Running and Physical Therapy: Running Analysis Part 5: Overview of The Active Movement Assessment

After I perform the Runner’s Interview, The Qualitative Assessment of Running Mechanics, and The Quantitative Assessments of Running Mechanics, the next step is The Active Movement Assessment.

I have evolved The Active Movement Assessment part of my running analysis over the years, and it now encompasses a range of movements that I have the Runner perform in many different body positions. I’m looking for consistent themes in the Runner’s movement patterns, mobility deficits, and stabilizing strategies across multiple movements, planes of movement, and body positions. The goal of these movements is to first assess the integrated movement patterns of the Runner in standing and weight bearing positions (standing, half kneeling, bridging, planks), then to look at individual joint active movement control with the Runner in non weight bearing positions (supine, prone, or sidelying) .  These movements all load the Runner’s joints and tissues through full ranges of motion and allow me to see how the Runner responds to the simple movement tasks. Two models that I credit for shaping the way I utilize and conceptualize the active movement assessment:

  • Kelly Starrett’s Movement Archetypes Model

  • Gray Cook’s SFMA and “joint by joint” Model

A quick side note, there are two big caveats for the Active Movement Assessment that I’ve learned:

  1. I don’t put too much weight on one single movement task in isolation. I take a bigger picture view and look for consistent movement strategies or compensations. Many Runners will look terrible at a given test, perform very well at other tests that challenge similar areas in a different position (eg. terrible glute med MMT, but excellent single leg stability)

  2. The Running Analysis is always the primary and final deciding factor. If I see a discrepancy between what the Active Movement Assessment is showing, and what the Running Mechanics show, I’ll default to the Running Analysis first and foremost. Running is a complex movement skill, and many Runners will demonstrate efficient, powerful running mechanics while not showing the same movement quality with a single leg squat or lunge. There’s sufficient research to show that Running Mechanics and Single Leg Movements do not correlate or change together.

Those caveats aside, I do utilize an Active Movement Assessment to allow me to gather more data on the Runner’s movement strategies. Christopher Johnson and Nate Carlson at The Runner’s Zone have a nice way of explaining that they are looking for whether a Runner can load a specific tissue during their movement assessments and running mechanics.

Here’s the quick list of Active Movement Assessments by position and weight bearing:

Standing

Standing multi-segmental flexion (aka. Lumbar flexion, segmental flexion, forward fold, toe touch)

Standing multi-segmental extension (aka. Lumbar extension with shoulder flexion, back bend)

Standing full body rotation right

Standing full body rotation left

Air Squat

Hip hinge

Lunge / Split Squat

Single leg balance eyes open and closed

Single leg squat (free leg bent to allow knee to go straight down to ground)

Y Balance (which includes pistol squat)

FMS ankle dorsiflexion test

Two leg jump

Two legged hopping

Single leg jump

Single leg hopping

Shoulder Flexion (Overhead Archetype)

Shoulder Extension PVC Pipe Lift Off (Press archetype)

Shoulder External Rotation at 90 degrees abduction (Front rack archetype)

Shoulder internal rotation at 90 degrees abduction (Hang archetype)

Kneeling / Half kneeling

Half kneeling static hold

Half kneeling rhythmic stabilization through arms

Plank + Bridge

Front plank variations: forearms, hands, shoulder taps, and Upper Quarter Y balance

Push Up Fist lift off (Press archetype)

Side plank: both knees bent, bottom knee bent, full, top leg lift off, copenhagen adduction

Double leg bridge > Single leg bridge

Bird Dog: contralateral arm and leg, and ipsilateral arm and leg

Supine / Sidelying / Prone

Active SLR

Active hip flexion

Active hip internal rotation

Active hip external rotation

Active prone knee bend

Active prone straight leg raise

Triple Flexion Static Hold (aka. tabletop position hold)

Gluteus Medius MMT

____________________________________

Looking at the list, that’s a lot of movements! With practice, I’ve been able to perform these movements within a good 15 minute time period. I’m looking for consistent, replicated themes across multiple movements. Deficits in mobility, stability, movement quality, movement quantity, or a Runner’s willingness to load a specific tissue will often appear as I work through the full active movement assessment.

Next up on the blog: I’m going to break down each section of the Active Movement Assessment with details about what I’m looking for with each movement and common patterns I’ll see with Runners.

Running and Physical Therapy: Running Analysis Part 4: The Quantitative Assessment

After performing the Qualitative Assessment of Running Mechanics, I then dive deep into the Quantitative side of the assessment. After doing hundreds of Running Analyses with a wide range of technology, what I’ve learned is that there are a few key numbers and quantitative metrics that really matter. The rest is just noise, and can be confusing or mis-leading.

My set-up for a Running Analysis: A treadmill, a 50 meter flat straight away of sidewalk, and an iPhone or iPad on a stand (all of which have awesome high-resolution cameras, I set mine at the highest available resolution). That’s it. No reflective joint markers, no Dartfish motion analysis software, no force plates embedded in the ground.

Here’s my basic video procedure for a Running Analysis:

  1. Over-ground running analysis

    Have the runner run over ground on the 50 meter flat straight away. I’ll usually have them do this about 10-12 times (5-6 times back and forth). I’ll watch from the front view, back view, and side view. I have them start with an “easy jog” for the first 2 passes, then ramp up to a “medium speed run” that is equivalent to their long run pace, then finally “fast run” closer to race pace depending on their experience and training. I will film each of these from at least the front and side views at each speed, so I end up with 6 videos total.

  2. Treadmill Running Analysis

    I will then repeat the same procedure on the treadmill, with the runner running for about 1 minute at “easy jog,” then 1 minute at “medium speed run” then 1 minute at “race pace / fast run.” This 3 minute period usually gives me enough time to observe from afar for the qualitative assessment, then film from the side and front views.

One important note: Research has shown that over ground running and treadmill running are very similar on average for most runners in terms of mechanics, and that just doing a treadmill analysis is sufficient. However, in my experience there are outliers and exceptions to this guideline, especially runners who have little to no experience running on a treadmill. It can be a disorienting, weird experience that definitely causes a treadmill-naive runner to use very different mechanics. Something to keep in mind.

The next step for the Quantitative Running Analysis is for me to break down the videos and focus in on specific metrics. Here’s the metrics and hallmarks that I’ve found helpful in almost any Running Analysis:

Side View:

  1. Cadence: What is the runner’s cadence at the different speeds?

    Typically I want to see a runner at least at 160 steps per minute (or 80 per side) even at the slow jog. There is sufficient evidence that running with a faster cadence decreases joint loading, vertical oscillation, and ground reaction forces. While there is debate as to whether this is optimal for performance or even injury risk-reducing, I have found in my practice that runners with cadences at 160-190 typically are more efficient, relaxed, and do not overstride.

    (Sidenote: I’m still working on reconciling the different findings in the research on cadence in runners and whether it helps. But I still think it’s important to measure cadence, because I will often change a runner’s cadence as a way to change other components of their running mechanics.)

  2. Footstrike #1: Rearfoot, forefoot, or midfoot?

    Simple determination of rearfoot, midfoot, or forefoot. This matters less from a perspective of something that I will forcefully change in a runner, and more from a perspective of knowing which part of the ankle/foot complex is being loaded first during the initial contact phase. If a runner has pain in the forefoot region and is a prominent forefoot striker, this is something that may be significant. Don’t get too lost in the weeds with this point though, it matters much less than I used to think.

  3. Footstrike #2: Where does the foot strike relative to the hip joint?

    This is a basic proxy for whether a runner is over striding, or not. From the side view, I’ll pause the video at the point of initial contact (whether that be forefoot, midfoot, or rearfoot strike), and then draw a vertical line from the part of the foot contacting the ground first. The further forward this line falls relative to the hip joint (which can be approximated with the greater trochanter), then the more posteriorly-directed braking force that is likely occurring at this moment of initial contact.

  4. The Runner’s Trunk Position: Is it relatively vertical?

    What is the fundamental trunk alignment of the runner? Is it vertical? Slightly forward? Very far forward? Bowed into extension at the thoracolumbar junction? Extended at the lumbosacral junction? Head way forward? Head looking down at the ground? I’m looking to identify where this runner is holding their trunk, as this will help dictate the balance of anterior / posterior muscle activation, as well as joint loading of the hips relative to the knees.

Front View

  1. Footstrike Crossover: How narrow are the Runner’s footstrikes?

    Does the foot cross under the midline of their body? Do they look like they are running on a tightrope? Do I do not want to see a Runner’s foot crossover underneath their body past a line drawn down the midline of their trunk. This crossover pattern will overload the lateral structures of the knee and hip (think IT Band syndrome, lateral hip pain).

  2. Dynamic varus or valgus: Does the entire leg cave in or buckle out during loading?

    Is there an obvious change in knee position in the frontal plane from initial contact to load acceptance? When I see dynamic varus or valgus, I’m thinking the Runner’s brain and body are using a sub-optimal strategy for eccentrically absorbing the load of running. I’m looking for the knee to stay in relatively neutral position when it is compared to the hip and foot. An obvious dynamic varus or valgus will lead me to explore if the runner has any overload in the lateral or medial tissues of the hip, knee, or ankle.

  3. Arm swing symmetry and line of action: Is it symmetrical? Do the hands cross midline?

    If the arm swing is asymmetrical, I’m thinking there is an asymmetry somewhere else in the stride. This asymmetry could be in the upper quarter (ie. scapular girdle, trunk rotation), but it could also be compensatory for a lower quarter issue (pelvis, hip, or ankle).

    If the runner’s hands cross midline, I’m thinking the runner is creating a lot of rotation in the upper body and trunk. This could be a purposeful strategy to try to generate more power, or an indicator of rotational instability somewhere in the kinetic chain. This rotational instability could be in the upper or lower quarter, as the arm swing in runners is primarily for balance and reciprocal movement.

That’s the basic steps for my quantitative running analysis. I used to use software to measure specific joint angles during a quantitative running analysis, but I’ve stopped doing it. I found that there are certain hallmarks that matter more, and there is a wide range of “normal” angles for different runners. For example, I won’t look for a specific dorsiflexion angle or knee flexion angle during the mid-stance phase, as I have not found this always matches how loud or soft the runner is running, or how they are eccentrically absorbing loads. I will make a note if I start seeing large changes in a single plane (for example dynamic varus or valgus).

Combined with the qualitative running analysis, I’ll have a plenty of information to help me decide where to intervene with a Runner’s mechanics. I’ll dive deep into the next steps of the Running Analysis: The Active Movement Screening, Passive Movement Screening, and Interventions.

Running and Physical Therapy: Running Analysis Part 3, The Qualitative Running Assessment

After I interview the Runner and get a good understanding of their goals and history, the next step is for me to watch the Runner run. This sounds like a basic idea, but this is something that many physical therapists skip. Observing a Runner perform the specific task of running is critical, whether I’m working with a Runner rehabilitating from a running-related injury or helping a Runner looking to improve performance.

For Part 3 of this series of posts, I’m focusing on the Qualitative Assessment of Running Mechanics. The goal of the Qualitative part of a Running Analysis is for me to pick up on the big picture components of a Runner’s mechanics, and to get an idea of the Runner’s Movement Quality and Movement Efficiency (Credit to Stuart McMillan of Altis) . The qualities I keep in mind during this Qualitative Assessment include Rhythm, Relaxation (or tension), Alignment, Symmetry, Sound, Consistency, and Efficiency.

For the Qualitative Assessment of Running Mechanics, I take a step back and observe the runner’s whole body moving through space. I watch from the side for 60 seconds to get a feel for sagittal and vertical movement, then I watch from the front for 60 seconds to get a feel for frontal, rotational, and vertical movement. I don’t get lost in the details just yet, (ie. don’t miss the forest for the trees). I have made the mistake many times of focusing in on one part of the Runner’s body, and lost sight of the bigger picture of a Runner’s mechanics. Basically, this can be distilled down into one overarching concept that I’m looking for:

The Key Thing I’m looking for: Does it look good?

After watching thousands of runners both in the clinic and casually observing on the streets and track, I’ve noticed that some Runner’s mechanics look really good, while others look like they are straining or something seems off. I often struggled to articulate what qualities make a runner’s mechanics look good versus not. Through a combination of learning, reading, watching, and practice, I’ve identified the key qualities that compose whether a Runner looks good.

  1. Rhythm: Does the Runner’s rhythm and cadence match their speed? Is their rhythm symmetrical and consistent, or choppy and variable? Much like a classical musician with mastery of different tempos and notes, I’m looking for a Runner's mechanics to be fluid and smooth over different speeds, inclines, and terrains. A runner who’s rhythm is too slow for a given speed will look sticky and inefficient (ie. bounding rather than running). Conversely, a runner who’s rhythm is too fast for a given speed will look like a shuffling gait.

  2. Relaxation: Does the Runner have the right balance of tension and relaxation? Distance running requires a Runner to maintain enough tension to produce force to maintain their speed, while at the same time relax enough to not expend unnecessary energy. I look at facial expression and relaxation, tension in the arms, and rigidity through the trunk and hips. Stiff, tense runners tend to be holding muscular tension in the upper trunk and have limited trunk and pelvic rotation. Loose, hypermobile, overly-relaxed runners tend to have not enough muscular tension at the moment of initial impact and load acceptance, which can lead to a runner appearing to sink into the ground, or stick to the ground for a long time.

  3. Posture + Alignment: Is the Runner running tall yet not too rigid? Similar to the relaxation - tension spectrum, I’m looking for a runner to maintain enough tension in their postural muscles to maintain their upright position to optimize breathing mechanics and propulsion. It is common to see runners over-extending (indicating excessive tension and energy use by the extensors), while other runners collapse with every stride (indicating a lack of tension in postural muscles). What I’m looking for is postural integrity from the sagital view, with spinal curves and pelvic and scapular girdles moving smoothly around the midline. From the front view, I’m looking for alignment of the trunk over the stance leg, and no obvious dynamic valgus or varus in the lower extremity as a whole.

  4. Symmetry: Does the Runner move symmetrically right to left? This one is relatively straight forward. I am looking for any differences right to left, both from the side view and the front view. While some asymmetries will always be present, I take note of any that I see at this point, and then later will determine whether it is significant. Asymmetries may be indicative of a Runner avoiding loading a certain joint or soft tissue, a movement strategy due to mobility limitations or mild instability, pain avoidance, or just a simple inefficient movement pattern.

  5. Sound: Does the Runner land loud, quiet, or somewhere in between? We’ve all seen and heard runners who are surprisingly quiet, and the converse, Runners who are really loud and seem to shake the ground with every stride. At some point in the first two minutes of a gait analysis, I’ll close my eyes and listen to the footstrike of the Runner. The louder the impact, the more force going into the ground. Ground reaction forces are not necessarily bad, as with faster speeds runners will definitely hit the ground harder and louder. But if a Runner is doing an easy jog and slamming into the ground, there’s a potential overload with the initial impact and load acceptance phases that can be improved.

That’s it! The Qualitative Assessment of Running Mechanics is complete. Admittedly, these qualities are subjective, but they are not meant to be the end of the Assessment. These are “Movement Quality” abd “Movement Efficiency” indicators that I use as a way to keep myself honest and capturing the big picture of a Runner’s mechanics. I’m purposefully avoiding the error of diving too deep, too early, and miss the forest for the trees. Next step is the Quantitative Assessment of the Running Mechanics. We’ll dive into that on the next blog.

Running and Physical Therapy: Running Analysis Part 2: Interviewing the Runner

The first step to any running analysis is spending some time getting to know the Runner by talking to them. Interviewing the Runner lets you build rapport with the Runner, gather relevant information, and identify the key reasons why the Runner is there at your clinic for a Running Analysis.

I like to ask questions that generally fall into a few categories:

  1. The Runner’s Goals

  2. The Runner’s History

  3. The Runner’s Medical and Injury Background

All of this information can be collected within a 10-15 minute period, which will set up the rest of the running analysis be successful.

The Runner’s Goals

When it comes to identifying a Runner’s goals, there are a few different time horizons that can be helpful to understand. Often, it is helpful to ask specific questions to help the Runner understand better the type of information you’re looking to gather. Take the time to drill down deep to understand the Runner’s goals for the given session, as well as the short and long term. This goal setting will help you set expectations up front, and give you a better idea about what will make the biggest different today. You will find some runners want to run more or run faster, which falls into a performance type mindset, while others are looking to run with less risk for injury, which may deviate slightly in your approach to your advice. Your goal is to identify their priorities, and fit these together with what they are currently doing, and what you are proposing as modifications, additions, or subtractions from their plan.

  1. Goals for this session

    • “What are your goals for this session?”

    • ”What would make today’s session successful for you?”

    • ”How can I help you today?”

  2. Goals for the next 1 month

    • “What are your goals for running in the next 4 weeks?”

    • ”What would make the next month of running successful for you?”

    • ”Do you have any races or competitions you’re training for in the next month?”

  3. Goals for the next 3-6 months

    • ”What are your goals for running in the next 3-6 months?”

    • ”Are you hoping to sign up for any races 3-6 months down the line?”

  4. Goals for the long term (5+ years)

    • “What does your running look like 5 years down the line?”

    • ”What are your long terms goals for running?”

The Runner’s History

Learning about the Runner’s history has many components, and goes beyond just running. You’re trying to get a good idea about their current training and lifestyle, as well as their past training and injury history. You’ll know you have a good handle on their history if you could write a story about who they are as a Runner and what they’ve done in the past. Here’s the components of a history I look for:

Current

  1. Running training: FIDM: frequency, intensity, duration, and modality

  2. What does their running look like over the course of a week?

    • Hills versus flat

    • Dirt, track, road, sidewalk, or a mix?

    • Speed workouts?

    • Short versus long runs?

  3. Training outside of running: biking, swimming, strength training, yoga, mobility, anything else?

  4. Lifestyle outside of running: work, family life, sleep, nutrition, general stress, commute / driving

  5. What has their running looked like over the past 3 months? What about prior to that? I’m looking for any big jumps in running duration / mileage, which would indicate a potential overload of tissues.

  6. How does running fit into the bigger picture for them? Is it their regular form of exercise? Something they are competing in?

Past / Bigger Picture

  1. How long have they ran? When did they first start running?

  2. Racing / competition history?

  3. Any long breaks from running?

  4. What is their movement and sports background? What did they do growing up for sports and fun?

Medical / Injury Background

Finally, I dive deep into the details of a Runner’s medical and injury background. I want to know whatever information the Runner finds relevant, as well as additional information that may help me determine what advice to give the runner during the initial session and into their future.

Running-Related Injuries

Initially, it’s helpful to get an idea of any injury related to running that the Runner has experienced, all the way to the beginning. Often, injuries or aches / pains will re-appear in the same areas they have in the past, and this will give you an idea about potentially where you may need to add specific strength & power training, mobility, or running gait re-training. I’ll ask Runners if they have ever experienced common injuries like Runner’s Knee, Shin Splints, Plantar Fasciitis, or IT Band Syndrome. Sometimes Runners have experienced these, but won’t necessarily consider them injuries. Here’s some of the questions I’ll ask about Running-Related injuries:

  1. Any significant running injuries in the past?

  2. Have you every had Runner’s Knee, Shin Splints, Plantar Fasciitis, or IT band syndrome?

  3. Any aches or pains you’re currently dealing with?

Non-Running-Related Medical & Injury History

After understanding a Runner’s injury history related specifically to running, I’ll take a step back and ask about their general health, medical history, surgical history, and injury history. This information may affect a Runner’s capacity, and provide you insight into how to approach your advice about running progression, reducing risk of injury, and additional targeted strength, power, or mobility that will help them perform better. Some sample questions:

  1. Any medical conditions or injuries that you’re currently managing?

  2. Any medical conditions, surgeries, or injuries in the past?

  3. Anything else that you think I should know about your health?

Once you gather all of this information, you’ll have a very good idea of why the runner is there, what their goals are, and how you can help them the most with your advice, strength and power exercise, motor control and mobility exercise prescriptions, and running gait re-training. We’ll dive further into the details of a qualitative and quantitative running analysis next, then into the tools you have to intervene and adapt a runner to improve their performance and make them more resilient.

Running and Physical Therapy: Running Analysis Part 1, The Overview

Running Analysis is a critical component of a physical therapists’s toolbox. Physical therapists will need to have the skills and knowledge to analyze a runner’s gait effectively and efficiently, then determine what is relevant to the problem they are trying to solve. In this initial post, I’m going to provide the 10,000 foot view on why a running analysis is performed, what the general components are for an analysis, and the general categories for interventions a physical therapist can apply based on the data collected.

Why perform a running analysis?

There are common reasons why you as a physical therapist would want to perform a running analysis. These reasons can be drawn out during your initial discussion with the runner to figure out their goals and history. Based on hundreds of running analyses that I’ve performed, here’s the most common reasons that I’ve heard:

  1. The runner is experiencing pain currently

  2. The runner had a running-related injury and wants to return to running

  3. The runner had a surgery and wants to return to running

  4. The runner is just getting into running and wants to reduce the risk of injury

  5. The runner has a race coming up and wants to do everything they can to optimize their training and performance

What are the components of a Running Analysis?

A running analysis can be broken down into 4 component::

  1. Subjective / History / Goal setting

  2. Running analysis

  3. Active movement screening (including mobility, stability, muscle performance, balance, power, movement quality)

  4. Passive movement screening (including joint mobility, passive muscle extensibility)

Each component of the running analysis is critical to gathering information that give you a better idea of what the runner’s movement strategies are, potential compensatory strategies, potential targets for intervention or change, and how these all fit into the runner’s goals and history.

How does a physical therapist intervene based on the running analysis data?

After performing a running analysis, a physical therapist then has a diverse toolbox to draw from, and needs fo determine what are the top priorities for the runner in front of them, depending on their goals. These tools include:

  1. Body weight and resistance training to improve strength, power, and muscle performance

  2. Motor control exercises (including balance, proprioception, coordination, muscle activation, stability)

  3. Mobilizations / mobility-bias exercises

  4. Manual therapy techniques (including passive joint mobilizations, passive soft tissue mobilizations, muscle energy techniques, mobilizations with movement / functional mobilizations)

  5. Running gait re-training (including trunk posture, cadence, footstrike pattern)

  6. Collaboration and education of the runner about lifestyle factors (eg. Sleep, stress, recovery, training program)

  7. Collaboration and discussion with the runner’s coach about the runner’s training program

In the subsequent posts, I will explain further this process for running analysis, interpretation of the results depending on the context for a running analysis, and how I figure out what are the top priorities for intervening.

Running and Physical Therapy: Changing running mechanics requires gait re-training

In a a clinical setting, there are a couple of key reasons why you would want to change a runner’s mechanics:

  1. They are experiencing pain

  2. They are coming back from an overuse injury, and they don’t want it to happen again

Now the million dollar question is how do you change their running mechanics? The short answer: you need to change their running mechanics.

This important paper by Willy and Davis et al. demonstrates that running mechanics will NOT necessarily change when you improve hip strength and single leg squat with an intensive hip strength program.

One of my key takeaways is that running is a complex motor skill that cannot be reduced to correlate tests such as single leg squatting and glute med MMT. You need to directly change their running mechanics through cueing and motor skill training while they run. If a runner has excessive hip adduction, cue them visually or verbally to run with less hip adduction. If a runner is overstriding, cue them to run with 5% shorter strides, or have them run with a metronome at a faster cadence.

Often we are over-reliant on what we see on the table with an impairment-based exam (eg. active ROM, passive ROM, MMTs, soft tissue palpation, joint mobility testing) and as a result, we miss the bigger picture in terms of changing the actual complex movement. In other words, we need to avoid over-reducing a movement into its component parts.

So, the big message here: to change running mechanics, you need to change running mechanics.

Pilates VS Crossfit - why does it have to be one or the another?

As a physical therapist, Pilates instructor, and Crossfit enthusiast, I’m surrounded by communities that seem to have some choice opinions about one another. For some reason, it’s my experience that Crossfit gets the shortest end of the stick. 

Crossfit. Strength and conditioning. Whatever you want to call it. It can include gymnastics, kettlebells, Olympic lifting, Power lifting, etc. No Crossfit gym is the same. Just like no Pilates studio or PT clinic is the same. In all of these settings, there are good movement coaches, and there are bad ones.

Some of the criticism I’ve heard of Crossfit:

  • “Too many people get hurt. I’ve seen a lot of broken Crossfitters.” - Research has shown that more people get injured running than doing Crossfit. Should we all stop running?

  • “Crossfitters don’t care about form. It’s all about weight and reps” - Unfortunately, many PTs, Pilates instructors, and personal trainers are guilty of the same thing. Secondly, do you know what that individual needs? Maybe it IS more weight...

  • “It’s a cult of meatheads.” - Simply, not true. However, I’ll admit I thought this before I tried it.

I’m not a Crossfit athlete by any stretch of the imagination. I’d be ecstatic if I had a fraction of a Crossfit athlete’s physical prowess. I take both Crossfit and Pilates classes. I crave the spinal articulation and deep motor control that I get with Pilates and I take pride in the strength and power I gain from Crossfit. I think they complement each other nicely and give me a well rounded, whole-body workout. 

Also, if you haven’t experienced a Crossfit workout, what are you basing your opinions on? Crossfit isn’t perfect, but there are skills that you can learn that will transfer over into other movement practices or functional activities. I’m all for having a personal preference - you chose what movement practice suits you best, but don’t knock another till you’ve tried it. How you practice movement seems more important than what your choice of fitness is. Go out and do a little research. Find a Crossfit gym that has coaches who are mindful movers. San Francisco Crossfit staffs physical therapists and exceptional athletes that can PERFORM and TEACH smart movement (biased promotion). Get out there, pick up a barbell, and learn a thing or two. 

Instead of criticizing other movement practices, I’d like to promote a conversation on what these modalities can bring to the table. Let’s all try and participate in intelligent fitness. 

Resilience

The resilience of the healthcare practitioner is something that we are not talking about.  Where does the health and well-being of the practitioner fit into the picture of healthcare?  In my experience, many healthcare practitioners get into the field because they want to help people.  Patient care is the primary focus; but taken to the extreme, many practitioners start to feel burnt out and look for an escape. Not only does the practitioner start to feel tired, overwhelmed, and frustrated, but the quality of care starts to suffer in parallel.

In graduate school, it’s all about “ evidence based practice”.  In clinical practice, it’s all about “patient satisfaction” and “clinical outcomes.”  Where does the well-being of the practitioner fit into these ideas?  I think we mistakenly or assume that the practitioner has their life together and are operating at their best.  The pressure to be productive, more efficient, and see more patients is only leading to more burn out and a greater need for balance in the clinician’s lives outside of work.

I think we need to start having more discussions about how we can help healthcare practitioners become more resilient.  We need to teach practitioners how to maintain balance in their lives.  This is not about being selfish, this is about clinicians being in a better place mentally and physically so that they can function at the highest possible level.  Decision making only gets better if the clinician is well rested, physically fit, and mentally engaged. 

So where do we start?

References: 

Ten Commandments for the Resilient Practitioner (http://bjgp.org/content/66/651/528)

Resilience:  what is it, why do we need it, and can it help us? (http://bjgp.org/content/65/639/e708?trendmd-shared=0)

 

The Modern Hippocratic Oath (Credit to the Freakonomics Podcast)

If you have never read the Modern Hippocratic Oath written by Louis Lasagna, former Dean of Tufts School of Medicine, take the time to do so.  It will make you reflect on your own clinical practice and ask yourself whether you are behaving in a way that is consistent with this incredible document.  It's important to note that this was written in 1964, and yet you will see components that are equally applicable today.

Some highlights from the oath with the themes that I think are applicable today:

"I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh a surgeon's knife or the chemist's drug." (Evidence-informed practice and the importance of empathy)

"I will not be ashamed to say 'I know not,' nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery." (Intellectual Humility and Inter-professional Collaboration)

"I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability." (Biopsychosocial Model)

"I will prevent disease whenever I can, for prevention is preferable to cure." (Focus on Prevention and Wellness)

Take a read for yourself and see what sticks out to you.  Then think about how you can change your clinical practice to match these guiding principles.

Link to a copy of the oath: http://guides.library.jhu.edu/c.php?g=202502&p=1335759

 

"Productivity is for robots" (Credit to Kevin Kelly...Again)

Insightful quote from Kevin Kelly in an interview with Tim Ferriss.  In the current healthcare environment, clinicians are constantly pressured to be more productive and more efficient in providing care to their patients.  On a big picture level, this makes sense, with the demand for healthcare far outweighing the supply (hence 6 to 8 week waiting lists to see your physical therapist or primary care physician).  But on an individual level, I think we need to be careful to not fall into the trap of just being more productive and efficient.  In essence, we can't become robots, mindlessly applying the same treatment to every patient.

So how do we do this?  Here's some ideas based on another quote from Kevin Kelly's interview:

"Where humans are going to be really good is in asking questions, being creative, and experiences." (Kevin Kelly).

- Ask better questions of our patients:  What are their goals and expectations?  How can we help them?  Why are they really here?  What are they fearful of? How is this problem affecting your life?

- Be Creative:  How can we take the best research evidence and blend it with our creativity and patient's input to come up with a customized treatment plan tailored to the realities of our patient's life?

- Experiences:  How can we make the experience of our patients better?  How can we earn more of our patient's attention and trust?  How can we make the patient walk out of the clinic and think "that was way better than I expected?"

Let's be better than the robots.  Let's ask better questions, provide creative treatment solutions, and create better experiences for our patients.

"Sit, Sit.  Walk, Walk.  Don't Wobble." (Credit to Kevin Kelly):  Single Tasking in the Clinic

"When you sit, just sit.  When you walk, just walk.  But whatever you do, don't wobble." (Ummon, Zen Saying)

One of the most powerful things you can do to be a more effective clinician is single-tasking.  Look at your patient and ask one question at a time.  Listen to their answer intently and openly.  Perform one test at a time.  Focus on what you're feeling and how the patient is responding.  

The current healthcare environment is not conducive to single-tasking.  We are asked to complete fifty tasks all at once, and do them now.  So our knee-jerk reaction is to multi-task all day, every day.  The problem with this approach is it's easy to lose sight of the reason we are there:  To help people and treat patients.

Resist this urge, and focus on one thing at a time.  When you ask a question, do so with intent.  When you teach an exercise, focus on just that.  But whatever you do, don't wobble.

Links

http://podcastnotes.org/2016/06/08/tim-ferriss-kevin-kelly-ai-virtual-reality-and-the-inevitable/

https://connect.gonzaga.edu/bormann/zen-quotes-6

http://www.mdedge.com/jfponline/article/103873/practice-management/ehr-use-and-patient-satisfaction-what-we-learned

http://www.wnyc.org/story/infomagical-challenge-1/

 

The Value of Having a Movement Practice

This post has two goals:  defining Movement Practice, and describing the lessons I have learned through my own Movement Practices that have made me a better clinician.

I wanted to write on this topic because I have seen recent campaigns by both the APTA and CPTA to re-brand physical therapists as movement specialists. In order to be a true "Movement Specialist," I think you need to have a Movement Practice of your own.  Knowing, doing, and teaching movement are all equally important parts of being a Movement Specialist.  It is really hard to label yourself as Movement Specialist if the "Doing" part is missing.  Having a Movement Practice and learning new movement practices will make you a better clinician for many reasons, including reminding you what it's like to be a beginner and student again.  

What is a movement practice?

There is no consensus definition for what is a "Movement Practice," so I'm going to make up my own.  I think a movement practice moves beyond exercise, and is any situation where a person is moving their bodies with purpose, and is mindful and attentive to their performance.  Reflection on the quality of performance, and planning future practice sessions with the goal of refining and improving their movements are equally important.  Yoga, pilates, feldenkrais, dance, martial arts, soccer, football, crossfit, weightlifting, running, biking, swimming, gymnastics, and even walking can all be considered movement practices.

How does having a Movement Practice make you a better clinician?

Some of my most pivotal experiences as a clinician have come during my own movement practices.  My first experience was learning different running styles in an attempt to make myself a faster, more efficient runner.  I explored Pose running, Chi running, Barefoot running, Natural running, along with trying to piece together my own running style based on the research.  It was a long process with a lot of ups and downs to learn what running style clicked the best with my mind and body.  I had multiple instances where I felt like it was so easy, but then the next day ran like I had no control over my legs.  Learning how to run differently and to refine your running technique is similar to what we are asking our patients and clients to do when we ask them to walk different, stand different, or squat different.  

Lessons I learned:  

1.  Learning how to change how you do something that you've been doing for a long time is difficult, and I need to be patient with my clients and patients when I ask them to do something different.  

2.  Really paying attention to how you move, with something that seems as natural as running or walking, instead of just tuning out, is the biggest difference between exercise and a movement practice

3.  The learning curve when learning to move differently is not linear, it's more like a roller coaster with ups and downs.  Expect this, and educate our patients and clients to expect the same thing.  It will save them a lot of frustration and doubt. 

My second experience was my experience was at San Francisco Crossfit when I started to learn all the different movements for the first time, including olympic lifting, powerlifting, and gymnastics.  Learning how to deadlift, snatch, clean and jerk, and kip was challenging, and a constant roller coaster of excitement and frustration. When I became a coach and started to learn how to teach other people how to do these same movements, it was like I was starting all over again.  I could do the movements with some basic proficiency, but teaching other people was a whole new ballgame.

Lessons I learned:  

1. Learning the basics of a new movement does not need to be complicated, but actually mastering a movement takes years.

2. Being a beginner again is a great, but humbling experience.   Taking the beginner mindset and being open to learning is critical when you start anything new.

3. Knowing, doing, and teaching a movement are different skill sets that all require a different level of understanding.  

4. There are a lot of different types of movement out there, and the more you can expose yourself to, the more you will start to see commonalities and differences between movements.

 

Choosing a Crossfit Gym

I just listened to a great podcast with Dr. Karen Litzy and Dr. Rick Daigle on the Healthy Wealthy Smart Podcast 217: Crossfit: It is for You? w/ Dr. Rick Daigle and I thought they had a great discussion about how to choose a Crossfit Gym, along with a lot of other Crossfit-related topics.  

In light of that podcast, I'm posting my thoughts on actionable steps you can take if you want to figure out if Crossfit is for you, and what the best gym is for you.

1. Be open, leave your pre-conceived notions at the door.  Walk in with an open mind and see first hand what it's like for yourself.  Relying on the internet or social media will leave you with certain impressions of Crossfit that may or may not be accurate.

2. Ask to observe a class, and hang out for the whole thing beginning to end.  Get a feel for the culture, community, and general vibe of the gym.

3. Ask if they have a class that is open to the community to try out.  If they do, take it!  There's nothing like experiencing a Crossfit class first hand to figure out if it's something that you might enjoy.

4. Ask to talk to a member, and ask them what they like about the gym

5. Find out the gym's schedule, and see if you can realistically make their class times.  Be honest with yourself.  There's enough barriers to working out already!

6. Ask about their on-ramp / introduction process.  Do they have an introductory class or series of classes? This can be a very helpful step to get you comfortable with the Crossfit class and gym setting, especially if you've never touched a weight before.

7.  Ask your family, friends, or co-workers who you know already go to a crossfit gym, and see if you can tag along with them to observe or take a community class.   The social aspect of Crossfit is huge, and if you have someone that you already know to goes to a Crossfit gym, you'll feel more comfortable going in for the first time.

That's it!  Comment below with any suggestions of your own.