Routine, Assessments, and Seeing the Bigger Picture

Jenn Pilotti

A fair amount of people initially come to see me for issues surrounding pain and discomfort. Often, it’s an area that has bothered them off and on for a long time, with doctors left shaking their heads, suggesting another cortisone shot or another round of physical therapy. These individuals are usually extremely active and frustrated they can’t resolve the issues on their own.

I am a fresh set of eyes in these situations. I don’t look, exactly, at how the muscles fire. I dislike hands on work, so I don’t do any manual muscle testing. Instead, I watch people move in a variety of ways. I watch their posture as they move in and out of positions, not because I think there is a perfect posture, but because transitions reveal habits.

Take the flexible dancer, for instance. I watch her move with ease and grace, as though she is barely grazing the floor with her feet. When her arms lift overhead, the motion is big, encompassing. Her ribs lift, her eyes lift, and energy fills the room. When she walks, everything is in front of her, preparing her for the next step. Nothing extends behind her. When asked to squat, her heels lift and her back arches as she moves into a deep plie.

Her understanding of movement is vast. She can do things with her body I will never be able to approach. Yet she lacks the ability to make small movements. She only understands extension as it applies to her lumbar spine, and her mind blends arm movements with spinal movements. Her world and, by extension, her movement, lives in front of herself. Her concept of the back of her body is a rough sketch that needs to be filled in.

Contrast this with the endurance athlete. He also lives forward, though in a much smaller way. He knows how to move his legs in a circular pattern beneath himself, but when it comes to moving any other direction, he is lost. His spine stays still, locked in place, while his arms swing and his legs propel him forward. His movements are tight, held in close. He runs a 5K faster than I ever did or ever will, but his legs refuse to fold enough to lower him to the ground, as though they are stubbornly fixed in a small range of motion from which he can’t deviate.

Fitness means many, many things. The dancer is fit; she can jump and balance and bend, but she is only fit in that way. She lacks the basic strength to pick a heavy object from the floor or to keep her spine still and move around it. Her awareness of where she is in space allows her to move and express, but it’s largeness prevents her from moving simply.

The endurance athlete is fit; he is the one you want on your team if you need to outrun a large mammal. He will outlast and endure. His legs are strong and powerful enough to carry him up a hill, yet he lacks the basic flexibility to interact with the floor in a comfortable way. If he is required to hang from a tree for any length of time, he will struggle because he doesn’t usually use his hands to hold things.

There exists an idea in the world of fitness that is shaped like a U. If you don’t exercise at all, you have higher risk of low back pain than if you exercise moderately (whatever that means); if you exercise too much, your risk of developing low back pain increases. The most protective place is in the middle. (A recent study of over 9000 Swedish individuals disputes the claims that high levels of physical activity are predictive of a higher risk of low back pain. What the researchers were able to conclusively report is more than 3 hours of strenuous physical activity a week is not associated with any additional decrease in developing chronic low back pain) (1).

Recreational runners are believed to be at the highest risk of injury during the first year. The joints and tissue of many adults aren’t ready for high amounts of load; the recreational runner that attempts to do too much, too soon risks exceeding the amount of load his system can currently withstand. After the first year, the risk of injury is remarkably low if the runner runs less than 30 miles a week; more than that, injury risk increases (2).

What does all of this mean? Is it repetitiveness within a specific activity that’s problematic? People who exercise a lot tend to be very habitual in their approach to life. They have a routine that involves lifting the same way, or practicing the same yoga routine, or running the same route every Tuesday, followed by a slightly different lifting program or yoga routine or longer running route Wednesday. Maybe variation (or lack thereof) matters more than the amount?

Lack of variation as a source of discomfort can be extended to breathing patterns, stepping patterns, and carrying patterns. We look for the path of least resistance to accomplish any given task. It’s part of our desire to conserve energy and make life easy. Unfortunately, when this path become habitual, over time the options available to us to move in a different way lessen. Habits limit our ability to vary movements, prohibiting us from moving freely; sometimes, habits lead to a sense of fatigue or persistent discomfort.

Identifying a habit requires the coach or teacher pays attention, not just to standard assessments, but to strategies adopted during learning a new task, unconscious movements, and general patterns. The ability to look at the big picture while also observing the finer details enables a clearer course of action for alternative suggestions.

Whenever I work with a client struggling with pain issues, my assessment is an observation of habits. How does he transition? How does he breathe? How does he interact with the floor? What happens if I give him alternatives? I watch as he gets up out of chair; I also ask him to squat. Are the two patterns different? Why? I notice how he stands while we chat; when I ask him to come into a standing position before a single leg balance test, I watch how he moves from two legs to one. What way does he cock his head while concentrating? Where do his eyes look when I ask him to do something challenging? What happens in his hands, his feet, and his jaw when I ask him to stand on one leg? How does he walk when he’s not paying attention?

In addition to what I observe, what does he say? When does he experience the discomfort? What activities make it worse? As I watch and observe, is what he’s saying consistent with what I see? If not, why?

I read recently in the book, “The Art of Fear,” by Kirsten Ulmer that striving for balance doesn’t mean we live our lives perfectly centered emotionally, all of the time. That is unrealistic. We swing between extremes, because life dictates there will be moments of high stress followed by periods of low stress. In movement, there will be the same. Sometimes we should work hard, pushing ourselves outside of our comfort zone, but we should also be able to move in an easy way, without much effort. We should be able to contract, but we should also be able to relax. When we live on either extreme, we lack a sense of centeredness and we begin to tip away from achieving an overall sense of balance.

So what about our athletes we met in the beginning? The dancer understands expansion in front of herself. That is her habit, the space her body knows how to occupy. Teaching her how to contract in and allow movement to occur behind her without the use of her spine will increase her options and create a different sense of her space. Her sense of center will be changed, creating a sense of stability that she currently lacks.

The runner, on the other hand, would benefit from more expansion. Learning to move his body in different ways and through different angles in space will increase his movement vocabulary and improve his overall awareness of the space he occupies. The ability to fold his legs beneath him and lower his body to the floor will make his world a little bit bigger because he will no longer fear stiffness or the feeling like he won’t be able to get back up.

When someone wants to perform a certain skill, it is necessary to assess the movement required for the skill to ensure the person has enough options available to perform the skill in a successful way. However, not everyone wants to perform a specific skill. Sometimes people want to move in a way that doesn’t hurt, and the information that exists is convoluted at best, contradictory, at worst. From a practitioner’s standpoint, I want nothing more than for my clients to be able to live fulfilling lives and to have the strength and flexibility to do what they want, when they want. Being a teacher or coach means being able to quietly observe and gently guide people down avenues they didn’t know existed between themselves and their bodies. Use traditional assessments, but observe what happens during the in between times. That’s the information that often makes the most difference.

 

References:

  1. Heuch, I., Heuch, I., Hagen, K., & Zwart, J-A., (2016). Is there a U-shaped relationship between physical activity in leisure time and risk of chronic low back pain? A follow-up in the HUNT study. BMC Public Health., 16. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4827170/
  2. Nielsen, R.O., Buist, I., Sorensen, H., Lind, M., & Rasmussen, S., (2012). Training errors and running related injuries: a systematic review. International Journal of Sports and Physical Therapy. 7(1), 58-75. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3290924/

 

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