely challenging for him. He walked slowly, but consistently, three times a week, rarely missing a day. He lost over 20 pounds in the first month, water weight, the supervisor explained to me. “The weight loss will slow, but he will continue to lose if he’s consistent,” she said.

And improve he did. When I left ten months later after graduating to go work at a country club in central California, he had lost almost one hundred pounds. He kept showing up, and though he never opened up, he seemed to like the gregarious personalities that came through the clinic, chatting and laughing, creating a sense of community. Maybe more importantly he appreciated the fact that it wasn’t a traditional gym setting. No one cared about how fast/how hard/ how long he went. As long as he showed up, that was good enough for the staff.

The obesity clinic taught me that, while the act of moving is important, treating people like people and taking the time to listen and to ask questions about their families and lives or to simply let people be if that’s what they wanted created a different type of experience. A lack of judgement coupled with compassion seemed to go a long way in keeping people returning, even when they didn’t want to.

Miller says, “And believe me: almost everyone who gets into healthcare really means well—I mean, truly. But we who work in it are also unwitting agents for a system that too often does not serve.” I got into fitness to make a difference in people’s lives. I became frustrated with the lack of resources I had available to create experiences that were meaningful for people, so I looked elsewhere, searching for tools that would help me make the act of moving more interesting. I found what I was looking for in systems that take more environment based approaches, including dance, gymnastics, MovNat, and Parkour. I also found it buried in motor control research and psychology research, but perhaps the most important lesson I have learned is if you want to make a difference, you need to connect with the person, in some way, whether that means listening, not judging, or throwing in things the person enjoys in addition to the things you think the person needs.

I also accepted, somewhere along the way, that not everyone needs to love movement to reap the benefits of strength, mobility, and variability, but most people enjoy a challenge. Making life more wonderful, as Miller says, can be done through connecting with others, connecting with the environment, and connecting with the self. Movement is a way to create connections and the side effects of regular movement make life more full and, ultimately, more wonderful.

I trained a woman for four years who began seeing me after her knee replacement. She was not athletic. She didn’t really like the idea of sweating or moving in a dynamic way, but she did want to feel less wobbly and more capable. She was intelligent, active with the community, and, at 75, still interested in living a fulfilling life.

I trained her once a week on Tuesdays at 10. She was incredibly consistent and willing to do what I asked. She taught me about British Royalty (she was English). I taught her how to use her entire foot to balance and made her navigate obstacle courses. She shared with me stories about her mother and moving to Canada where she got her PhD. I helped her gain strength and feel confident picking things off of the floor.

She would come in occasionally, excited. “Jenn, I worked out in the garden for the first time in 3 years. I wasn’t worried about falling,” or, “Jenn, I was able to wear two inch heels and not feel tottery. They look much better with my dress pants than the flats.” These little things, I hope, enriched her life.

Over the course of our time together, she would have stomach upsets. The doctors did colonoscopies, but other than polyps that were to be watched, never found anything wrong.

She e-mailed me on a Monday in December to let me know she wouldn’t be in. “I seem to have a bug. I feel extremely weak and doubt I would make it up your stairs,” she wrote.

She was admitted to the emergency room later that week. An ultrasound of her abdomen revealed cancer throughout her organs. She died 6 week after her original e-mail, on my birthday.

Creating an environment that supports movement for people fo all ages and abilities is not only necessary, it’s where the fitness industry is failing. Life is experiential and about so much more than the perfect set/rep scheme or the most effective way to work your core. Creating less dogma and more compassion would benefit the fitness industry and maybe, just maybe, help us reach the 80% whose lives could be enriched if they felt better.

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Interoception: what it is, why it matters



My last post was on proprioception and body awareness, or kinesthesia. Proprioception, according to dictionary.com is “the unconscious perception of movement and spatial orientation arising from stimuli within the body itself.” A really interesting paper by Gaffin-Cahn, et.al points out we engage with the world through the motor system; its accuracy and its ability to self correct are dependent upon information from both the visual and the proprioceptive senses. How we accomplish any motor task depends on visual and proprioceptive feedback which can be altered by things like fatigue or practice (a pianist’s touch is a learned skill. So is a pitcher’s fastball, making both of these tasks more predictable in pianists and pitchers, respectively).

If proprioception is a sense like vision is a sense, kinesthesia is a branch of proprioception like peripheral vision is a branch of vision. Training the peripheral vision will improve aspects of vision, but it probably won’t improve the ability to focus on things really close to you. Kinesthesia, your conscious awareness of body position and how it’s moving, will improve your ability to do things like stand on one leg, but it probably won’t improve your ability to accurately jump to a rock that’s far away. It’s a branch of proprioception, but it isn’t proprioception in its entirety.

(I did find this very cool study that looked at a small group of individuals with Parkinson’s disease who underwent somatosensory feedback training. The individuals in the training group improved their ability to feel their wrist position and saw improvements that were comparable to healthy adults in similar studies. They also had greater functional range of motion which correlates to motor learning. Somatosensory training is training that uses visual and proprioception training. Your eyes and your proprioception work together to determine and create appropriate movement, so training these two systems together is a logical way to improve overall body awareness.)

Interoception is your ability to sense your internal state of your body. Researchers haven’t quite agreed on an exact definition, but Ceumen, et.al explain interoception as the product of the central nervous system. Your central nervous system consists of the nerves in the brain and the spinal cord. The somatic nervous system sends information to your central nervous system via peripheral nerve fibers, so you could say the peripheral nervous system chats with the central nervous system to help you form your perception about you and the world.

In the academic literature interoception relates to a number of things, including:

  • Pain

  • Negative emotions

  • Anxiety

  • Emotions

  • Emotion regulation

  • Decision making

  • Subjective time perception

  • Subjective self awareness

  • Food and water intake

  • Eating disorders

  • Addiction

  • Empathy

  • Meditation

(This list isn’t exhaustive, but you get the idea.)

Your perception and interpretation of your internal body state is closely related to cognition and emotion, which is why when you read the list above, you see things like self awareness, anxiety, and decision making. Your ability to accurately interpret the information you are receiving about your internal state contributes to your emotional state.

Let’s say you are feeling a little bit nauseous. You assume it’s because you are about to find out bad news in the meeting you have with your boss, when in actuality, it’s from the egg you ate a few hours ago. You are taking the information regarding what you are feeling and interpreting and predicting it’s because of what’s about to happen—you interoceptive accuracy is influenced by your conscious thoughts and, in this case, is inaccurate. (Which is normal. It’s part of being human. We are constantly making predictions about our world based on past experience and our current reality.)

Your interoception can be honed just like any of your other senses (and yes, interoception is considered by some scientists to be a sense, just like vision, hearing, and touch). Interoception is unconscious, but you can become aware of certain aspects, like how you are breathing, your heart rate, and recognizing whether you are actually hungry or if that chocolate chip cookie just sounds really good. Training your overall self awareness can also create a more balanced relationship with emotions such as anxiety—for instance, if I am about to lecture to a room full of people I don’t know, I can observe my response in a more detached way. I feel my heart rate elevate, I notice my breathing quicken, and I feel that slightly jittery feeling kick in. I am also able to calmly say to myself, “you are feeling anxious because you are about to lecture to people who may or may not care about what you’re saying. And that’s okay,” which immediately takes my jitters down a notch.

Interoception is affected by things like prolonged exposure to stress or traumatic stress. People can become either hyper aware of their internal state or detach from it completely, correlating to PTSD and substance use disorder. Interestingly, people with joint hyper mobility may also have hyper-awareness surrounding interoceptive sensations. Joint hypermobility, specifically joint hyper mobility syndrome/Ehlers Danlos type 3-hypermobile syndrome, is also linked to anxiety and heightened perception of pain.

I have always felt the link between anxiety and joint hyper mobility makes sense. I imagine it goes something like this: if you don’t feel like your joints are stable and you can’t detect your body position in space, it becomes stressful to feel like you can move through the world in a safe way. If you are unsure about how you can navigate your environment, that causes fear and worry. If you don’t trust your body to support you, you become hyper-attentive to the rest of your body sensations, hence, heightened interoception. (Maybe I’m way off base, but whenever I imagine what it would be like to be hyper-mobile, this is what I come up with.)

So, to quickly recap before we get into the practical applications of interoception in a training or movement setting, interoception is not proprioception, but, because it is, for the purposes of our conversation, your interpretation of sensations that derive from the central nervous system, it is influenced by your experience of your internal state of the of the body. When you use your body, a number of things happen: muscles contract and relax, respiration rate changes and heart rate changes. Your body state changes in a way that is noticeable.

Your ability to detect how your physical body is feeling is considered your kinesthetic awareness. Your kinesthetic awareness is tied to emotional states. For instance, I have a client whose right big toe sticks straight up when she’s stressed. She works out barefoot, and it has become a running joke between us—when she takes her shoes off and her right big toe is resting on the ground, I know life is going well. When her right big toe is reaching towards the ceiling, I know she is experiencing stress.

It’s difficult to build a lot of awareness around the right big toe, but through kinesthetic drills, improving foot and toe strength, mobility, and paying attention, she notices when her big toe lifts right away. She feels her feet much more, and she has far more control than she’s ever had of her foot and ankle complex. When her big toe responds to her emotional state, I can usually get it to return back to the ground by the end of the session and she feels calmer.

More obvious examples are jaw clenching, glute clenching, and general bracing. If you can feel when you do these things it makes it easier to not do these things. If you observe how you feel emotionally when you clench/brace/tighten you can begin to establish connections between your physical and mental state.

Breath holding is another common strategy under stress. Exercise is a form of stress, so people who hold their breath when they are stressed in life often hold their breath while they’re exercising. The ability to feel your breath is an interoceptive sense, so becoming more aware of what it feels like to breathe will increase the chances you feel yourself not breathing. (So will having a teacher or coach point out to you you have stopped breathing.)

Let’s break this down a little more concretely into types of training and how they can potentially benefit interoception, beginning with cardiovascular exercise.

Cardiovascular exercise has a slew of health benefits, but the main focus today is the fact it’s correlated to reductions in anxiety. A large reason for this likely has to do with the fact cardiovascular activity decreases sympathetic nervous system activity and lower hypothalmic-hypothalamic-pituitary-adrenal axis reactivity. Basically, your physiology changes when you do regular cardiovascular activity.

In animals, exercise increases neurogenesis, or new neuron growth, which leads to neuroplasticity. So cardiovascular activity promotes learning, which improves feelings of well being through serotonin, endorphins, and BDNF; with all of those happy hormones floating around, anxiety abates and you feel calmer.

From an interoception perspective, cardiovascular activity functions as a way to improve tolerance to feelings that provoke anxiety. There is a term in the literature called anxiety sensitivity. This occurs when someone misinterprets and catastrophizes sensations associated with anxiety, such as a rapid heartbeat. Cardiovascular exercises causes rapid heart rate, helping anxiety prone individuals build up a tolerance to the very interoceptive experiences that can be interpreted as negative.

It also builds self efficacy. High self efficacy occurs when you feel like you have some way to exert control over a potential threat. In the example of cardiovascular exercise, you learn that you can cope with the stress of exercise AND it gets easier/less uncomfortable/you can go further over time. Building endurance creates feelings of strength and competency.

This brings us to training type number two: engaging with the environment or another individual as a way to improve interoception. In a study done on clinically depressed individuals by Bodin, et.al, (2004), researchers found martial arts training reduced state anxiety, improved affect, and increased self efficacy when compared to stationary bike riding.

Another study, performed by Schaffner (2017) found martial arts training caused an increased sense of body connection, as well as increased feelings of strength and empowerment in an intensive program for individuals with eating disorders. (Individuals also received yoga and art therapy, cognitive behavioral therapy and/or family-based treatment.) Poor interoceptive awareness is associated with eating disorders; the author concluded martial arts training was empowering and challenged study participants to remain aware of internal experiences and perform movements that were new and outside of their comfort zone, enhancing interoception.

You can apply the same concepts to a movement training setting if you don’t have access to things like a martial arts teacher through obstacle course creation, challenging balance, game play, and creating opportunities for people to learn skills that are outside of their comfort zone. The key is providing an environment where it’s safe to try and fail and where, with practice, people feel themselves improving. When you first try something that’s new or out of your comfort zone, your heart rate will increase and your muscles will stiffen as you try and figure out what needs to happen for you to be successful. With practice, your heart rate won’t increase as much and your muscles won’t stiffen. Your internal sense of the experience will change, creating an opportunity similar to cardiovascular training. Improvement reminds you your internal experience isn’t necessarily bad and you have the ability to change. This, ultimately, creates a feeling of control, not of your environment, but of your self.

(I use similar techniques when I am working with people who have sensitivity to specific movements. If it hurts to lift the arm one way, despite the fact there is no damage to the tissues, I have the person lift the arm a slightly different way or in a smaller range of motion so it doesn’t hurt. When a person perceives sensation as permanent, it can lead to fear, anxiety, and make the world smaller.)

This brings us to strength training, an activity that can also be empowering. A fascinating study in the journal Nature found subjects who underwent mindfulness training in conjunction with strength and cardiovascular training had actual changes in their insula, a small region of the brain that separates the frontal and parietal lobe from the temporal lobe. This area is linked to emotions and the regulation of homeostasis. Remember how interoception is the sense of your internal state and is connected to emotions? We can make the leap that mindfulness training improves interoception. (The exercise group that did not receive mindfulness training didn’t have visible changes in their insula.) Based on this study, we can’t quite make the leap strength training alone is enough to improve interoception. But we can say strength training plus mindfulness training is a combination worth exploring.

(I do a lot of this, as well. I don’t have the personality for 60 minutes of somatic work, but I frequently warm people up with mindfulness or end their sessions with mindfulness and open monitoring. I have found awareness and strength are a potent combination.)

And finally, we arrive at mindful movement. Yoga, Tai Chi, Qi Gong, Feldenkrais, Body Mind Centering… The list is long and the techniques can be a powerful way to improve interoception. Mehling, et.al (2018) found a 12-week integrative exercise program combining resistance exercise, aerobic exercise, yoga, and mindfulness-based principles led to significant improvements in interoceptive bodily awareness and positive states of mind in war veterans. Mehling, et.al (2013) found differences in interoceptive awareness between people with past or current low back pain and mind-body trained individuals. Mind-body trained individuals had at least 20 hours of teaching in things like meditation, yoga, Tai Chi, or Feldenkrais and had a different relationship to low back pain than those who did not have any mind-body training.

As I mentioned earlier, not everyone needs more interoception. Some people need less. A person’s choice of movement modalities should reflect the needs of the individual. I will re-route my sessions if someone is emphasizing the internal state too much, just like I will consistently bring a person’s attention back to his internal state if he is detached from it. Interoception is complex because we are complex; researchers are still sussing out the exact definition, but what we know is movement is good, paying attention is good, and moving outside of your comfort zone once a while makes you stronger.


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Kinesthesia and proprioception

While I was researching a chapter for my book on awareness, I was searching for research to back my ideas that improving your sense of self and your internal body schema were related to proprioception. What I discovered was my understanding of proprioception and how it works was actually misinformed. Somehow, in all of the years I have spent researching and writing about movement, I completely missed the kinesthesia research, which is the word that more accurately depicted what I was trying to convey with my statements. Hopefully, I can clarify the terms kinesthesia and proprioception for you, two concepts which inform each other, but aren’t exactly the same thing.

Where am I in space? It’s a question you learn to ask if you do any form of exercise or movement modalities. Your ability to discern where your arm is, feel your foot on the ground, and understand how to rotate your right thumb away from your body is useful for certain skills. This internal “knowing” permeates your overall sense of self and comes from the act of using your body regularly.

This body awareness is called kinesthesia. It can be improved through things like touch, focused attention, and the sensation of effort in the muscles during specific tasks. It’s a valuable awareness to cultivate because it makes you feel more in control of your body and its parts. It begins to merge the mind body connection by creating a relationship between your thinking self and your physical self.

When you reach for a glass, how do you know how much you have to extend your arm? Or when you are walking, how do you know when there is a ledge and you have to step your foot up on to the ledge? These things happens unconsciously, every day, allowing you to navigate the world safely. This is your proprioception, considered by some to be the body’s sixth sense, an eerie sort of knowing that occurs every time you move over or around something, or you “just know” and object is nearby, even though you didn’t consciously see it.

“Jenn, this is all fine and dandy, but really, it’s just semantics,” you may be thinking, and while that may be true, it could also be argued semantics matter. These words are thrown around in the fitness and movement world, often incorrectly, which must frustrate the neuroscientists who devote their lives to studying the mechanisms behind mechanoreceptors and motor control. (Or maybe the neuroscientists are so busy studying the underpinnings of how we work they aren’t following how their work is being misinterpreted. I hope it’s the latter.)

Anyway, I do think there is value to understanding what these two terms means and how they differ, so let’s look at things a little more closely.

My almost 13 year old pomapoo has cataracts. He doesn’t see well and bumps into things regularly. I took him out in the early morning recently, letting him roam and do his business. I called him back to me. He turned, trotted towards me, and stopped, just shy of my shoes to sit down. How did he “know” where I was?

His sense of proprioception kicked in, telling him where he was in relation to me. I was in an open space, there was nothing else around, and he was able to accurately detect me and the space I took up as opposed to the succulents that line our walkway, which are often a source of lots of bumping and reorienting.

Proprioception is how athletes know how to navigate their bodies between players and get to the ball. It’s your ability to lift your foot just the right amount to clear the step. It’s the feeling you get when you look at the obstacle between you and where you want go and you instinctively know whether you can make it over the obstacle—or not.

Like all things in life, proprioception is heightened when you practice it. Just like a sommelier has an ability to taste subtle differences in cabernets, picking up on hints of fruits and wood, the elite athlete’s proprioception is finely tuned, enabling him to inherently know exactly where his body is in relation to a ball/balance beam/another person. The athlete, then, is able to move through an obstacle course fluidly, while a desk worker who doesn’t use his body in a comprehensive way regularly will struggle, stopping regularly to figure out how to lift his leg/place his arm/step over the elevated obstacle.

Try this:

Place a block or book on the ground. Stand in front of the block or book with your feet even and reach your right foot back to touch the block without looking. Bring your right foot back to the ground. Now, reach your left foot back to touch the block. Once you touch it, bring the left foot back to the ground.

Look down. Are your two feet even?

Your ability to touch the block without looking is proprioception. Where you placed your foot after touching the block is also proprioception. Both skills required a “sense” of the objects around you and your relationship to them.

Kinesthesia, on the other hand, is your conscious awareness of you, your body, and where it is located in space. If you were to ask me right now which sitting bone is heavier to the floor, I would immediately respond “left.” If you were to question how my shoulder blades were resting against the wall I am leaning against, I would be able to give you, what I think, is an accurate description quickly. I have practiced feeling different parts of myself and where they reside. As a result, my body schema, the internal map my brain has of me and its parts, is a fairly accurate representation of my actual physical self.

Curiously, just because athletes have amazing proprioception, it doesn’t mean all of them have amazing kinesthetic awareness, and just because I have good kinesthetic awareness, it doesn’t mean I have great proprioception. In fact, my proprioception is less good when it comes to accurately gauging jumps and landings than it is when it comes to balancing on uneven surfaces or knowing where I am in relation to another person.

Your kinesthetic sense can be further altered by things like fatigue or injury (kinesthetic literature review), which just means your sense of how you are moving may not be an accurate representation of how you are actually moving, and those two representations, your felt sense and your actual self, may move further apart as you get tired or after you’ve sprained an ankle or had surgery.

Try this:

Close your eyes. See if you can feel each of your left toes. How long are they? Where are they resting in relation to each other? Now shift your awareness to your left foot. What shape is the top of your left foot? Where does it meet the ankle? What shape is the bottom of your foot? What does your arch look like? What shape is the heel of your foot?

Now, open your eyes and look at your foot. How accurate was your visual representation? Is there anything about your foot that surprises you when you look at it compared to what it felt like in your mind?

A number of things influence your ability to accurately gauge both your body position and your kinesthetic sense of self. They include detecting a sense of tension or force, the sense of effort, and the sense of balance. Your ability to observe limb position and movement is certainly based on these things, and so it’s safe to say kinesthetic awareness informs proprioception. I would also venture to say good proprioception makes it a little bit easier to improve your kinesthetic awareness. If you have spent time thinking about how to manipulate your body in space, it generally makes it easier to feel your body and how it is moving.

Think of it this way: in the earlier example with the block, you may have known where the block was behind you and you may have felt yourself touch the block, but are you able to articulate how you touched the block? Did you point your toe or extend your hip? Did your knee bend? Did your body rotate? What was your strategy? The more kinesthetic awareness you have, the easier it is to articulate how you performed a specific skill. For those of us who teach, our ability to put into words what the body is doing at specific points throughout a skill creates an opportunity to teach a deeper awareness. Sometimes, just asking “how are you accomplishing that?” Is enough to give a person a deeper sense of his physical self.

Ultimately, what matters is the ability of an individual to feel secure during movement so he can interact with the world in a meaningful way. Proprioception and kinesthesia are two pieces to a larger puzzle that includes strength, mobility, awareness, and integration. Practice both for a well rounded movement experience.

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How freezing and tonic immobility translate into movement

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I was taught there were two main responses to the stress response: fight or flee. I never questioned the simplicity of this model, or the fact that having only two choices was rather limiting (if you have read any of the research on choice, you know there is a sweet spot between too few options and too many options. And yes, in case you are wondering, I went through a phase where I became curious about choice and read a handful of books and a few papers on it).

Anyway, back to this world where the only response humans have to a life threatening event is to either begin throwing punches or run away, slowly, since not very many of us train the skill of running fast. The odds don’t seem like they would be very good in certain circumstances, do they? I could write a disturbing scene here involving several people, one gunman, and a grocery store, but that would give me nightmares, so instead I will leave the details to your imagination, but let me ask you this: would you really want to fight the lone gunman if you are unarmed and untrained? Or would you really want to run away and draw attention to yourself without weighing your exit strategy? Probably not. So what would you do instead?

You would stop, freeze, become completely immobile and wait for an opportunity to get out.

The Freeze Response and Tonic Immobility

The freeze response is an opportunity to assess the threat, scan the environment, and prepare for whatever you need to do to survive. It’s different than the flight or fight response, which is a sympathetically driven stress response that results in an increase in heart rate, respiration, and pupil dilation. Freezing, on the other hand, is associated with the slowing of the heart rate and a reduction in body sway. It’s a strange combination of tense muscles and slowing down.

Another response to stress is tonic immobility, which occurs when an animal “perceives little chance of escaping or winning a fight”. Tonic immobility is like paralysis. It’s when the freeze response lasts longer than is necessary to benefit the situation, or could be thought of as missed opportunity to fight or flee. It’s when the gunman is across the store, distracted by the noise happening far away and you are right next to the door and could get out, but you can’t because you are frozen, unable to change position. Tonic immobility can have long lasting effects, including anxiety and dissociation.

Orienting

Another form of the stress response is orienting, which is kind of like freezing, but with a little more activity. Let’s say you are being followed while walking home at night. Orienting might mean slowing down, scanning the environment, and deciding whether the person you think is following you poses a threat.It’s what happens when you hear a loud noise in the middle of the night and you, startled from sleep, slowly orient your body to the noise, assessing the situation before figuring out where to go and what to do.

The translation to movement

“Jenn, while this is interesting, what does any of this have to do with movement?” I am getting there. But first, take a moment to reflect on any trauma you have ever had in your life. Do you remember your response? Did you fight, flee, freeze, or some combination of the above? And if you’ve never had trauma, can you reflect back to any stories you have been told about trauma?

There are other forms of trauma we don’t necessarily think of. Things like surgery, for instance, can be a form of trauma. Think about it—someone cuts into your body and you are immobilized for a set amount of time. You can’t fight or flee. Basically, surgery is forced tonic immobility, and if you are forced to keep a body part immobilized for a long period of time, the tonic immobility is isolated to one area.

Remember earlier how I mentioned tonic immobility corresponds to dissociation? In this hypothetical surgery situation, the affected area becomes foreign, as though the body part doesn’t really belong to you.

I have a client I will call Greg. Greg is a medical doctor who had surgery on his rotator cuff and biceps tendon a few months ago. He went through physical therapy, diligently did his exercises, and still had sensation in his right arm (which also happened to be his dominant arm). The sensations Greg described and his uncertainty using his arm caused me to load it thoughtfully, slowly, in a variety of ways, without moving into the areas that he described as uncomfortable. By the end of our second session, after presenting him with information on trauma (which he ran with and began reading several books on), he said to me, “so surgery was trauma and my shoulder is experiencing PTSD. I never thought of it like that. Oh, and my shoulder feels much better.”

In the book, “The Unspoken Voice,” Peter Levine discusses how shaking is one way for the organism to work through a potential stressor. It’s moving through the freeze response to action, even if action isn’t needed. (This, of course, is the strange thing about some of the traumas we experience as humans. They aren’t always predator/prey related so there isn’t always a reason to fight or run away, even though the stress may have been very real.) So, the uncontrollable shaking that sometimes occurs after a traumatic event could be viewed as a way for the mind/body to use the pent up muscular tension from the freeze response in an actionable way to dissipate the muscular tension.

There are other form of somatic and movement therapies that are used with individuals who experience trauma, including thoughtful movement modalities, tapping, and open monitoring meditation techniques. The opposite of paralysis is movement, and the more of yourself you can feel, the more of yourself you will use.

I have witnessed the immobilization of body parts in clients how have experienced excessive blood loss after child birth, car accidents, and surgeries. I have also worked with individuals who experienced major trauma and need more than I can provide to work through their scars (abuse victims, I find, have a lot of holding patterns can be very difficult to improve). Creating a movement environment that is safe, yet challenges the individual to feel the limb/sensation of work/awareness helps people with trauma based holding patterns decrease immobility and begin to move in a more complete way.

I have a client I will call Angie. Angie had a serious fall at work that set off a cascade of symptoms, including a painful (and chronic), bout of sciatica. Angie’s symptoms were made worse by most things, including Pilates, which she really enjoyed.

Her doctor referred her to me, and when we first began working together, I was surprised by the heaviness on the right side of the body. This was the side she had fallen on as well as her dominant side, and it was as though her body was “stuck” there. The sciatica was on the right side; she walked to the outside of her right foot and the inside of her left foot.

Over the course of several months, I helped Angie feel different parts of herself, including her left side. I explained to her the left side needed to be more like the right in terms of heaviness and the right side needed to be more like the left in terms of lightness.

Her symptoms gradually improved and her movements became more balanced. Angie is prone to anxiety and cares for her aging mother, which causes stress. Her pain isn’t gone, but it’s much more manageable than it was.

Think of what the term “tonic immobility” connotes. It’s hypertonicity to prevent movement. If you only work on the side that’s immobile, you are missing a huge part of the equation.

I do this with Greg as well. I make him use his left arm, picking up kettlebells with it, reaching for things with it. The mere reminder that he has another arm he can use calms his nervous system down and gives his right arm an opportunity to relax.

There are interesting things you see with individuals who have experienced some type of trauma, like when the left arm reaches, the right arm will tense, or when the left foot lifts, the right shoulder will hike. The human system is an incredible interplay of past experiences, current physiological and emotional states, and psychic medium, predicting what is about to happen and how to respond. I think the role of coaches and movement professionals is often to be a mirror, to help people feel what is currently happening and offer alternatives, creating an opportunity to do the same movement differently.

Several years ago, I was riding my bike too fast, down a hill, when I came upon a garbage truck. I swerved to miss the garbage truck and ran into an oncoming car’s driver side mirror. The collision was strong enough that I took the mirror off with my left arm.

I didn’t think much about it, and while my arm was sore, I assumed with time, it would heal.

It did, and while I was able to move it in a variety of ways, but for years, it felt heavier than the right arm. There were times I could feel the exact place my arm struck the mirror. I tried a variety of things, including body work, strength work, and yoga, but it wasn’t until I began focusing on a) strengthening the opposite position it was injured in (which happened to be straight arm shoulder extension), and focusing on my right arm that the sensation gradually disappeared.

The thing with sensation is it creates a focal point for your attention, a place for you to return to, again and again, like a scratch you can’t quite get. When you are in the middle of it, it’s difficult to wrap your head around the fact focusing your attention somewhere else may be the key to creating less noise.

Trauma is strange, and almost every paper I have read on the topic notes how little research has been done on humans, the freeze response, and tonic immobility, which makes me sad. If you are a movement professional, listen to people’s stories. Listen to their descriptions of what they feel, and if are working with someone who has experienced trauma, create opportunities to feel something different.

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Urinary incontinence, the pelvis, and training

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A client came in recently, slightly irritated. “Jenn, you aren’t going to believe the commercial I recently saw. You are going to be upset.”

Intrigued, because this client knows me well and she knows very few things phase me, I went ahead and bit. “What?”

“One of the feminine hygiene companies is making incontinence products targeted towards younger women. Just what women need—to be told they need to spend more money on products when they could get stronger and save themselves the money and the embarrassment of peeing themselves.”

A little background. This client had two children via C-section. One of her main goals when she started seeing me was not to pee herself when she got older. We work on things. No leaking has happened in the 13 years she has worked with me. In the last two years, she found out both her stepmom and her sister struggle with urinary incontinence (UI). When she asked me what they should do, I told her they should both get referrals from their doctors to a pelvic floor physical therapist. I also told her I don’t think it’s a topic that’s talked about often enough. I train a lot of women who have had children, and I care about their total body strength, including the strength of their pelvic floors.

At some point, she looked at me and said, “I am beginning to think you’re right about why women take so long in the bathroom—they are cleaning themselves up as discreetly as possible.” (Women in the bathroom used to perplex me until I started realizing the sheer number of women struggling with incontinence. I have become more patient and understanding in recent years when waiting several minutes for a stall.)

After our session, which involved a lengthy discussion about the importance of strength and some challenging deeper abdominal exercises (for her), I began a search of urinary incontinence and exercise on my lunch break. What I found was interesting and (in my opinion, anyway), article worthy. Let’s start with the obvious.

Vaginal birth and UI:

One of the risk factors for UI is denervation of the pelvic floor muscles. Denervation means there has been a loss of nerve supply to a specific area. Nerves provide sensory and motor information to a body part—if you can’t feel an area, it’s more difficult to control that area. One of the things associated with denervation to the pelvic floor is vaginal birth, so it shouldn’t come as a surprise that statistics show up to 37.9% of women experience UI, even after 12 years of child birth. Hence, UI products.

It’s not that cesarean delivery guarantees you won’t have UI, but the odds are less. Risk of pelvic organ prolapse is also less during a cesarean delivery; however, it is surgery, and there are a host of other factors that increase following C-sections.

As an aside, I have found training women post c-section is related to different concerns than working with women post vaginal birth. I will speak more about this in a later post.

Female athletes:

It’s a problem that extends beyond vaginal births. An observational study published in the European Journal of Sports Science found the prevalence of UI in high impact sports athletes was 70%. At the risk of stating the obvious, Chances are low the 82 out of 118 women surveyed reporting had given birth, which makes this number seem really high.

A meta-analysis examining the prevalence of urinary incontinence in female athletes found female athletes had a 177% increase of presenting with UI when compared to sedentary women. The researchers suggest physical exercise places women at higher UI risk because of increased intra-abdominal pressure that’s generated during high-impact activities, but aren’t we designed to run and jump and climb? And if we are designed to do those things, shouldn’t our pelvic floors respond by getting stronger?

Curiously, a literature review by Steenstrup et.al, (2018), found that while data is limited, sedentary lifestyle also appears to be a risk factor for UI. It appears it is difficult to escape UI risk if you are a female.

Menopause:

Lest you think the issue disappears with age, in China, more than 20% of women between the ages 45-59 experience stress urinary incontinence (SUI). SUI refers to leaking during elevated abdominal pressure, which happens when you cough and sneeze.

Data collected from a questionnaire given to women between 1995-2005 found that of 1339 women reporting UI, 61% did not seek treatment because 73% believed the UI wasn’t “bad enough,” and 53% believed UI was “a normal part of aging.” This begs the question: how many women struggle with UI and don’t report it? Hence, products aimed at women specifically for UI.

And don’t forget about the men…

Prostrate cancer happens. One of the treatments for prostrate cancer is a radical prostatectomy (removal of the prostate). When the prostrate is removed, risk of UI increases.

And maybe UI just happens. A survey of 23,240 Danish men found 1657 reported various forms of UI. Granted, this is a lot lower than the numbers reported for women, (7% as opposed to 20% or more reported in the sections above), but it’s not insignificant.

Implications for movement professionals and personal trainers:

So at this point I think we can all agree UI is a bit of an issue, probably one that’s bigger than many of us realize. What can movement professionals do?

As always, creating a line of open communication is key. If any of your clients shy away from a higher impact exercise without offering an explanation, respect there might an underlying issue she/he doesn’t want to discuss. If, at some point, if someone does share with you she’s struggling with leaking, encourage her to get a referral to a pelvic floor physical therapist.

Here’s what we know: pelvic floor muscle training has a positive effect on UI in women. In men with UI following a prostatectomy, research showed improvement in UI following a strengthening program that included kegals, squats, supermans, and bridging; interestingly, hip extensor strength and endurance was significantly higher in the continent group. Women who regularly exercise have stronger pelvic floor muscles mid-pregnancy than women who are sedentary. Ankle position facilitates greater contraction of the pelvic floor muscles.

Let’s look at this another way. Getting strong will effect the entire body, all of the way down to the skeleton. Your pelvic floor muscles are no exception; if you load the pelvis in a variety of ways, the muscles that support the pelvis will get stronger.

A brief note about the physiology and anatomy:

Muscle tone and strength maintain your structural integrity. When the muscles of the pelvic floor are stiff and/or stretched out, the muscles fibers are less able to generate power. The majority of the muscles that comprise the pelvic floor are made up of slow twitch muscle fibers, so contraction during urination is initiated by a small number of fast twitch fibers. These muscles are affected during denervation, but with the appropriate exercise and pelvic floor training stimulus, can be strengthened. Kegels are a low level activity, and while they may be appropriate to begin to improve coordination and awareness of the pelvic floor, in a movement and strength setting, the structure of the pelvis should be challenged in a way that stimulates strength and mobility.

*Please note: I opted not to discuss breathing, but breathing is also a low level activity that can improve awareness of pelvic floor contraction and relaxation.

The muscles that support the pelvis should be trained in different positions. If someone doesn’t have the ability to move the pelvis in isolation, chances are slim the pelvis is going to participate in an integrated way during movement. From a practical perspective, it’s less about anterior or posterior pelvic tilt being bad, and more about the ability to being able to move the pelvis both directions, as well as laterally and rotationally. Basically, if you can channel your inner burlesque dancer, you have good access to mobility in the pelvic region.

Putting theory into practice:

How many positions can you perform a pelvic tilt? Can you do it in supine? Quadruped? Tall kneeling? Half kneeling? A squat? A lunge position? A plank? Seated? Long sitting? You own the movement when you can translate it into a wide variety of positions.

External rotation:

Strengthening external rotation of the hip may increase pelvic floor muscle strength, possibly because of the orientation of muscles such as the obturator internus and piriformis. The piriformis is actually one of the muscles of the pelvic floor; it’s also one of the rotator cuff muscles of the hip, so it stabilizes the femur in the socket during movement. It’s not only implicated in UI, it’s also implicated in non relaxing pelvic floor dysfunction, which can involve pain during urination and sexual intercourse (different topic for a different day, but worth noting).

Putting theory into practice:

External rotation should be strengthened progressively. There is so much value in ground work and different floor transitions; I frequently use the floor work from the MovNat system and squat variations from the GMB elements program to work on external rotation. I also using breathing techniques and isometric holds to feel movement in the pelvic floor. If someone struggles with external rotation, teaching the basic clam shell exercise creates awareness and the ability to isolate the movement of external rotation. Like Kegels, these are a low level movement and clients/students should be progressed to more dynamic movements fairly quickly.

The shin box/seated 90/90 exercise is an excellent way to teach external and internal rotation at the hip. A wide number of variations and transitions can be implemented from this position once basic points are covered. Prone frogger is also an excellent exercise for isolating external rotation at the hip joint. Both the seated 90/90 and the prone frogger are ways to build awareness and strength in the muscles of the pelvis and the pelvic floor.

Ankle position:

How you use your feet and ankles affects how you experience work in your pelvis and hips. Have you ever cued someone to push through the heel when stepping on to a step in order to get the person to feel the gluteal muscles more? Or maybe you’ve cued the pressing of the big toe and arch into the floor while staying centered in the heel in order to help someone feel the adductors. Your feet and your hips works together to create movement; it shouldn’t come as a surprise that ankle position impacts pelvic floor activity.

Think about what happens when women wear high heels. What position does their pelvis naturally move to accommodate the motion? Anteriorly, right? Again, this isn’t about anterior or posterior pelvic tilt being better or worse, but it should make sense that ankle dorsiflexion or a neutral ankle improves resting activity in the pelvic floor muscles. Try this: come into standing on the balls of your feet. Try and contract your pelvic floor on your exhale. Now, lower your feet to the ground. Try and contract your pelvic floor on the exhale. Which was easier?

Now, in a standing position, move your pelvis into an anterior pelvic tilt. Contract your pelvic floor. Move your pelvis into a posterior pelvic tilt. Contract your pelvic floor. Which variation was easier?

Putting theory into practice:

Our pelvis should be able to move anteriorly and posteriorly. Our ankle should be able to plantar flex and dorsiflex. If you are working with someone who struggles with UI, early on in the programming, work on ankle mobility and create awareness from the feet to the pelvis by utilizing a variety of positions while working on the feet in a flat position. Conveniently, squats, squat walks, and low lunge variations strengthen the hips and pelvis while also improving ankle dorsiflexion. You can also spend time simply working on foot exercises barefoot in order to create more mobility in these areas.

A brief note about the female athlete and UI:

I noted earlier female athletes appear to have a higher incidence of UI than their sedentary counterparts. This is probably (like all things), multi-faceted, but I do wonder if more restorative, mindful interventions surrounding the pelvis and the feet would help? Slowing down a little bit and paying attention to feeling how different areas move can create awareness, down regulate the nervous system, and improve overall coordination. While gravity, force, and pressure all play a role in the function of the pelvic floor, so does having access to a variety of positions and balanced strength. I couldn’t find any meta-analyses that looked at these types of interventions, and it’s an area I think that deserves further study. Strength happens from the inside out.

Urinary incontinence is a topic that’s considered taboo. It affects men and women of all ages and athletic capabilities. Creating programs that strengthen and mobilize the pelvis, hips, ankles, and feet in a variety of ways, utilizing isometric holds, and knowing who the pelvic floor physical therapists are in your area so you can refer out are all excellent ways to help clients deal with an issue that can decrease overall quality of life.

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The trunk: mobility, stability, or balance?

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What do you consider your core? Is it different than the trunk? And what, exactly, is its role during specific movements, like walking?

From an anatomical point of you, the trunk is the structure that consists of the neck, thorax, abdomen, and pelvis. The spine, structural component of the trunk, serves as a connecting point for the head and the pelvis. The ribs, another structural component of the trunk, protect the vital organs necessary for life and connect to the thoracic portion of the spine.

The architecture of the spine with its four curves, is designed to withstand axial stress. Axial stress is a stress that changes the length of the body. The four curves allow you to remain upright even though compressive forces (like gravity) are constantly exerting a downward pull.

The muscles of the spine keep the spine upright during day to day life by continually making small adjustments to hold the body seemingly still. They are also involved in breathing and voluntary movement.

The spinal muscles are often divided into two systems for discussion purposes: global and local. The global system is the one that enables voluntary movement. If you want to roll yourself up into a little ball? That’s the global system. Move into a deep back bend? Also the global system.

The local system, on the other hand, maintains stability, for lack of a better word. If you were to be hooked up to an EMG all day, the muscles that comprise the local system would show low level activity, always. That’s because these muscles keep you upright. Without them, you would be like the Wicked Witch at the end of the Wizard of Oz—a big puddle.

If you were to place pressure mats that measure force underneath your feet during quiet standing, you would see that the pressure doesn’t remain constant. This is because of a concept called postural sway. The body is kind of like a pendulum, with micro adjustments happening at the ankles and hips that cause a ripple effect up the body. In fact, when rigidity sets in, like in Parkinson’s, at least one research study shows an absence of postural sway.

Postural sway, then, is predicated upon both stability and mobility of the spine (as well as other factors, which I won’t discuss today). In fact, some studies show increased postural sway during dynamic tasks in subjects with chronic neck pain. This makes sense when you consider the suboccipital muscles are sensory rich, sending lots of information to the central nervous system about the position of the head; the cervical receptors also have reflexive connections to the visual and vestibular systems. If the spine has a lot of extra movement (i.e., doesn’t have good stability), the neck may feel like it’s doing far more work to keep the head stable than it would if the spine were quieter (i.e., had more strength).

This is also consistent to what I have experienced when working with clients with non-specific neck pain. Once they gain a little bit of strength, the neck pain dissipates.

Three of the muscles of the local system, the transversus abdominis, the multifidus, and the psoas have been accused of being “off,” or not firing properly, or having a delayed activation time, or being chronically tight. I do not work in a laboratory setting, nor am I an anatomist, but if local stabilizers keep you upright, it would stand to reason these individual muscles aren’t really the sole contributors to low back pain/pelvis positions/lumbar lordosis. Instead, what those of us who work with people in a movement setting can say is a lot of muscles keep us upright. Our experience of feeling unstable/tight/discomfort is multifaceted. Learning how to control movement in a variety of positions will help all of the muscles get stronger, even the ones that make up the local system because load causes changes in the ability to withstand force all the way down to the skeletal level.

The muscles of the global system include the pectoralis major, latissimus dorsi, rectus abdominis, external oblique, rectus femoris, and gluteus maximis. These muscles cover large areas, are capable of producing high amounts of torque, and are the first line of defense against extrinsic load. Remember, extrinsic load can come in a variety of forms, so someone like Matthew Fraser, the Crossfit Games winner the last three years, has a very different external physique than Alex Hannold, the free climber who soloed El Capitan. Both, however, have visibly strong lats and abs, just different sizes to meet the demands of the external loads regularly placed upon them. They both also have high amounts of mobility to get into the positions their respective sports demand.

If you are a movement practitioner, why should you care about the different core muscles and how things work together? Understanding that the spine is designed to be both stable and mobile is key for helping people of all ages and abilities feel better in their bodies. Let’s look at this a little bit closer.

One way to quickly assess the mobility of the spine is to observe a person’s ability to receive the floor. People who struggle with feeling sensation when they are lying down and need cushions and blankets to create a barrier between them and the floor are a) not used to the feeling of a hard surface, kind of like the princess and the pea or b) not distributing pressure well across the points of the back that are in contact with the floor. In either situation, spending a little time down on the ground and mobilizing the muscles that move the trunk will probably make the person feel less sensation when he or she lies down. It will also decrease the amount of stiffness the person likely feels and almost certainly demonstrates during movement.

Additionally, just the act of getting up and down from the floor requires the spine to bend and be mobile. Helping people explore different ways to get up and down from the ground can create more mobility and adaptability of the trunk and torso.

Here’s what interesting about the muscles of the global system (at least to me, and it could very well be argued that what I find interesting veers towards unusual). They are the very muscles that are frequently considered the culprits for “tightness” when it comes to things like decreased shoulder flexion and a tendency towards an anterior pelvic tilt. Maybe the problem is less that specific muscles are tight and more that the trunk isn’t able to move in a variety of ways. “Aren’t those the same thing?” you might be wondering?

Not necessarily.

The ability to rotate the spine during walking allows the arms to swing. You don’t have to force an arm swing, they just do it because the trunk is rotating. If the arms don’t swing, there is a very high chance the thoracic spine doesn’t rotate, and when muscles aren’t used for basic, everyday motions, range of motion decreases. Again, another example of how the torso and shoulder girdle are connected.

The isolated view that’s often taken when it comes to something like improving shoulder mobility typically ignores whether the spine can flex, bend, extend, and rotate. So maybe when addressing shoulder mobility it makes sense to work on spine mobility as well. Maybe.

So what about stability? How does that work?

Well, it’s two fold. As we’ve already discussed, basic strength is helpful for gaining a sense of stability.

When I say sense, that’s really what stability is. Research shows posture isn’t indicative of pain or dysfunction, so you can’t say looking a certain way is problematic, and I have met people over the years who are active, have posture many movement professionals would consider less than optimal, but don’t have any pain (and these are people in their 70s and early 80s). Whatever they are doing is enough to create a sense of security. Stability means you feel strong enough to support your structure and external load and that you have a sense of control in your spine, so if you are knocked off balance, you can catch yourself. Basic strength creates stability.

The other way to help people feel more stable is to train…balance. That’s right, the best way to improve postural control is through balance training. In fact, a systematic review and meta-analysis showed balance exercise training improves postural control in older adults, while strength and multi-component exercise interventions don’t.

Let me guess, you threw the BOSU away and the stability balls are sitting in an exercise closet somewhere because of the 2008 article in the Journal of Strength and Conditioning Research that showed using unstable surface training did not increase muscle activation in “highly resistance-trained individuals.” There are a number of ways to train balance. Unstable surface training isn’t necessary. You can use single leg variations, eyes closed conditions, split stance positions, heel to toe variations, obstacle course variations, ball throwing options and more to challenge balance. Dynamic balance training feels and looks a lot like play, which makes it enjoyable for both the practitioner and the student. And if you sort of liked using unstable surface training, but you are embarrassed to use any of it because you are afraid your co-worker will judge you for your lack of an evidence based approach, pull the unstable surfaces back out and let your general population clients walk on, . Their balance will improve and they will have fun doing it—just know that standing on a stability and doing squats probably won’t improve anyone’s golf game.

Unless you are working with a very specific population, most people can benefit from a movement or exercise program that incorporates a little bit of mobility, a little bit of strength, and a little bit of balance. If someone is more strong than mobile, work on a little more mobility, and if a person is mobile, but lacks balance, work on more dynamic balance. If you address a person’s needs while maintaining his strengths and keep it at least a little bit fun, the entire process is a lot more enjoyable. Plus, you get the added benefit of the global and local systems working in a balanced way.

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Balance, context, and anxiety: balance beams, part 2

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We are a nation that’s plagued by anxiety. We worry about what’s going to happen tomorrow, we worry about what others think, we worry about the state of the world. 

The worry can be incessant, and for some, the worry feels overwhelming. Another way to think of anxiety is that it’s fear- fear of what will be. 

Fear works in a very specific part of the brain, the amygdala. The amygdala, a small portion of the brain located in the mid temporal lobe sends out all of the appropriate physiological signals when fear is present, including elevated heart rate, elevated breathing, and a change in muscle tone. Fear also sharpens our memory and increases perception- it’s probably no surprise that obsessive compulsive disorder is related to anxiety

Living in a state of constant worry or fear is exhausting, It affects our relationship with our body and makes the perception of pain more present. As Robert Sapolsky notes in the book “Behave,” “The amygdala receives news of that reliable trigger of fear and aggression, namely pain. This is mediated by projections from an ancient, core brain structure, the “periaqueductal gray” (PAG); stimulation of the PAG can evoke panic attacks, and it is enlarged in people with chronic pain attacks. Reflecting the amygdala’s roles in vigilance, uncertainty, anxiety, and fear, it’s unpredictable pain, rather than pain itself, that activates the amygdala. Pain (and the amygdala’s response to it) is all about context.” 

There is also a correlation between hyper mobility syndrome and anxiety (and pain), perhaps partially because individuals with hyper mobility have decreased proprioception due to their joint laxity. Basically, the brain doesn’t quite know where the joints are located in space because the information it’s getting from the joint’s internal GPS is a little off, so we could also say the state of the body affects the state of the mind. 

What does this have to do with balance beams? One of the most intriguing research articles I have happened across in the last year examines rats that are bred specifically to exhibit anxiousness. One group was placed in a contextually rich environment, filled with balance beams, things to hang from, and obstacles to maneuver. The control group was placed in an environment without obstacles. The rats in the first group exhibited a reduction in anxiety, despite the fact they were born anxious.

If rats can reduce anxiety through interacting with their environment, it stands to reason humans should be able to do the same. (Or maybe it doesn’t, but you can obviously see where I am going with this). 

A few things happen when you figure out how to use your body to balance, climb, and maneuver over and around things. First, you become stronger and feel more capable in a way that promotes adaptability and problem solving. Those of you who have read previous blogs know I am all for mindfulness and improving awareness—in fact, it’s a large part of what I do. I also strongly believe in giving the body and the brain a chance to learn through doing, with less input from me. It gives people a chance to self organize and, if they don’t succeed the first time, their neuromuscular system works to figure out a new way to try based on its available options. I feel like this is valuable. I step in and offer suggestions when people are stuck, but learning by doing, I think, is empowering.

It could be argued that being able to figure things out gives an individual back a sense of control. People exhibiting traits of anxiety often don’t feel in control, so the context of controlling an outcome, such as successfully maneuvering the body through space, potentially increases a sense of resilience.

Additionally, when you move in a novel environment, if you are successful at least some of the time, dopamine, your brain’s reward chemical, is released, making you feel good. It’s difficult to feel anxious when you feel happy. Plus, according to neuroscientist Daniel Wolpert, our brains evolved for movement, so maybe incorporating this type of contextual problem solving calms us down simply because we are using our brains in the way they were intended: to produce complex motor coordination.

Finally, moving your body and interacting with the environment directs attention, so you are no longer thinking about whatever you were feeling anxious about and it improves your sense of physical self. Motor control research suggests simply by interacting with something you find challenging, in a variety of ways, you will become more efficient, indicating a reduction in motor noise. Noise can be thought of as the awkwardness you experience when you are trying something new. Whatever you are trying doesn’t look pretty—it looks disjointed as your neuromuscular system figures out the best way to accomplish the task, throwing everything it has at it, even if your right elbow has nothing to do with your ability to land on your right foot, or your jaw doesn’t really help you turn around on a narrow surface.

With practice, things get smoother and more efficient Another way to look at this is maybe by working on a physical challenge and reducing the noise it takes to do the task, you also reduce the noise in your head. Maybe.

Plus, when you use your physical self, you begin to feel the body parts and muscles that are required to navigate the obstacle. The more of yourself you feel, the more complete picture you have of yourself. 

I am not suggesting walking on balance beams will cure anxiety, but I do think it might very well help. Clients differ from baby rats in a number of ways, and one of the most important thing to take into account is current skill level and fear.

Fear activates the sympathetic nervous system and makes it harder to perform certain physical tasks. If someone doesn’t feel secure on his feet and you ask him to walk across a slightly elevated surface, heel to toe, it will probably make his anxiety worse because he is afraid of falling. It’s important to make sure whatever obstacle you are giving someone is appropriately challenging and isn’t going to send the person’s sympathetic nervous system into overdrive.

How can you tell whether or not an obstacle is appropriate? If the likelihood of the person trying and succeeding is about 80% and the risk of injury is extremely low, then you are on the right track. Let’s look at two examples.

I have a client I will call Ron. Ron has had 6 open heart surgeries and several little strokes. He has neuropathy in his feet and his peripheral vision is poor. How can Ron be challenged in a way that is appropriate?

Ron is scared of falling and doesn’t have very good balance because of the neuropathy and lack of vision. However, I can challenge Ron by having him by doing things like walking around obstacles, walking through spaces that are narrow for him, and walking over very low obstacles like dowels.

Ron struggles with these tasks, but feels safe doing them and gives 110 percent. He is (usually) successful, and the risk of him falling is very low--I spot him so he feels safe. He often tells me that he feels like he gets his money’s worth from these types of activities because they make him feel more confident in navigating his environment during every day life. Confidence reduces overall anxiety (and he does have a bit of anxiety), so it’s a win/win.

Let’s contrast this with a client I will call Megan. Megan is in her mid 30s and is also prone to feelings of anxiousness. She has a lot of natural mobility and had a lot of pain when I first began training her from a stint of bed rest during her most recent pregnancy. Megan quickly progressed to balancing on 2x4s, walking side ways, and moving between 2x4s. She often jokes that I am training her for the circus, but in addition to her pain completely resolving, her husband tells me she is the most confident and calm she has ever been—a change he credits to the confidence she has gained through physical training.

The less capable we feel when interacting with the outside world, the smaller our world becomes. Fear comes from so many things, not the least of which is not feeling confident in our physical abilities. Physical challenges that don’t require much instruction and give the client an opportunity to figure things out using his body and his brain closely resembles play; play is something children need in order to thrive, so wouldn’t it make sense that adults who use some form of play training would thrive physically and emotionally as well?

 

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2x4s, balance, and hip mobility

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Five years ago, while I was training for my MovNat level I certification, I purchased an 8 foot long 2x4 to practice the balance skills of walking forwards, backwards, and sideways. Sideways was challenging for me, so I set it up in my living room and practiced every time I walked through the house. (Side note: our house at the time was tiny, and our living was literally open space so we could move around on the floor. The 2x4 was the only piece of “furniture” I had).

Walking on the 2x4 intuitively made sense, and clients found it to be a fun challenge. I noticed foot and hip mobility were often better after a few passes, which I found interesting, but I wasn’t quite ready to dive into the potential aspects of why.

Five years have passed and I have read and thought a lot about the feet and gait mechanics. I have a few theories about what happens when you walk across a 2x4 and what might be happening, but first, let’s look at how the foot responds to the ground during regular walking.

When you take a step, a foot stays in contact with the ground while your body passes over it. There are a few things that happen when the foot absorbs the impact from the ground and transmits load up the leg before it propels the leg forward. Think about it for a second- your foot is responding to the ground. Would it make more sense for the foot to stay stiff or for it soften a bit?

Soften, right? Otherwise, it’s like hitting a steel beam with a rigid arm- it doesn’t feel very good or result in an elastic response.. 

The technical term for the absorption phase of the foot is pronation. The technical phrase for the stiffening phase of the foot that happens to propel the foot forward is supination. Before we get too bogged down with technicalities, let’s focus on the pronation phase and what else needs to happen for all of the joints to play happily together.

Walking is a series of rotations that results in a forward looking trajectory. From the ground up, rotation occurs as the arch comes closer to the ground, pronating to attenuate the force of the ground. The ankle responds a little bit as well; the inner edge of the heel comes just a little bit closer to the ground, moving into eversion.

The next bone in the chain is the tibia, the shin bone in the front of the leg. If the arch is coming closer to the ground, what way is the tibia moving? Is it rotating in or out?

If you guessed (or logically processed), that the tibia rotates inward, you are correct. The tibia responds to the movement at the foot by internally rotating.

Above the knee joint (which responds like the ankle by moving slightly inward during the stance phase, a fancy way of saying the stage of walking when the foot is on the ground), is the femur, the long thigh bone. If everything below the femur is moving in, how would the femur respond to best absorb the load?

Yes! You are right- it would move inward, internally rotating. The pelvis internally rotates as well, allowing the foot to pull the pelvis over it.

The whole situation reverses to propel the leg forward and push the foot off of the ground- the foot becomes rigid and the arch moves away from the floor, the ankle inverts just a little bit, the tibia externally rotates, the femur externally rotates, and the pelvis externally rotates. It’s like a chain- one thing moves, affecting the next above (or below) it until at some point, the whole system reverses. If the goal was to define neutral, it would be the point where everything is balanced- right before the foot moved from stance to propulsion. 

Another way to think of it is pushing is associated with externally rotating and pulling is associated with internally rotating. When the foot lands, it’s pulling the pelvis over it, and at just the right moment, the foot pushes off of the ground. 

You can feel this entire situation in a squat, if you think about pulling yourself down- you will notice an internal movement of your tibia and femur. When you decide to push the floor away from you and return to an upright position, there is a shift and the bones move into external rotation.

So what about the balance beam? Why does this improve balance and general mobility in the hip for some people?

Imagine you do the pushing off aspect of walking really well. Your foot supinates, your tibia externally rotates, and your femur externally rotates, but when the foot lands to absorb forces, the bones don’t change position very much and internal rotation is limited. What would that do to your balance and basic mobility in the hip joint?

If the foot has a tendency to be rigid, you are going to spend a lot of time using the outside of the foot and not very much time using the arch area, the center of the heel, or the big toe side of the of the ball of the foot. That’s a lot of surface area that you aren’t using when you balance and that’s a lot of information you aren’t receiving from the pressure of the foot against the ground- there are mechanoreceptors that respond to change in position and pressure in the bottom of the feet. Those mechanoreceptors let the brain know where the body is located in space and help inform which options are available for movement. If they don’t detect a change in position or pressure, they have no information for the nervous system- a bit of a conundrum when it comes to motor planning and execution, and a problem when it comes to balance.

If the foot is rigid and the femur responds to the position of the foot by remaining mostly in external rotation, how would that feel in the hip joint? Imagine you sat on the ground, knees out to the side and feet crossed at the ankles for three hours and then tried to sit in a chair with your knees touching and your feet moving away from each other. How would that feel?

Probably not great and you would more than likely experience a sensation of stiffness. So if, day and day out, your femur remained mostly in one position, it probably would feel a bit stiff when you tried to move it in a different way.

Okay, so what does a 2x4, possibly the world’s least expensive piece of fitness equipment, have to do with all of this?

Now is a good time to do a (brief) review of basic motor control terms. When you go to perform any physical task, there are an infinite number of ways the task can be done. The amount of options you have at any given joint is the degrees of freedom available at the joint to perform the task. Think about the act of walking: you could walk with your knees high or your knees low. You could walk with your feet wide or narrow. You could walk with your feet landing in front of your or behind you. You could walk with your knees really straight or with your knees really bent. You get the idea. 

What’s interesting is that even with all of these options available, you probably walk in a very consistent way. Movement is funny like that- unless you practice doing things differently, your neuromuscular system decides which way it prefers to do things based on past experiences and sticks to it, even if there are more efficient ways to do the same task.

A constraint reduces the amount of options you have to perform a task- it lessens the degrees of freedom available. Task constraints can be used to introduce a different way of doing a well established skill or improve coordination.

A 2x4 introduces a constraint to the activity of walking. If your habit is to avoid internal rotation, it’s going to be difficult to balance on the 2x4. 

Why? The nature of being slightly off the ground on a surface that requires walking with one foot exactly in front of the other and having a board that dictates your feet point (mostly) straight ahead means that if your tendency is to spend the majority of your time on the outside of the foot without moving into pronation, you won’t have good contact with the 2x4 when you transition from the back foot to the forward foot. The lack of stability you experience means you will try and figure out a way to stay stable, This can include less efficient strategies such as clenching your jaw, holding your breath, and tightening your fists. If your coach (or the voice inside your head that is serving as your coach), notices you are doing these things and asks you not to, you will figure out how to get across the board another way. If you are moving slowly and given repeated exposure to the task, your foot (or feet, depending upon the situation), will do this by moving into pronation. Assuming your lower limb functions in a coordinated fashion, the other parts will follow. 

Since walking across the 2x4 is dynamic, once the nervous system realizes it’s safe, it’s a way to repeatedly expose yourself to a position you aren’t used to being in and since that position is a natural part of an efficient gait cycle, there tends to be a transference of neuromuscular coordination. Your balance will improve, your hips will feel less tight because they have more options, and things will feel a little more coordinated, all because you walked in a constrained way. Kind of interesting, isn’t it?

Obviously, this won’t be the case for everyone, because not everyone has a habit of avoiding pronation and internal rotation, but for those it does help, it’s a pretty simple exercise to implement.

The other way I use a 2x4 for working on gait mechanics is to teach big toe loading during plantar flexion. Plantar flexion is a movement that is synergistic with supination (meaning they often occur together during coordinated movements). Remember how I mentioned supination goes with tibial external rotation during gait? It also goes with big toe dorsiflexion- the big toe bends up when you toe off. Except when it doesn’t because you are avoiding placing load in that area, a common occurrence in a society that often neglects toe and foot health. If you don’t load the big toe during gait, your foot travels less smoothly through the area. 

Think about it. The big toe has more surface area to push off of than the other toes. If you aren’t pushing off of the big toe, the neuromuscular system gets creative to propel the foot forward. Creativity doesn’t always equal efficiency.

Back to the 2x4. If you stand so the 2x4 is horizontally in front of you and you place the toes/ball of the feet on to the 2x4, you have a constraint that orients your toes straight ahead. If you lift your heels off of the ground so they are above the balls of the feet, if the weight moves into the little toe side of the foot, you won’t feel secure. The nervous system prefers feeling safe, so if you have the mobility, your neuromuscular system will change your strategy so the load is on the big toe side of the foot. If you start to move sideways, every time the weight moves to the outer edge of the foot, you will feel unbalanced. As a result, there will be a continual correction towards the big toe side of the foot, teaching efficient loading of the big toe.

Aside from the mechanics of what is going on, balance work is fun. People enjoy it and when they struggle, they become curious, trying over and over again until they succeed. Introducing variability, challenge, and novelty into anyone’s program is a good thing. Using simple tools and understanding how to use constraints can provide an element of play and have a profound impact on someone’s movement.

Part II will discuss how balance training can decrease anxiety, a subject I’ve written about before, but focusing more on the practical application.

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The shoulder and the hip: how are they connected?

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*I wrote a blog three years about the connection between the shoulder and hip during movement. It’s one of my most viewed articles. Time has marched on, I continue to study and read, and have a more full understanding of the relationship between these two body parts. Read on for an updated look at how these areas function together.

The musculoskeletal system is comprised of a variety of tissue, including muscles, ligaments, tendons, fascia and bones. The place where two bones meet, the joint, is an opportunity for force to be passed from one place to the next. The muscular tissue supports the dispersal of force up the skeleton; the ability to do this efficiently enables coordinated movement. 

How well our musculoskeletal system does this simple job is predicated upon a number of factors, including strength, the degrees of freedom available at each individual joint, and how coordinated we are. Our coordination is a reflection of how often we move on a regular basis, in a variety of ways. 

One of the most basic coordinated movement we perform is walking. When you walk, one of the legs swings forward, while one foot remains back, on the ground absorbing the ground reactive forces so it can be propelled forward. If the right foot is swinging forward, the left arm is swinging forward, while the right arm is back.

Think of the words that are used to describe the forward arm and leg- they are swinging, easily, using the elastic properties of the fascial system so no effort is required. It’s an amazing system, one that is taken for granted until it’s not working as well as it used to.

How well the arms and the legs swing is partially dependent on the rotation that happens at the torso and pelvis. As the right foot swings forward, the thoracic spine rotates and laterally flexes to the right. The shoulder girdle is neatly located on and around the thoracic spine- as a result, the swinging forward of the foot and the rotation at the thoracic spine allow the right arm to swing backwards.

On the left hand side of the body, the opposite is occurring. The body is moving over the left leg, so the left leg is behind the pelvis, while the left arm swings forward. All of this occurs in a very dynamic, spring-like way. It’s elastic in nature, and results in basic walking feeling almost effortless.

What happens when one side of the pelvis doesn’t move when the leg is supposed to be propelled forward? Or when the thoracic spine doesn’t rotate to one side? How does this change things?

We’ve all seen it, the walking gait that looks a little bit funny, but you aren’t sure why. How does this affect general mechanics and why does it matter?

Walking, crawling, and even throwing are movements that are based on the idea that as one leg moves forward, the opposite arm moves forward to propel something (the body, an object), through space. In fact, the large amounts of internal rotation at the humerus that occurs during the throwing motion is the fastest motion the human body produces- but it isn’t the reason an object can travel a large distance. Shoulder rotation contributes at most to 1/2 of the power produced during the throw. The rest comes from the contribution of the torso and hips. And, while other mammals can and do throw objects, none do so with as much force or power as humans. With bipedalism came rotational power.

Crawling, of course, is often the prerequisite to walking, and is consistently performed in a diagonal pattern, with the right hand and the left knee moving forward, followed by the left hand and the right knee moving forward. Think about what is required for this movement to take place. The right hand bears load through the right shoulder while the left knee bears load through the left hemi-pelvis when those two limbs are on the ground. The thoracic spine rotates a little bit to the left to accommodate the movement.

Throwing and crawling illustrate how connected the shoulder, torso, and hip are in providing stability and creating power. During the walking gait, the arms swing passively, requiring little effort. In fact, experiments that reduce or prevent arm swinging result in an increase in energy required to walk and an increase in ground reaction force, signifying a reduction in overall efficiency.

From a movement perspective, why does this matter? Because it’s a reminder that if movement is only viewed in isolation, the ability of the system to work together, like it’s designed, is being ignored. 

For the arm to swing freely during, there needs to be movement at the glenohumeral joint, with subtle movement at the scapula, acromioclavicular joint, and thoracic spine.  For the leg to move from providing support to swinging through the air requires movement at the rearfoot, forefoot, tibia, femur, hemipelvis, and lumbar spine. If the arm can’t move freely, or the leg can’t transition from providing support to swinging, there will be a loss of efficiency. Here is the tricky part- the loss of efficiency is occurring across a system, not across one joint.

If you work with people in any sort of setting that involves movement, whether it’s yoga, personal training, strength and conditioning, or Pilates, if you observe an arm that doesn’t swing during walking, do your eyes stop there? Or do they look further? Hopefully, they make their way to the shoulder girdle and rib cage, but what about to the pelvis and opposite hip? 

For things to regain a sense of elasticity, you are probably going to need to consider how things work together. What happens at the right shoulder? What happens at the left hip? What way do the ribs like to turn? Can they rotate the opposite way? 

Another question to ask yourself is do you put people into positions where rotation has to occur? And if so, where do you cue the movement from? The hip that’s moving forward? The shoulder that’s moving forward? How the hip and the shoulder move together? Or maybe you cue it from the shoulder and hip that are moving back? Or from the thoracic spine? Each option will lead to a different experience for the client, and hopefully help reinforce the way different parts of the body work together during the natural act of rotation.

The body is designed to move and attenuate forces in a variety of ways. The cross patterning that occurs during gait is one of the most fundamental movement patterns, and translates into larger force production during throwing and stability in quadrupedal positions. If you only look at what’s happening in one place, you are missing, perhaps, the most important part- how things work together.

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July newsletter:

July Newsletter, 2018: on business and growth

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While I was up recently in the middle of the night, pondering deep things like which size kettlebell rack I should purchase and the best storage solution for yoga mats, medicine balls, and Jenga pieces, I left behind the world of fitness storage to read something- anything, that might help me fall back asleep.

The first descent into sleep is never a problem for me, but when something is on my mind, like storage solutions, my brain gets busy and I find myself wide awake at midnight. Even though I rationally know I can’t solve my organizational problems for my new studio in the middle of the night, it’s sometimes hard to quiet that part of the mind down once it gets going. 

I also recognize there are far bigger issues at hand in the world, and that my “problems” don’t exactly warrant sleeplessness.

My workspace transition is on my mind nonetheless, and in an effort to distract myself with something non-studio related I found a short, but potent, piece on Elephant Journal about the importance of connecting with your audience outside of social media. The author’s argument was social media sites trend; e-mail subscribers are the people who truly deserve your energy.

It re-routed my brain from focusing on how to organize the perfect training studio space to pondering how I could provide better information using my newsletter. I decided to recalibrate my energy and provide short tutorials for those of you that allow my newsletter to sit in your inbox once a month. 



If you have any ideas for a tutorial you would like to see, drop me a line. If it’s not in my wheelhouse, I will reach out to my network of professional colleagues and see if anyone can get you the information you are looking for, like the upcoming webinar I am doing with Trina Altman on how to effectively market yourself to find private clients + fill your schedule.
Someone reached out after the last webinar to ask if I would consider doing a webinar on building your business of private clients. Though I have had a full schedule for years, my path to get there was slow (you are probably noticing a theme- I am the consummate turtle). 

Trina and I have different backgrounds and skill sets. In addition to being an experienced movement teacher, Trina also has an extensive background in sales from her first career, which involved working on commission selling high end clothing, and later promoting her own jewelry line at Barney’s and other retail stores.

In this webinar, we’ll show you how to:

    •    Convert people who are taking your group classes into private clients
    •    Cultivate a social media presence to build local visibility and fill your schedule
    •    Describe what you do in a way that builds interest in your work and creates more referrals
    •    Balance the need between creating a thriving business while also taking care of yourself

If my last two webinars are any indication, this will fill up. If you would like to join, just reply “yes” to this e-mail and I will make sure you receive the registration link as soon as it’s up. 

Happiest of summer days!

Upcoming events:
Saturday, June 23: The art of cueing, a free online webinar FULL. If you would like the recording of this, please respond to this e-mail and let me know- I will send it to you the next day.

Saturday, July 28: Getting Private Clients: a one hour, free webinar with Trina Altman. Info above.

August 5-25: The art of cueing- an online course. This 3 week course is limited to 10 participants and includes homework, tutorials, and feedback. If you want an opportunity to think about and improve your cueing skills, registration link is here: Cost for three weeks: $129 To register: http://www.bewellpt.com/events/2018/8/5/the-art-of-cueing-a-three-week-online-course

 September 3-29: mentorship group
Do you want to take your skills as an exercise and movement professional to the next level? 
Join me for an in-depth, 1 month online course on a deep dive of how the spine relates to movement. We will cover trouble shooting abilities, understanding how to design and apply corrective exercise interventions using a variety of methods and modalities, and how to work with special populations. Maximum participants in session: 5. In addition to guided course material, I will work with you via e-mail and video chat to provide support and answer questions.

Cost: $399

Goals:
Support professional growth of fitness and movement professionals through online coaching. Topics that can be covered include:
Troubleshooting/problem solving specific client issues such as working with clients with low back pain, knee pain, shoulder pain, post partum, or hyper mobility
Deepening your understanding of specific areas and how they integrate into movement and exercise
Establishing a niche
(This course is partially full. If you would like to be considered, please view registration here: http://www.bewellpt.com/events/2018/9/3/september-2018-mentorship-group

Saturday, 10/20/18: Free your neck, and the rest will follow (LA workshop)
Registration opening soon. More info: http://www.bewellpt.com/events/2018/10/20/free-the-head-and-the-rest-will-follow