Syllabus as of 5.5.23

Welcome

Meet the Instructors

Quinn

Hello! My name is Quinn Henoch and I’m a Co-Founder of ClinicalAthlete and CALU.  I’ve been a practicing Physical Therapist for about a decade now, and before that, I was a strength & conditioning coach.  I’ve worked with and programmed exercise from youth to completely deconditioned all the up to international and professional level athletes.  I’ve also personally dabbled in many different sports including competitive weightlifting for the last 10+ years, college football before that, and powerlifting, crossfit, track and field, basketball, lots of different stuff.  That is to say, I’ve implemented many different avenues of exercise and training and have also dealt with many injuries and had to take those into account when planning training.  Along with my passion for learning and teaching, this course is somewhat of a culmination of all those things.  I couldn’t be more excited to go on this journey with you, so let’s discuss what this course is all about.

What Is Foundations 2?

So, what is Foundations 2? 

Well, first of all, if there’s a Foundations 2, then there must be a Foundations 1.  So, I’ll start with a disclaimer, if you have not yet taken F1, please do so.  It is a prerequisite for a reason.  F1 will expose you to the big picture concepts of Mindset, Critical Thinking, Communication, and exercise prescription. It will create your Foundation. The Foundation of your Foundation.  So, please, please, please, go and take the most recent edition of F1 if you have not done so. 

Ok, welcome back, I hope you had a great time in F1. Foundations 2, this course, builds on those big picture concepts.  Making them more and more applicable to your practice. Foundations 2 is about exercise prescription, yes. But at the same time, exercise prescription is more of just the vehicle that we can use to help you transform into the professional that you want to be, and in turn, you help transform the people that you work with. 

Foundations 2 is built and will continue to be built based on what you tell us that you need, in order to have that transformative experience. And with that feedback, we’ve identified some main tenets, that you bring up again and again.  The “pain points” so to speak that you’re experiencing as you continue on your learning journey.

One of which is just a general overwhelm with the crazy amount of information that’s out there on exercise prescription, combined with the craziness of working with people in real-time. You have all the information at your fingertips, but lack direction or a way to organize your thoughts into something that you can actually use. It can also be hard to organize your thoughts with each individual case that you see, and maybe you feel that you’re always starting from complete scratch with your exercise prescription, or maybe you even feel like it’s random at times. And because of this, maybe you don’t feel very confident in what you prescribe or your interactions with the people you work with during the process. 

Another Pain Point that we’ve identified based on your feedback is creating that “initial plan”.  Synthesizing all of the information you get from your person - and saying, ok, where do we start?  How do we get the ball rolling towards your goals? 

And then, we have the longer term. So many of you expressed the desire to become more skilled at monitoring the process, being able to progress or regress the plan with decision making that you’re confident in.  This is the “seeing the person through to the end” phase, and all of the decision making that comes with that. 

And finally, it’s managing the human element of things.  The conversations we have with the person as they are going through their exercise prescription plan.  How best to manage the inevitable ups and downs both from an exercise standpoint, but also from a communication standpoint.

Imagine a version of you in which you have a stronger command of all of these elements, being more confident in what you know, being more comfortable with what you don’t know, and overall having developed a process that makes your exercise prescription and expertise incredibly valuable for the people you work with.

THAT is what Foundations 2 is all about.

How NOT to use this course

Scenario 1

*Looking at phone, playing F2 in the background, *gets email notification*

IF, you want a transformative experience, F2 should not be consumed as distracted, passive entertainment.  If that’s how you’re going to do it, you might as well just click the complete button on all the videos to get that short term dopamine fix, bc you’ll get just as much as out it that way, which will be nothing. 

The act of “Learning” anything is a skill in itself, and it must be honed with attention and focus.  

Scenario 2

*Do post-lesson assignment - shhhh that sounds like work.  Participate in live mentor calls, volunteer for growth seat, post one of my exercise programs in CALU+ and get feedback - shhhhhhhhh that sounds scary and uncomfy..   But, you know what sounds easier and will trick my brain into thinking I’m being productive - not do any of that other stuff and just press play on this next video.

Cut:

Exercise prescription is a skill as well, and must be honed with doing, messing up, being confused and frustrated, and pushing through those barriers to make the Brain Gainz.  You will NOT become better at exercise prescription by only watching videos and reading research. Unless your goal is just to “know” a lot about exercise prescription to be able to regurgitate a bunch of information in order to argue on the internet.  But we know you want more than that. You’re looking to transform your professional skillset.  So, let’s talk about the proper way to use this course in order to do just that.

How To Use This Course

Scenario One:

*Phone - away.  These 100 other tabs open?  Gone. 

Active attention and focus. Try to put the phone away, close all the other tabs you have open and hone in.  Each video is short for this very reason. Now, I know you might say - but I like to have my phone out so that I can look things up while I’m watching.  And yes, I’ll give you that, I do that sometimes too, but if there’s ANY chance that looking things up on your phone somewhere turns into you mindlessly scrolling instagram for 15 minutes, or getting side tracked by an email notification, then that time is counterproductive. My recommendation is to have a pen and paper or whiteboard beside you, and make notes of what you want to look up after watching the video. 

Scenario Two:

Oh there’s this post-lesson assignment that requires me to reflect or take some type of actionable step to improve my exercise prescription skills.  Cool, I’m gonna do that and really reflect on it before I move on to the next lesson. 

Oh there’s a prompt for me to post one of my exercise programs in CALU+ for feedback? Duh of course I want feedback on my work, how else am I gonna get better?

You know, I do have a question about this lesson, and I know that I’ll get some great answers if I post my question in CALU+, but I have the scaries and I might feel dumb for like 3 seconds. But who cares I’m tryna learn plus I bet other people have the same question and the discussion is going to be helpful for everyone.

Cut

This course, Foundations 2, is only a PART of your transformation into an exercise prescription all-star.  While obviously we think this course, is great and special, there are many great stand-alone, non-CALU exercise courses out there.  Hell we promote a lot of them.  What sets F2 apart is that it’s embedded within the Amazing CALU+ community, where you’re surrounded in a virtual sense by like-minded individuals who want to get better, just like you, and who support you in that endeavor.  

AND, you get access to me and the other CALU+ mentors to help you further refine and implement what your learning into practice.  The actual course content itself is the guiderail, but being active in the community is where the transformation happens.  So, DO the assignments that we have for you as part of some of the lessons. Come to the live calls when you can and ask questions, volunteer for the growth seat or any other opportunity we might present.   

Write exercise programs for your clients based on what you’re learning and post those in community for feedback. Be vulnerable, show your work. It’s painful sometimes, but that’s where the most growth happens. Remember, we are in this together.  If there was ever a safe place for honesty and transparency, it’s CALU+

Your Commitment

This is not a commitment to us, but a commitment to yourself.

You’re looking for a transformative experience and to take your clinical skillset to new heights. You also know that type of growth doesn’t come easy.

So, your commitment to yourself means:

• You will do your best to go through the course content with full, active focus and attention.

• You will complete any course assignments with thoughtfulness, taking as much time as you need to get the most out of it.

• You will lean on this community when you have questions, hit barriers, want to show your work, want to celebrate wins, or anything else. You understand that we are here with you.

If you’re down with this, then comment on this post with your Initials and date.

This will serve as your formal commitment to yourself and to your continued journey toward excellence.

LET’S GOOO!!

Complexity & Systems & Models, Oh My!

We Shall Not Fear That Which is Complex

I struggle with analysing complex problems and integrating all the knowledge I get from different fields.

Go ahead and pause the video and give this a read. I’ll give you a second. “I struggle with analysing complex problems and integrating all the knowledge I get from different fields.”  This comes straight from one of you. We weren’t kidding when we said we’ve built this course based on your feedback and where you said you need the most help.

And this (point to quote), is exactly what we’ll be addressing in the lessons to come. 

We’re going to take the brief complexity component from my lecture in Foundations 1, and we’re going to greatly expand on it.  

Afterwards, we shall not fear complexity or see it as some abstract idea that always talked about with no context . We shall understand it as something we can actually define.  As a specific concept that helps shape our clinical approach. 

We’ll understand what it means to be a Systems Thinker who’s able to zoom in on the finer details when needed, but is also able to zoom out to see the bigger picture. 

We’ll understand the difference between principles and methods and how that applies to exercise prescription, and how drilling down to First Principles can help us filter the overwhelming amount of information that we have at our disposal, that seems to come from everywhere…

..All of the training and rehab approaches and models out there.  Well we’re going to talk about what “models” really are, what they represent (or don’t), and how they can help us manage complexity.  And this will truly be the start of you constructing your own mental model of exercise prescription. 

All that to say, this part of the course, is instrumental.  Whatever superlative that we can use here, that’s how important this part of the course is for your overall success. Take your time and really reflect on what’s being put forth, and I look forward to it sparking some great discussions in the Community. 

Alright, let’s learn about complexity

Objectives

Understand Complexity as a defined construct that molds how we think about clinical care, not just some term we throw around to sound smart.

Understand what it means to be a Systems Thinker and why that’s important in clinical care.

Understand the difference between principles and methods, and why considering one before the other matters.

Understand what models are and how they are used to help us manage complexity.

What is a Complex System?

We start this course as every good course should, with a meme.  

*Read meme*

You ever feel like this one on the left here?  I know I have.  That feeling is literally why this course exists.  Now, there’s nothing wrong with taking in good information from social media of course. I do it all the time, we all do, and that’s not really the point that’s being made here.  The point is, what drives our ExRx and plan of care decisions? And, what makes all of this so difficult to organize our thoughts around in the first place?  

Well…

I know you didn’t forget.  There’s that word again. The word that if you’ve hung around CALU at all, you've probably heard a million times, including in Foundations 1. But we’re going to really dig in here. 

Humans are complex and so are our interactions with them. Guiding somebody through their exercise program is an ever evolving, complex process. It probably looks a lot more like this squiggly line here than this linear path here. But, I’m not telling you anything you don’t already know.  We can probably all agree on a surface level that guiding somebody through an exercise plan is a complex process  But often, this is where a lot of conversations about complexity stop. The term has almost become just some vague, generic platidude with no context or meaning. 

But we're not gonna end with that., by just saying, ‘Oh, it's complex’, and leaving it there - Just like we wouldn’t say, ‘it depends’ without talking about what it is and what it depends on. 

There are entire fields on the study of complexity. Complexity theory is an actual thing. It’s the study of dynamic (or ever-changing) systems, like the human for example. That seems relevant for us, so let's continue to give some real meaning to the term complexity - then we can talk about how to deal with it.

SLIDE

Let’s come back to this quote that I introduced in Foundations 1.  This short paragraph encompasses the essence of this entire course, and also introduces us to several important terms and concepts that we will revisit throughout.  I’ll give you a second. Pause and read this.  

Let’s just take the first two lines there:

“It is increasingly emphasised that people are complex biological systems that do not behave in a linear fashion.”  I’ve modified it with the word adaptive, because you will hear that term often as well, complex adaptive systems.  I also like that word’s connotation in relation to exercise.  So, “It is increasingly emphasised that people are complex adaptive systems that do not behave in a linear fashion.”  

Let’s dig into that.  We’ve got our word there again, “complex”.  But we’ve also got the term “system”.   And if there are complex systems, there must also be simple systems, but what’s a system in the first place?

Two Definitions - Decide which to use:
A system is a group of interconnected elements working together to achieve a common purpose or function (Ludwig von Bertalanffy, who wrote in General System Theory 1955) and if you so happen to be able to observe the system long enough, *appear* you might see a pattern of behavior over time.

*Slide*

A system is a set of things interconnected in a way that has a certain function or purpose and produces a pattern of behavior over time. - thinking in systems

*CLICK*

Let’s highlight some key elements there.  A system is a set of interconnected things.  Those things have a function or serve a purpose. And there’s a pattern of behavior that emerges over time, and if you so happen to be lucky enough to observe the system long enough, you might pick up on the pattern. 

SLIDE

A system has 3 things:

• Parts / elements / components / stuff

• Interactions and interconnections between those parts

• A purpose: In the car example, it’s to get you somewhere. The objectives of the organization as a whole have a higher priority than the objectives of any subsystem or part.   Taking the seat and steering wheel out and sitting in the driveway wont get you anywhere.  So, in a system, the parts interconnect in a way that serves some higher purpose or function.

SLIDE

*pipe / faucet pictures*

Here’s an example of a simple system:

We’ve got parts, (pipes, liquid, faucet, reservoirs) that interact (water goes through the parts), for a purpose ( to take fluid from point A to point B). 

A simple system is often linear in a proportional and predictable way.  Meaning, in this case, adjusting the faucet to be more open or closed will cause a proportional amount of change to the output. More or less of A, causes more or less of B to the same degree. This is linear behavior that’s predictable, because there’s only so many outcomes that can come of this system. We can also take this system apart and put it back together again and predictably get the same performance or behavior - in other words, the whole of the system can, more or less, be explained by the sum of its parts.  

Let’s scale this piping system up for a whole house. 

*SLIDE*

That looks like a more complicated system doesn’t it?  

CLICK

*watch appears*

This is also a complicated system.  A watch. This is a fancy one, but just think about 

*CLICK*

how all the parts have to fit to have it function. Notice I’m saying the word ‘complicated’.  You might have noticed that distinction, but maybe you didn’t, because often the terms “complicated” and “complex” are used interchangeably. They are not the same thing.  I know I know, you’re like, “omg seriously does this level of semantics really matter you asshole.”  I’m going to say it does, because the difference in meaning is relevant for us.  

SLIDE

A “complicated system”, like this watch or this upscaled piping system, or the car have a lot of parts.  But these complicated systems still have similar characteristics of simple systems.  For example, in this more complicated piping system, you can still create proportional cause and effect with how much water runs through, so it’s still a linear system. And you could take this watch or car completely apart, all the way down to each component part, and put it back together to get the same function - assuming you knew what you were doing.  If you didn’t, you might say, “damn this is complicated”, but if you had the instructions for the watch or proper training for the car, you’d nail it.  So, a complicated system has lots of parts, and those parts interact, but those parts still explain the whole; which can be broken all the way down, and built back up to still function or behave predictably. 

So what makes a system complex? 

*SLIDE*

Well now, we think of that house’s water system as part of a gigantic city water system that includes countless interconnections and interactions between elements, but also includes humans managing subsystems and making decisions that affect the system as a whole, with things like budgets and government policies affect decisions that they can make.

Not to mention, this system is also potentially affected by climate and weather patterns, which are themselves complex. 

This whole system has the same purpose really, to take water from point A to B just on a grander scale, but it’s almost impossible to disassemble it into “parts”, and put it back together again like a watch or a car. 

In a complex system, 

*CLICK*

the whole is greater than the sum of it’s parts, and the parts interact in ways that ebb and flow and are less predictable.  Inputs and outputs are not always proportional.  There’s not simply a “master faucet” that makes this city water system more or less efficient with the twist of a knob. Big changes somewhere could have little affect on the system as a whole, and a small change (or perturbation) could have major, unforeseen ramifications. In other words, a complex system is non-linear, unpredictable, and there’s no “instruction manual” on how to piece it together. 

Ok, so let’s take this back to the human now, like we did in Foundations 1, but dig deeper.

Consider the human brain for a second.  It’s a system itself right?

It’s got parts - neurons, fat cells, etc

The elements definitely interact

And it’s got a purpose - to help control the body’s subsystems let’s say and interact with the environment. 

But how does any of that, and especially any of those individual components explain the phenomenon of consciousness?

This emergent property that comes out of our brain. And of course, we can't explain how that comes about, how those component parts self-organize and how consciousness emerges from that.  

SLIDE

And, can we even really think about consciousness as something coming solely from the brain, or even think about the central nervous system by itself for that matter, without considering the other systems of the body?  

What good is the brain without blood being pumped to it, and every other system of the body that supports the function of the brain with the brain supporting the functions of them. A complex system of complex systems that is the human body. This idea of systems within systems within systems is called a 

*CLICK

“Systems Hierarchy”. Which is a useful concept to internalize to help us make more sense of complex systems.

SLIDE

And to illustrate that point, our body as a whole doesn't just exist in a vat. Can we talk consciousness without talking about the physical and social environment we’re embedded within and interact with every second of the day? We are an “open system”, which means we can’t be screened off from the environment that shapes many of our behaviors, and the cause-effect arrow points in both directions. Another layer of complex systems within complex systems. 

*CLICK*

So, if we look again at that systems hierarchy, the path continues 

*CLICK*

and we are but a small subsystem of larger systems ever increasing in complexity. 

*CLICK*

So, back to our example of “consciousness” - it’s this emergent property that arises from a stupidly complex, self organizing web of systems. As healthcare professionals and coaches, we’re probably surfing up and down this region of the hierarchy on average, but let’s say you’re a molecular scientist, then we might take this molecule level and shift it right on down to the center, then consider what comes before it - atoms, protons, neutrons, electrons, quarks I don’t even know.  Or say you’re studying the biosphere, shift that one down, and what comes after that - I don’t even know, the galaxy.   I think you’re getting the idea, and probably see that this could go on forever.  When talking about complex systems, there’s really no end to the systems hierarchy in either direction, whether you’re zooming in or out, going up or down the hierarchy. It’s up to us to decide to what extent zooming in or out is helping when working with our people. 

*SLIDE*

Ok, so to summarize so far: when defining a complex system, we’ve got certain traits:

The parts of a complex system interact and self-organize, to create some type of emergent whole.  The whole is greater than and cannot be explained simply by the sum of its parts.

A complex system’s behavior can be non-linear. The input doesn’t always equal the output. Large inputs to the system could have little to no effect, and small inputs to the system could have large effects.  Or, small inputs could have proportionately small effects, until some critical threshold is reached, and something happens.

Think about exercise and adaptation. We’re sending inputs into the system hoping for some type of “state change” in the system.  But goodness knows our gains aren’t linear and don’t always seem to equal the amount of work required to get them, especially as ones training age increases.  Ah but then there’s those days when it seems like the stars align, and you hit a PR out of nowhere.  

And on the flip side, from an injury standpoint, 

*CLICK

think about an athlete who performs a seemingly similar movement for thousands of reps, like change of direction, until one day, 

*CLICK

an injury occurs when performing that very same movement. 

How do we explain these non-linear events? These abrupt state changes in the system.  

*CLICK

Well, for one, the contributing factors are constantly interacting, which feedback into the system itself. These recursive feedback loops are everywhere in complex systems, which makes it very difficult to distinguish cause and effect and pin down any type of linear relationship between factors.  Not impossible depending on the scale at which you’re trying to do it, just difficult. 

*CLICK

Let’s illustrate that here hypothetically.  We’ve got an event.  Each of these little circles represents a potential contributing factor. And when we’re talking about adaptation or injury, a lot of these potential contributing factors could be same when looked at in isolation. Some factors modifiable, some not.  Force production capabilities, age, training history, fatigue, range of motion, injury history, sleep & nutrition status, psychological profile, unexpected event in a game, on and one. Thick circles means that’s a strong contributor to adaption or injury and thicker connector lines between circles means those variables interact with each other more strongly. This web of interacting factors drives the systems behavior, and in turn, the system’s behavior alter the way these factors interact.  And of course, you don’t think these factors switch places from time to time, altering their interactions with each other, and in turn, altering the system?  You betcha they do.  

*CLICK

And for all those these reasons, predicting the behavior of a complex system is very difficult, as you can imagine, and as you probably know just from living life. Now, I put “less than predictable” instead of just straight up upredictable, because our ability to make useful predictions can depend on the scale at which we try to make them. And whether we realize it or not, we make predictions with our exercise prescription all the time. More on that in lessons to come. For right now, we’ll just understand that there will always be a certain level of uncertainty when it comes to the behavior of complex systems because of all of the interacting factors that we either know about and can’t measure, or that we can only measure them in isolation, or that we’re not even aware of. 

Ok, finally, what makes a complex system “adaptive”?

*SLIDE

I think this is probably the most intuitive descriptor of the term complex ‘adaptive’ system. 

Well, to what extent do these complex systems change with changes to their inputs and environments?  To what extent can they repair themselves or renew their own parts? I don’t have an exact statistic for you, but they do it all the time, right?  The body and environment respond to stimuli every second of the day, our cells are constantly turning over, the system has the capacity for self repair and to change itself based on the stressors placed upon it while interacting with its environment. It self-organizes based on its needs and current capabilities in order to maintain its function. 

- i.e. it adapts.

*SLIDE*

Complex Adaptive System.

We flipping did it.  You can just use this slide as a quick reference for the traits of a complex adaptive system.  And you know, it isn’t just your client here in the middle.  

CLICK

As soon as you start interacting with someone, you’re now an influential factor in their web.  And your therapeutic alliance with that person is, itself, a complex system. Let’s not underestimate how powerful that can be.

Ugh, ok, back to our home base meme.  No wonder why this process is so challenging, especially when we feel pressure to control everything, which of course, we can’t.  Or we zoom too far in and get overwhelmed with minutia. Or zoom too far out and get overwhelmed with all of the factors that could possibly be considered in someone’s plan of care. Which is then very easy to get stuck in the Nihilist trap of “Nothing Matters”.

We are going to talk much more about relevant examples of complexity within the contexts of injuries and exercise as we go through this course. 

But now, let’s start getting into some actionable strategies for how the heck we deal with it. 

Assignment

Ok, that was definitely a jam-packed crash course on complex systems, so this first assignment is just a bit of a pulse check to see how you’re doing after that. 

Specifically, here are some things you can reflect on: 

Was it helpful to define terms like “complexity” and “systems” more explicitly like this? How did your prior understanding of those terms compare to what we talked about?

Did you find any of the concepts that we discussed to be particularly helpful? Like the idea of the “systems hierarchy” or the “web of determinants” aka “contributing factors”, or anything else?  If so, in what context(s) do you think it will be helpful?

The most common question that we get from this lesson is, "How do we apply these concepts clinically?"  We’ll be digging into that in the lessons to come, that’s essentially the crux of this course..  And then we’ll check in during future reflections on how your understanding and comfort level with managing complexity is evolving. But, right now, we're going to be mean (😂 ) and flip this question back to you - How would you apply these concepts clinically?  Think back to your answer to #2, above.  If there were certain parts of this lesson that you found helpful, how could you apply those in clinic, right now? You can think big picture or narrow, zoom in or out as far as you'd like.  It could pertain to exercise selection, communication, clinical decision-making, etc. There's no wrong answer here because just the act of brainstorming the practical takeaways will really help bring the clinical relevance to light.

And then, just as a general reflection, what’s your relationship with complexity? Do y’all vibe or does it give you the scaries? Is it something that you’ve struggled with in practice? Or maybe something that you’ve actually gotten more comfortable and confident with over time? If possible, maybe provide a specific clinical example of how this has played out. 

And a little fun thought experiment you can do - Can you identify any complex systems that you interact with just in every day life?  I guarantee they’re there whether you’ve thought about it in that way or not. If you think of something, throw it in your reflection as well. As that will be a good starting point in becoming a Systems Thinker, which we’ll be detailing that in a coming lesson.

So, chew on those questions, and when you’re ready to share, click the link in the caption here, and I’ll look forward to some great discussion. 

Become a Systems Thinker

We’ll start with areas of friction that a couple of YOU shared with us. Maybe they hit home for a lot of you.

I struggle most dealing with the balance of complexity versus simplicity. 

I’m having difficulty in putting together the skills and knowledge I have learned from different courses/workshops.

I have something that will help.

In an effort to learn to manage the complex process of exercise prescription and seeing our person through that journey, we want to start to become a “Systems Thinker”.

Now, we learned about systems in the last lesson, but what does it mean to “think in systems” or to be a “systems thinker”...?

FADE TO POWERPOINT

Well, being a systems thinker is to also be a relational thinker.  

Just from what we learned, about the definition and characteristics of complex systems, you’re going to start seeing complex systems everywhere, because they are everywhere. And it’s going to make you start thinking differently about phenomena in the world.

CLICK

From climate and weather patterns 

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to cities and traffic 

CLICK

to animal and insect kingdoms 

CLICK

to economics and commodities like oil and gasoline consumption. And pretty much any other system involving humans. COVID is probably about as clear an example of complexity on the grandest of scales for humankind.   

CLICK

And, as we mentioned, the therapeutic relationship between you and your client.  A systems thinker considers the possible interactions between individual factors that could influence the behavior of the system, in examples like these.  Or at the very least, a systems thinker understands that there are probably multiple factors at play. 

SLIDE

Remember that “web of determinants” or “web of factors” that we saw earlier, and how each potential contributing factor to injury or adaptation interacted with each other to influence the system’s behavoir? And the behavior of the system can even feedback to affect the interaction between parts?  

To illustrate that, think about strength as one of these determinants or potential contributing factors, to an event - an injury or adaptation for example.  We think oh, strength will interact with other factors in a positive, protective way for the athlete. That adaptation will allow the system’s behavior to be sustainable, preparing them for the rigors of sport. Except, now the athlete is able to subject their system to higher forces and stress on a more regular basis, which feedsback into how these factors interact, potentially affecting recovery and thus the way you program.

CLICK

Or think about our traffic example.  All the lanes are moving slow, but you see an exit coming up.  You think of the brilliant idea of getting off the exit but then getting right back on the onramp, in order to bypass a big chunk of traffic.  You’re thinking you’re the only genius who could have possibly thought of that. And of course, you’re not, and by the time you get off the exit it’s jammed up to, and at best, you saved no time. Nothing in a complex system works in a vacuum, there’s often multiple actors, and everything feedsback into the system. 

I’ll say it again, to think in systems is to adopt a relational view. That is, to look at any event or entity in terms of, not just itself, but also of the circumstances surrounding it and of its relation to other factors.

Learning to adopt this kind of thinking leads to asking better questions, more effectively identifying problems, improved decision making, and better processes. 

CLICK

Let’s revisit this excerpt.  “It is increasingly emphasised that people are complex biological adaptive systems that do not behave in a linear fashion.”  

Ok, I think we have that part now. We covered that ad nauseum in the last lesson. But then, it reads:

CLICK

“Effective healthcare must be grounded in a non-reductionist paradigm focused on understanding relationships”

“A non-reductionist paradigm focused on understanding relationships”.  Ok, let’s dig into that, that sounds fun.

SLIDE

Imagine you’re at a scientific conference where a scientist gets up and talks about their favorite molecule and why it’s the best.  

CLICK

Remember, our systems hierarchy.  So, at this conference, we’re kind of living here.   Then, another scientist gets up and talks about their favorite molecule. Then another scientist does the same, on and on.  All having spent decades researching that very specific molecule in a very specific environment.

SLIDE

But then, we scale the hierarchy a little, and consider the mapping of an entire individual cell.    Each small colorful shape is a different molecule.  So, maybe scientist A’s favorite molecule was the green one, and scientist B’s was the purple one, and scientist C’s was the yellow. So, then does the framing of each scientist’s “favorite molecule” change a bit when looked through the lens of this entire cellular ecosystem?  How’s that for complexity?  And that’s just one cell. Now, in this example, this is NOT to say that the research on each individual molecule wasn’t important.  And, in general, it is absolutely beneficial to hone in on component parts (aka reductionism). Many scientific breakthroughs were had through reductionism - such as the relationship between smoking and lung cancer.  But considering what we learned about complex systems - that interactions between parts can create emergent phenomenon, 

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STAYING in your reductionist silo, without considering how the parts interact within the whole or within the systems hierarchy, can limit your understanding of the system. This can create blind spots. Blind spots in your exercise prescription, but also just how you’re managing someone’s care as a whole.

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Now imagine you’re at a PT conference or an athletic training conference or S&C conference, something like that.  

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Someone gets on stage and shows their favorite exercise for knee pain, then someone else has their favorite exercise, then another.  

As your favorite PTs are telling you their favorite exercises, someone stuck in linear, reductionist thinking will just try to memorize the exercises, to which you might as well flip a coin as to who’s favorite exercise to choose. 

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 A Systems Thinker will consider things from a relational persprective, like this systems hierarchy here pertaining to exercise - which will lead to useful questions . Why that exercise?  Would that be your choice in scenario A versus that scenario B?  Are we thinking about this exercise from a specific tissue perspective or from a task/skill perspective and how does that relate to the person’s overall goals and plan of care?  What’s a step below and a step above if we needed to regress or progress? Remember, a systems thinker is a relational thinker. Now, we’ll revisit each of those questions with more actionable context in the future. But right now, we’re just focused on the idea of generating questions in the first place. 

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I want to reiterate that reductionism, or concentrating on parts of the whole is not bad.  It is often necessary.  It shouldn’t be thought of as a competing or inferior strategy for knowledge acquisition, but as a complementary strategy to considering the system as a whole.  

Again, the problems arise when we get stuck in a reductionist silo, fixated on a certain level of the systems hierarchy without considering how it interacts within the whole.

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A systems thinker can zoom in to one aspect of the plan of care, but is also able to

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zoom back out to see how that part interacts with the whole. In other words, you’re able to practice reductionism when it’s necessary or useful to do so, but you’re able to zoom back out

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as to not miss the forest through the trees, so to speak.

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Or to understand that what you have in front of you is a whole ass elephant, and not just a bunch of parts. Or a fan, or wall, or rope, or tree, or a snake, or a spear.

Or in our case, a whole as human with a whole ass exercise program.

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Now, as we come back to this, “effective healthcare . . . must be grounded in a non-reductionist paradigm focused on understanding relationships”, hopefully you have a little better grasp on what that means.  But let’s keep building.  See you in the next lesson. 

Principles & Methods

Some more pain points from a couple of you, that I bet are relatable to others.  

I struggle to unify methods and ideas across clinical care and performance training, in a way that allows me to rely on principles first.

I struggle to turn my knowledge of the “gray” in our field into concrete, tangible, principles I can feel confident in applying to patient care.

Hmmm…. Principles you say.  Struggling to filter all the knowledge you’re getting from various sources into actionable concepts. 

Ohhh you are in luck…

FADE INTO POWERPOINT

So, when we think back to that imaginary conference that we were at, and started digging deeper and asking more questions about why people were choosing different exercises and how that fit into the overall plan.

What is it that we actually doing there? What is it that we’re trying to uncover?

Well, I’ll take you back to his quote by the engineer Harrington Emerson from Foundations 1 (which I mistakenly attributed to Ralph Waldo Emerson [oops]).  Pause the video and give this a read and really think about this.   

*read quote*

A similar idea is shared in the old adage that methods are many, but principles are few. Methods always change. Principles never do. 

So, what are we trying to uncover at the conference when we’re asking questions? We’re trying to understand the principles that led the person to their decision. 

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We all have lots of facts in our head, X’s and O’s about various treatment techniques and approaches, even if they are kind of fragmented bits of information.   Pieces of a bigger puzzle that we’ve just accumulated over time.

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Think of principles as the fundamental pieces of knowledge that help connect those bits of information that you have on a topic. 

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Principles create the mental support structure for your overall understanding. Methods are how we carry out that understanding to achieve some end. Methods are what we actually do.  They are how we put the principles into action. 

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This brings us to the proverbial toolbox. We’ve all heard about this toolbox. We’ve probably been told at some point, to build our own toolbox and that this technique or this treatment strategy is “just another tool in the toolbox”.  But what they’re really saying, is, here’s another possible method that you can implement.  So then, what’s actually the most important tool in this scenario?  

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It’s the brain of the person who owns the toolbox.   Because what good is a random assortment of a bunch of tools or “methods” if you don’t understand what they do, when to use them, which tools do similar jobs, the pros and cons of using one over another in a specific instance, and even when it doesn’t matter which tool you use at all?

A skilled clinician or coach, a system’s thinker, has their box of tools, or their methods, 

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but also has an understanding of when to use certain tools based on the underlying principles they feel are important.

If we can identify underlying principles of a topic, we may find that we have lots of methods to carry those principles out and achieve a similar end.  Or maybe methods are few as well, but we were able to come to that conclusion by thinking about principles first.

Now, applying this back to exercise prescription….

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I introduced you to a slide like this in Foundations 1, and probably disappointed you when I said that these were great examples of things that we were not going to discuss.  And now the difference is, that at some point in this course, we will go into the weeds to various degrees for these things.

But right now, we’re going to have fun with a little Brain Gainz exercise, and that is the practice of trying to identify underlying principles when claims or assumptions are made.  Or, what we’ll affectionately call, 

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“Digging For First Principles

So, what I have on the slide here are what I would categorize as methods.  How do we make that distinction between something being a “method” or a “principle”?

Well, you can ask yourself, are these things “why” I’m doing something, or “how” I’m doing something.  And if it’s “how” you’re doing something, it’s probably more of a method. 

And, when looking at these things, if one could come up with “what” and “why” follow up questions and/or you have to make assumptions about particular claims that you’re not sure are correct, then there is probably room to dig deeper for underlying principles.  

And when we do that, it’s often useful to strive to dig all the way to “First Principles”.

Think of a first principle as a fundamental truth that kind of stands alone. We can’t deduce the claim or assumption down any more.  What are we sure that we know?

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Or as Aristotle defined First Principles, “the first basis from which a thing is known.” First principles are the building blocks from which to layer more knowledge on top of. 

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An analogy that might be helpful here is that of sports strategy.  Think of the rules of the game as the first principles.  They govern what you can and can’t do. But everything else is possible as long as it’s not against the rules.  

So, when we’re digging for First Principles, we’re trying to figure out, the “rules of the game” so to speak.

Now in some of the hard sciences these things can be a little more clearly defined, 

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Like the the physical laws of nature, and things like that.

But we don’t have to be physicists for this to be a useful exercise and habit for us.  Attempting to dig and reason from First Principles is a way to reverse engineer problems or questions to come up with answers or better questions. It helps remove assumptions.  It’s also a great skill to hone in becoming a Systems Thinker. 

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Ok, let’s try to do this together 

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 And we’ll use the Blood Flow Restriction claim here.

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And this is kind of short hand, but let’s read this claim as, resistance training with Blood flow restriction is more effective for muscle hypertrophy than low load resistance training without BFR.  

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And let’s say that someone made this claim because they read a study, like this one, and it showed that, in fact, low load resistance training with blood flow restriction produced more muscle hypertrophy than low load resistance training without blood flow restriction.  Now, if this finding was ubiquitous or consistent no matter what, across the literature, that resistance training with BFR always produced greater hypertrophy than resistance training without BFR, well then BFR is pretty much the principle. Or whatever mechanism at which BFR works, if those hypertrophy gains are unable to be replicated in any other way without BFR, then that’s it.  No need to try to dig further, just do BFR with your resistance training, if you want to maximize muscle hypertrophy. 

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Now, to look for counter evidence and to attempt to find some explanatory principles, you might ask, is there evidence in which BFR resistance training did not produce superior hypertrophy than non-BFR resistance training. 

So, you dig.   And the answer, is, yes, in fact this evidence does exist.  

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These are all papers comparing groups using low-load resistance training with BFR to groups who used low load resistance training without BFR, and all found both groups yielded the same level of hypertrophy gains.  

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So, you’re like damn, did I read the first paper wrong that showed low load resistance training with BFR was superior?  And nope, you read it correctly the first time.  

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And then you find a bunch of other papers supporting that finding as well - that low load resistance training with BFR produced superior hypertrophy gains than low load resistance training without BFR.  

So, what the heck?  A pile of evidence on the left showing BFR produces better hypertrophy and a pile of evidence on the right showing it’s no better.  

So, you think to yourself, are there any key differences in how they administered the exercise intervention, between the papers here on the left and the papers on the right?

And the answer is yes, there was.

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In the papers on the left, that showed LLBFR-RT was superior to LL-RT without BFR, the groups were “work-matched”.   Meaning both groups would do the same rep schemes, volume of exercise, and external load.  And those external loads were anywhere between 20-60% of 1RM.  And for one of the groups, they slapped on BFR.  So, you can imagine that the group without BFR, working at a pretty low % of 1RM, was likely pretty far from complete muscular fatigue.  

So you wonder to yourself, if they set up the exercise parameter differently in the papers here on the right that had shown no difference in hypertrophy between groups.

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And sure enough, the titles of a lot of these papers on the right even clue you in on that. 

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These groups were “Effort-Matched”.  Meaning, all groups were taken to momentary muscular failure for all sets.  Now, in order for all groups to get to muscular failure, the non-BFR group had to do more volume, but when the groups were effort-matched, these studies showed equal hypertrophy gains.

Wow, so when not controlling for a certain variable, in this case, intensity of effort, you see one effect and when controlling for that variable you see a different effect.  

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Sounds like you might have just dug yourself up an important principle.  

But you’re like one last thing, does this whole effort-matched thing hold up in the non-BFR resistance training literature as well?  

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And by-golly it surely does.  Even when comparing low load resistance training to high load resistance training - when intensity of effort is matched between groups, meaning all groups are training to the same degree of proximity to muscular failure, hypertrophy gains, specifically, are pretty much equal.

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So, back to our toolbox. If you wanted to program for muscle hypertrophy, 

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you could use BFR.  But we saw, that you don’t have to

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And as long as youre within a sufficient intensity of effort, you have a lot of flexibility to use 

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Different rep schemes

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Different loads

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Different set and rep scheme techniques. 

The methods are many.

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But again, an overarching principle seems to be that you just need to train at a sufficient intensity of effort to achieve hypertrophy gains.  Now, of course, context matters in terms of what method you choose; so, when would you pull a tool or method like BFR out, well maybe your person is post-op and can’t really handle much external load at all, and/or the amount of volume they’d need to do with a super low load to get a hypertrophy stimulus is annoyingly high, so BFR, allows you to get to that sufficient intensity of effort within the set faster.  That’s just one scenario, but it’s an example of principle-based reasoning in choosing your methods. 

Now, if you’re freaking out a little bit thinking that this is the BFR lecture of Foundations 2 or the hypertrophy lecture or the autoregulation lecture and you don’t know what APRE or DAPRE or cluster sets are - this is not those lectures.  Those lectures are coming and we will go over all of these things in great detail.    

All we just did was use BFR and hypertrophy as a real life example of how uncovering principles can lead you to many methods to carry out a goal.  And if you understood that, you’re right where we want you to be.  Now, obviously all of the hypertrophy stuff that we just went over is useful to know clinically, but don’t sweat the details yet. 

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So, going back to this now, I hope you have a little better understanding of how to distinguish between principles and methods, and how you could potentially dig into each one of these examples, like we did with the Blood Flow Restriction one. 

Like the quote Best Cue for squat technique.  You could memorize the same “go-to” cues for coaching a squat, or you could ask yourself what behavior you’re trying to elicit from the system and choose your cueing strategy that way, which might still be a verbal cue or it might be a different way to set up the exercise entirely. The context will matter of course. 

Or this one down here, “The 15 Best Exercises for…Knee Pain” or whatever, that you’d see posted on social media.

We could memorize someone else’s list of the 15 best exercises for… knee pain, or we could ask ourselves why we selected a certain exercise in the first place. Now, memorizing the “15 best exercise list” might get you really good results a lot of the time, especially when you're just starting out. 

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It’s akin to memorizing the recipe when first learning to cook something new.

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Or memorizing the plays from someone else’s playbook to coach your own team. You’ll probably have success a lot of the time. And there’s nothing inherently “bad” per se, with the “memorizing the recipe” approach.  

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But what happens when things don't quite turn out? When the unexpected happens, even though you followed the recipe to a T? Where do you go from there? 

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Or when the playbook stops working. Do you know how to adjust?  

Or heck, what happens if you just accidentally lose the recipe or playbook.

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The skilled chef understands how those ingredients interact on a more fundamental level. The chef understands the principles behind the recipe. So, then, they can troubleshoot, adjust, and make more informed decisions going forward. 

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The skilled coach, same thing.  They know the rules of the game, or the “first principles” inside and out, which allows them the understanding to adjust strategy when things don’t work.

In both cases, the skilled practitioner is anchored to principles.

And, of course, things don’t always go according to plan for us with our people either.  So, what do we do when the 15 best exercises for knee pain that we memorized don’t quite work in a certain scenario?

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Well, we make memes of course. 

Read this one, this is a good one.  And feel yourself becoming the omniscient being at the bottom.

So, instead of only memorizing the ingredient list, so to speak, a principles-based, systems thinker goes deeper.  In our list of the 15 best exercises for knee pain posted by our favorite Insta PT - What are the common underlying principles among each of these ‘methods’?  

What you might find is that at a certain level, distinguishing between best, better, and good as far as exercise selection goes might be tough to do, and you might have several options that will tick off the same box. 

But, because you’ve started to identify the underlying commonalities and principles of these viable choices, you’re also able to identify methods that seem too far a field from the first principles that you think are important. 

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For example, if at that PT conference, someone states that their favorite exercise for the knee is

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the seated arm bike - you might be like 

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wait a minute.. Arm bike for the knee?  

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And you go through some of the first principles you think are important - um, that doesn’t put mechanical load through the knee joint or surrounding muscles, that doesn’t require access to full, active range of motion of the knee, etc.  Now, I know that example is beyond obvious, but it illustrates the process.  Often, it’s darn near impossible to determine the “best” option, but if you do your best to drill down to first principles, it at least becomes easier to trim away the less useful options. 

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In this case, it’s addition by subtraction, in terms of considering potential exercise options. This is part of “managing complexity”.  This is principles-based “systems thinking”.

The bottom line is that if we never learn to or are not confident enough to dig deeper, to challenge an idea, to test its assumptions, and then build it back up within our own mental structure, we end up feeling a bit lost with our own practice. Basically just doing what others tell us is the “right” way.  And it is our sincere hope that this course and the CALU Community as a whole will help you develop your own unique thoughts and voice in this space. 

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Now, a really important point.  Remember in the last lesson on Systems Thinking when we talked about how reductionism was not bad, that it’s actually necessary, and that reductionism and zooming out to consider more layers of the system are “complementary” rather than competing concepts.

The same thing applies here when discussion principles and methods. We need both principles AND methods. 

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They are complementary.  We need both the “why” and the “how”.  After all, we have to actually do something with our people. Without methods, we’re just floating in the ether philosophizing about abstract concepts. 

It’s easy to get lost floating in the clouds of the theoretical.  We got that person in front of us, and eventually we need to make a decision and do something.  The principles are the foundation which help guide our decisions, and the methods are how we carry them out.  Both are important. 

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Lastly, whether you realized it or not, you just totally developed a life Hack.

Any time you want to learn about a new topic and you feel overwhelmed with how many “facts” you have to memorize or papers you have to read.  Try to uncover underlying themes and search for first principles.  Think about our Blood Flow Restriction example.  Just from having an understanding the difference between work-matched and effort-matched groups, and the importance of intensity of effort for hypertrophy, you have just greatly enhanced your fundamental understanding of that topic and have significantly added to your mental support structure.  Now, if you see a new BFR paper, you can skim the abstract and have a better idea of how that paper relates to your current understanding of the topic, and whether or not it would be useful to dig into the full paper. 

This is also a super useful practice, if you’re ever trying to understand something in a totally different field, and are, again overwhelmed with the amount of ‘facts’ you’d have to memorize to get a handle on it.  Well, don’t try to do that. Instead, try to find 3-5 first principles that lace all of those facts together and internalize those. That will allow you to have a much easier time understanding where the methods and facts fit.

Ok, you made it.  Brick by brick, let’s keep building. 

Assignment

Ok, for your next Foundations 2 Brain Gainz exercise - you are going to replicate what we did with the blood flow restriction example.  This is more practice with the process of drilling down to first principles.

Here are a few ideas to help you get started:

You can choose an overal topic or method that you’re interested in within the realm of exercise prescription, like we did with blood flow restriction, and find a claim that’s made about it. You could still choose blood flow restriction, there’s many more claims made about it then just hypertrophy.  And if you can’t think of a topic, you can reverse the order and scroll social media for 2 minutes, and you’ll probably find people making claims about certain exercise strategies or modalities or whatever. So, whatever the claim is about, that can be your topic of choice.  You can also try to find a “15 best exercises for X” as your example.  And whatever X is, would be your overall topic and the 15 best exercises would be the claim.

Then, you you can start asking questions:

What would be required for the claims to be true?  Or what would you want or need to know, to accept that claims as true? 

Remember our anchoring question for First principles - “What are we sure that we know” about that topic and how does it compare to the claim that’s made?  Digging for the answers to those questions will likely lead you to some important principles on the topic.  

I’m also going to share 2 specific strategies for asking questions that might help you attack this.  One of them is the “5 Why’s” aka the “Because I said so” strategy:

But imagine a little kid, asking “why do we have to do this” and you answer “because blah blah blah” and the kid says, well why, why, why, why, and then finally you yell, “Because I said so”.

Except we won’t yell that, bcause the why questions are helping us dig for principles. So, if you get stuck, just keep asking why until it’s really hard to go into another layer of why, and you’re probably really close to first principles. 

And then the other questioning strategy is the Socratic method.  Of course, Socrates was all about drilling down to find people’s fundamental understanding of topics.  So much so, that he was killed for it.   Hahah Don’t worry….

But the Socratic Method of questioning might help you direct your thought process.  I’m going to put details in the caption of this post, so you can digest it more, but essentially this Socratic questioning will help you, clarify your current thoughts on a topic, probe for assumptions, reasons, and evidence for your thoughts, question viewpoints and look for alternative explanations, and so on.  

Again, these are just different suggestions to help you go about it, but this is YOUR Brain Gainz exercise.  You go about it however you feel you will get the most out of it, but I think you have enough here to at least give you some direction.

And then, when you’re ready to share your experience, we’d love to hear about:

What was your topic or method?

What was the claim that made about it?

Is this a topic that you had some knowledge on, or were you starting pretty fresh on it?

What types of questions did you ask to dig further?

What resources did you use to answer these questions?

What kind of road blocks did you hit and how did you navigate them?

What principles did you discover about the topic that either support or refute the claim that was made?

Do you feel like your understanding of the topic has grown from this Brain Gainz exercise compared to before?

Ok, all of this is below, including the link where you can post your thoughts, questions, reflections, all of that.  I know there’s some absolutely fire in there.  Let’s get it

Theories & Models

Let’s start with some more pain points that a couple of you expressed.  

I struggle with implementing the different schools of thought and application of different theories in a clinical scenario.

I find it challenging to synthesize all the different perspectives on treatment which impacts my decisions in the moment and leads to freezing and defaulting to basic options (aka the dreaded clamshell).

So, in our last Brain Gainz exercise, we worked on dissecting claims that we might see about exercise prescription, digging for principles and separating principles from methods.   But what about entire schools of thought, or all the trademarked ‘systems’ that are out there - that make multiple claims on how to go about exercise prescription.  Some overlap, some contradict each other.  So, how do you know what system or school of thought would be better to adopt over another?

Well let’s dig into that right now.

Back to our home base meme.  Maybe you’re still this person on the left, but we’re kind of getting there!

*SLIDE* 

Let’s huddle up a little and summarize what we’ve done up to this point.  We’ve added some important concepts to our arsenal - we want to try to become a system’s thinker, and we want to consider underlying first principles that we can layer methods on top of.  But this is all still a lot to think about, and like we just mentioned, there’s so many schools of thought out there on exercise prescription, so how do we organize all of this information into something actionable.  

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Well let’s take a look at how this is often done in science.

They observe, they collect data, they make hypotheses, they test them, they collect more data that helps to form and test more hypotheses, on and on and on.  And at various points during this process, a theory might develop. 

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A theory is a body of knowlege that explains a phenomenon. Could be pain, how injuries happen, muscle function, the economy.  And, obviously, this theoretical knowledge can vary in terms of its robustness, or the quality of evidence that it’s built upon.  We could look at the underpinnings of the theory that explains the phenomenon of gravity, compared to, say, the theory of 

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intervening on vertebral subluxations with spinal manipulation to cure medical diseases. One has pretty robust theoretical underpinnings (gravity), one not so much.  

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Now, often, during the process of theory formation, various models are developed to represent some aspect of the theory or target system, in whatever way is most useful. 

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So like this visual representation, or model, of the way gravity warps space-time, which is a very complex, mind-numbing concept that we won’t go any deeper into. But this visual model is depicting the fact that a more massive object warps space time more and creates a stronger gravitational pull than a less massive object.  So this visual model helps us better conceptualize this particular aspect of gravitational theory. 

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It also adds to our own ‘mental model’ of the phenomenon.  A mental model is how you represent and organize information in your own head.  Your ‘mind map’ so-to-speak.

Now, a visual model or representation of something, like this one, is a concept that’s probably pretty intuitive to grasp, or if we can imagine a model airplane - well that’s certainly something that represents something else. And maybe you grew up making things out of leggos, and that’s what you think of when you hear the term ‘model’.    But there are all sorts of different kinds of models that are relevant in our field. 

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One type that we won’t talk much about in this course, probably to your relief, but that exist in plentidude are statistical models.  Now this example, a linear model does have a particularly lucid visual component, which helps us conceptualize things - in this case, could be the strength of the association between two variables.  But a statistical model’s job is to process data and information in certain ways.  

What we’re probably more familiar with are that of “conceptual models”.  And we’ve actually already seen a couple of examples of these.  

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Our web of determinants 

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and our systems hierarchy.  

We’ll call these as ‘conceptual’ models because they are trying to illustrate general concepts based on an existing understanding or hypotheses of a particular topic. 

These two in particular, the systems hierarchy and the web of determinants, don’t necessarily answer specific questions, but they might help generate questions and serve as a basis for future research initiatives.  And they can certainly add to our understanding and mental models or represenations of, in this case, complex systems interacting factors, etc. 

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Now here’s little summary slide or model for you with terms and definitions of a hypothesis, model, and theory. You can just use this as a quick reference.  Don’t be too concerned with the order or the direction of the arrow. In reality, this is all circular - we have a certain level of understanding of a phenomenon, we make hypotheses and predictions, we use models to help test those hypotheses and represent the theory, we gain more knowledge and update the theory that leads to updated models and more hypotheses, on and on.  

This slide is mostly so that when you’re around a group of friends, and you’re talking about something, and one of your friends says, “I have a theory about that” - you can passive aggressively interject and say, “Um, you mean you have a hypothesis”.     Aaaanndddd then you don’t have any friends. 

Ok, moving on…

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So, what about this?

You’re probably somewhat familiar with this conceptual model.

The BioPyschoSocial Model of Pain. 

Think of all of the factors that could go into the phenomenon of pain or the thing in itself. All of the information that could make up the theory of pain.  Well we’re relatively confident that there are biological, psychological, and sociological factors that contribute.  So, what do we do to help “shape” this theory a bit? 

We create a conceptual model, which is a representation of some aspect of a system, that helps us organize our thoughts, or our mental models (aka our mind maps), around the topic, to ask better questions, drive useful research initiatives, direct better clinical care.  

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And speaking of maps, we use models all the time in our day to day life. These are two maps or models of the earth on the left. If I want to know the location of the countries of the world, I wouldn't go into a literal hundred million foot view and look at the whole earth, the thing in itself. I'd probably just look at this model here on the top left. But if I wanted to know streets in my local area, then the model on the top left would no longer be useful. 

And I'd probably look for a model like the one on the bottom left here. And what else is interesting about these two models on the left is that they're representing the world in a flat two dimensional space. So they are “wrong” in a sense. They purposefully leave out certain aspects of reality.  But if I need to know the best route to drive through the awful traffic in la, this two dimensional representation of the world does the job. So we use models that are limited or “wrong” all the time, depending on what we need.

*SLIDE* 

And this is all why the statistician George Box said this famous quote that you might have heard.  All models are wrong, but some are useful. The fact that a model is not a perfect representation of reality is a feature, not a bug; and it’s on us to determine if it’s leaving in or out the right information to be useful. 

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A mental shortcut that can help you make sense of all of this is thinking about it in

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 “Small Worlds” and “Large Worlds”.   In the Large World or the real thing or real world, the phenomenon itself, things are difficult to measure or predict, cause and effect is more unclear and uncertainty reigns supreme. 

So, we use “small world” models to try and make sense of things.  To attempt to manage the uncertainty, to try and calculate things like risk, make predictions, trying to better highlight cause and effect

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We’ve already seen many examples of these small worlds or these ‘small world models’

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  = 

We just used two of them to understand the countries of the world and also the streets of a city. 

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We saw a “small world” model to represent gravity

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Our small-world model of injury & adaptation with the web of determinants

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And a “small world” model to try to make sense of the phenomenon of pain.  

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These “small worlds” serve as intermediaries between the theory and the large world. 

But of course, this is reductionism. Based on how we defined reductionism in our systems thinking lesson, that is what we’re doing when we use small world models to represent phenomena.  Understanding and measuring the small worlds does not necessarily explain the uncertainties of the large worlds.   

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Let’s illustrate this with the BPS model of pain.  A useful Brain Gainz exercise for us is to consider a conceptual model like this, and brainstorm limitations, or where it’s “wrong”.  Except it’s not to do so in a negative way, because remember, limitations are inherent in models, because after all, they are just models.  But trying to identify as many limitations as we can has many benefits - for example, it keeps us from putting any model on a pedestal beyond reproach, and it helps us explore our own understanding of both the model itself and topic as a whole. After all, it would be difficult to identify limitations of a model, if you don’t have a great understanding of what the model is supposed to be representing in the first place.  

Every model also comes with a set of assumptions about reality.  As in, the model sets “boundaries” as kind of a starting point to jump off from.  It’s on us to both identify the assumptions and boundaries and decide if we accept them, in order to deem the model useful. 

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As a quick example, we go back to our street map.  This model assumes the earth resides in a 2-dimensional space.  But because that assumption doesn’t affect its usefulness if I just want to know the best streets to get from point A to point B, I accept those assumptions, and I use the model.  

So, let’s add identifying ‘assumptions’ to our little exercise here.  When we see a model, we’ll try to identify both its limitations and its assumptions.  This is going to help us solidify our understanding of a topic and uncover blind spots.

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Ok - so, looking at this biopsychosocial model, let’s just brainstorm some possible assumptions, boundaries, limitations:

• Assumes equal contribution between biological, psychological, and sociological factors

• Due to the structure of this diagram, it assumes there are factors that are bio or psycho or soc independent, or that two factors are involved and not all 3. 

• Assumes “B-P-S” encompasses all relevant factors

• Does not tell us how to specifically assess each component

• Does not tell us how to intervene on each component. 

And for those last two, assessing and intervening, we’d need separate models for those. A multi-model model of addressing pain, if you will

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So, let’s apply this to exercise prescription

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And we’ll start by defining exercise prescription as applying a stressor to a complex system in order to elicit a reaction from that system, and hopefully then subsequent desired adaptation. I say hopefully because we can really just try to nudge the system in the direction that we want. And because this is a complex process we try to create models of rehab or models of training to organize our thoughts around it. 

And there's a lot of them out there. And you've probably seen many, but here is one example.

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This is the famed Vermeil’s hierarchy of performance. Al Vermeil is a legendary S&C coach, and this is a very useful conceptual model of the training process. I use it as a part of my own mental model, my mental map, and I know others who use it.  It gives you a certain representation of what the training or rehab process would look like. It’s telling a little story of the journey which is what a model does.  

So, looking at this pyramid structure, the base or foundation of the process starts with evaluation and then you build work capacity and strength as a means to achieve a higher potential peak for something like speed.  

But of course, there's lots of questions just looking at this model.  Like, what do each of these terms actually mean? It also looks like there’s some assumptions for the correct ordering of things. Does it have to be this phase, then this phase, then this phase? Or do they blend in reality? Do I have to do all the phases for every case that I see? 

And those are just a few questions that you have probably looking at this. And this is just one model that's out there. You've probably seen others, and I bet if we asked 10 different clinicians or coaches out there about this particular model, you'd probably get 10 different opinions. 

But let’s just say we accept the assumptions and limitations that come with this, and we decide to use it as a general overview of our ExRx process. Which, in my opinion, would already leap frog you well past the general standard of care. End of rant.  

So, you decided to adopt this conceptual model of training or rehab, and let’s say now you’re kind of focused in on the strength portion, and you ask yourself - “Self, Ok..  what is strength and how do I train it?”

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Then, you remember that we did a CALU Journal Club on this paper!  

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You dig into the paper and come across their model of different “types” of strength, that’s similar to vermeil’s hierarchy, but includes more actionable details.

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They even include this sweet visual of exercise examples with respect to time and external load.  Like up top here, you have jumps that involve force production with time highly constrained, as as in, force production in short periods of time, and then down here, something like a grindy back squat, with high external load, but less of a time limitation.  And they use an example of an isometric mid thigh pull, as something that’s is high load, but could be done with a slow ramp up to a certain force level, or could be done with an emphasis on rapid force development. 

So, you’re like damn ok, this is helpful. 

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Let me update my mental model real quick.

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Which might, very crudely, look something like this.  Then, as you’re getting reps in clinical practice and working with more and more people, writing more and more programs, maybe you realize that some of these distinctions are blending together.  

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For example, maybe you find it more useful to just lump these two together in terms of how you actually program or measure strength. Because you don’t really find it useful to separate maximal dynamic strength with maximal isometric strength, and you just want to simplify a little. So, you’re further refining your own mental model of the process.

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Ok, I’m going to move this to the side, so we can see everything, but let’s summarize where this hypothetical example took us.  

You found a general conceptual model of the rehab or training process that we thought was useful. And you found a sub model for the construct of “strength” and how to think about and program for that. It even includes jumping and plyometric activities, 

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which jives quite while with Vermeil’s hierarchy.  

But you’re finding that you’re actually still having trouble with that aspect of things. Still struggling with how to progress jumping and plyometric activities.  There’s just so many different ways to classify the movements and so many different variations, you’d just like some more direction on that. Something a bit more granular. More detailed, more broken out.  So, you go digging, and you come across 

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this paper, which we also did a ClinicalAthlete Journal Club on:

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And inside of it, there’s a pretty awesome proposed progression.  Just what you are looking for to help you organize your thoughts.

You really like how they’ve sequenced the exercise progression here, and it makes sense based on the “first principles” of how you understand force and time.  You’ve got this first zone here in green of movements that can be really scaled back in terms of how much force the athlete needs to put into the ground to perform the task. During pogo jumps, for example, you can put as little or as much force into the ground as you want, or the person can tolerate. The task inherently allows for that scaling.

Then, we move up the progression towards movements that have a higher minimal requirement of force generation.  All the way up to a drop jump, where the person is stepping off a box and trying to jump off the ground as high as possible, while spending as little time on the ground as possible.  The quintessential plyometric movement, if you will. 

But you notice something interesting. You notice that they base the rate of progression off of how much the person can back squat.  As in, perform these green zone movements until the person can back squat 1x BW, then you can move up to blue, and so one.  You say, “that’s interesting, but I have some questions - why those thresholds specifically? Should an athlete never perform bounding, for example, if they don’t have a 1.5x BW back squat?  You ask, “I wonder what evidence they base that off of”.  Then, you dig into the paper and the references and you notice it’s a lot of expert opinion that recommends those back squat thresholds.  So, even though it makes some sense, you decide that the evidence to support using back squat strength as a means of deciding when someone can progress in their jump is just not strong enough as a standalone criteria.  And you’re not going to adopt that as part of your current mental model.

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So, we just kind of, do one these…..

But you still really like the sequence of exercises here though, you’ve just decided to use some other means of deciding when to progress, which is a convo for a different lesson. 

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So, you’re mental model 

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continues evolving over time based on your needs!  And you know the fun part, is that there might be someone who does feel those back squat thresholds do have enough theoretical evidence to support their use and they use back squat strength as a means of progressing their plyos.  And maybe, just maybe, both of your mental models work really well, for your purposes of prescribing exercise programs.  Perhaps that other person works with a demographic who already has back squats as an integral part of their training process, and so using that movement as a gauge of strength levels for plyos was easy to implement within their existing training framework.  

But - because both of you have done the work to develop your own mental models of the process, you can at least have a conversation and probably be able to learn from each other. And probably disagree on some things, like that particular element, but GOOD.  Those types of healthy professional dialogues are how we all move forward.

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Ok, I know that was a lot, but hopefully helpful for you in being able to filter all of the different perspectives and schools of thought about exercise prescription that you will encounter. 

So, let’s end with some really important points.  

Firstly, in the same way you might have been panicking during the principles and methods lesson thinking that was the blood flow restriction and hypertrophy lesson, maybe you were worried here that this was the plyometric lesson or something.  Now, I do encourage you to dig into those papers, they’re great and can probably give you a lot of information that you can use right now; but this was the models lesson, and those were just what we were using as examples. Don’t don’t sweat it, we’ll come back to all of that.

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Also, you probably noticed as we were going through that little Brain Gainz exercise, that it’s common to need 

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multiple models to try and make sense of a phenomenon.  And I encourage you to do so.  Be a multi-model thinker. 

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Or a “Model Pluralist”

Because remember, models are just ways to tell a story about things that we cannot fully see or comprehend. 

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We are beings subject to bounded rationality. Meaning we must constantly make decisions based on limited information.  This keyhole of perception, so to speak. And because of this, our entire understanding of the world and how we interact with it 

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is built upon models. Including the words and language that I’m using right now, to convey meaning to you; if we want to get super meta.  

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So with that, considering how all models come with limitations, how could we possibly explain the large world with a single small world?  

The small world model 

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Is not the “thing in itself”.  

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Those maps do not equal the earth

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Vermeil’s Hierarchy does not equal training or rehab 

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And the BPS model of pain is not pain itself, no matter how strongly we support that model.

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As the Anthropologist Gregory Bateson said:

“The map is not the territory, and the name is not the thing named” 

And we mustn’t become so attached to any particular model that we’re unable to update our own mental model over time.

Think on all of this a little, and then we’ll keep building.

Assignment

Ok, your next Brain Gainz exercise:

1. Find a topic relevant to rehab or performance

1. Could be pain, injury mechanisms, plyometrics, running technique, exercise progression for a body part, testing, pathological progression of tendon tissue with tendinopathy - anything you want. 

2. Then find two different conceptual models (small world models) that try to explain or make sense of your topic. 

3. Then identify limitations and assumptions of each model. This is a braindump. 

1. If you having trouble ask yourself these things:

1. What do I need to assume in order to implement this model?

2. What does this small world model assume about the large world?

3. At what point would I need to search for complementary models to supplement my understanding of the topic. That lets you know what this model doesn’t provide. 

4. Is this a “map” of a territory that even exists? (What is the theory that the model is based on?  Going back to the example of spinal manipulation to fix spinal subluxations and cure medical diseases. There’s probably a model of treatment on that, but it’s a model representing some questionable threoretical underpinnnings. 

4. Then, compare the two models you chose directly.

1. This will be another opportunity to practice digging for First principles:

1. What differences do they have? 

1. What are these differences due to? Different foundational evidence? Cultural differences (sprinting models used in different countries for example)?

2. What commonalities do they have?  

1. Continuing with the sprinting technique model for example, do both still describe ground reaction forces similarly during the acceleration phase?  Do both consider similar determinants important in max velocity running technique? (maybe they don’t).

Map, Compass, & CheckPoints

A Process

What is a Process?

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Ok, let’s huddle up again. We’ve been on quite the journey so far.  We started very broad learning about the traits of complexity and systems. Then, we started to bring in a little context, and practice a way of thinking that will serve you well for the rest of your career - in terms of being a systems-thinker and considering relationships between factors, understanding the difference between principles and methods and digging for first principles where able, and understanding that models of exercise prescription are just that - models, all coming with limitations and assumptions.

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Really, the crux of this entire course is helping you build your exercise prescription process. So, what is a process?

Put simply, your process is your mental model 

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Or mental map of exercise prescription. 

Now, as we have learned, you might use several different models for exercise prescription based on context. You might have a process for prescribing plyometric exercises specifically or returning a barbell athlete back to their sport or return to sprinting, or helping to guide a not-so-active person with chronic non-specific low back pain back to their desired activities - all in line with what we talked about before, in terms of being a multi-model thinker.  

And you’ll also have a “meta-process” kind of an overall process, where you have these big picture principles that would translate to any person in any setting, high or low level in any sport or activity, things like a “Needs Analysis”, which we’ll talk more about - but is basically a determination of what the person is going to be asking of their body with their desired activities, and then, working backwards to determine where they currently are.  Your meta-process might also include periodic re-defining and refining of the person’s goals, and of what their definition of “done” or “successful completion of rehab” actually means, which can change over the course of care. So, the guiding principle there would be, that you make sure to revisit those things with the person periodically. 

So, your overall ExRx process is how you structure the principles that are important to you that underlie the plan and that you can then plug in whatever other methods or small world models that are useful. 

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It’s your overall framework for how you conceptualize rehab and training.  Your prinicples are your anchors and your process is how you structure those principles and put them into action with various methods.

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Why Have a Process?

So, why are we harping on this idea of having a processed-based approach to ExRx?  Why have a “Process”?

Well, there are several good reasons. 

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Many of which are highlighted right here.  I know this is a long excerpt.  But it’s powerful.  

“There is no one right answer to a situation, no formula of best practices to follow in every situation, no assurance that any particular act or practice will yield the results we desire. The world we live in is a complex world; a world where each situation has its own unique qualities; a world without deterministic certainty; a world where predictions are always problematic and where our decisions are our interpretations, always clothed in ambiguity and uncertainty.”

This is why having a process is important.   And, I’d even encourage you to pause the video and re-read this, and really let it sink in.  And think about how all of this relates to your practice, and maybe some of the challenges that you face.  

And because there’s no right answer or best practice to follow in every case, because there’s no guarantee of success, because prediction is difficult, and there’s always going to be some uncertainty around our decisions, that can stir up certain challenges for the clinician in terms of their exercise prescription, many of which you told us that you were facing in clinical practice:

Randomness

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I’m struggling to provide more efficient care to my patients based on my lack of organization in my clinical thought process.

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It feels that I'm just throwing a barrage of exercises to hopefully target their impairments and their problem.

So, having a process helps with planning and reducing that feeling, and potentially the reality, that your ExRx is “random” in nature. Now, random is not the same as being general with your exercise prescription. The not-so-active person with chronic non-specific low back pain, probably doesn’t need a super specific program with sets and reps, down to a T.  And you may provide a very general program, but you made that determination through some thought process.  And that process helps you develop your “Whats” and “Whys” in terms of your prescriptions, so that your “Hows” or the methods can be implemented more efficiently and effectively. 

Confidence & Communication

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I often lack the self confidence I would like to have in order to approach patients in a way that is assuring to them AND myself. 

Having a process helps with confidence in your decisions and with your communication both with your patient and with colleauges. When your decisions are based on a line of reasoning that helped get you there, those checkpoints now become a basis for the conversation. Speaking to the client: “These are my recommendations because X,Y,Z - what do you think about that?”  You’re more comfortable discussing your rationale because you have one, and that will lead to a more constructive dialogue as a part of the informed consent process, and during your interactions within the CALU Community. You’ll get more out of those experiences because you’re able to describe your reasoning. 

Consistency

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I struggle with managing pts at grossly different levels.

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I struggle maintaining consistent principles of ExRx in a busy outpatient setting.

So, maybe you have patients dealing with similar issues, but at much different levels. Or maybe you have a mix of more straightforward and more complex cases that are difficult to manage concurrently. Maybe you feel like you’re always starting from complete scratch with every new person you see. Having a process will give you the framework that allows for more consistency with your decision-making and prescription. You’ll have those big picture principles that can be applied to anyone, that will serve as your anchors and starting point.  Which, over time, will help you develop pattern recognition. Each new case won’t feel so “new” anymore, but your principles are still there to make sure you don’t assume too many things.

Audits

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My struggle is having a wider lens, a big picture, the ‘map’. It’s too easy to get lost in the details of the territory and stop moving toward the destination.

Phew… This is fire.  And I promise these are exact quotes from you all. But read this one again, because we’re going to run with this analogy a bit. 

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So, as we said before, think of your ExRx framework as your mental map of the territory, the person’s entire journey with you.   You’ll have principles within your framework

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That will act as checkpoints.  Things that you can always come back to, to re-orient yourself and the person to the overall goals of the plan - like that needs analysis and revisiting what successful completion is going to mean.

And, the feedback from the person, their response to the program, and any new information that you get along the way 

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acts as your compass - all helping to guide you and your person along the journey.

These checkpoints and feedback loops allow us to audit ourselves and the plan, during the course of care.

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Let’s say your person has a setback. 

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They come in like this, just not a happy camper

And you’re like Oh damn, 

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Or maybe they’re not that mad, but they’re not progressing the way that was expected, 

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you can go back and audit your process, by revisiting those checkpoints - “Are we addressing the most important buckets of need for this person’s desired activity and where are we with those things, has our definition evolved of what “successful rehab or “done” means, have I touched based with other stakeholders relevant to this person and what’s the person doing outside of the clinic”.   

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So, any of that information, any new information, the feedback that you got from the person both subjectively and objectively, is just information to help you re-evaluate where things are at. 

Then, maybe after this quick process audit you have a conversation with the person and modify things a bit, or maybe you decide to stay the course a little longer - all the while using future feedback as your compass, to orient you to the person’s journey, their response, and to make sure things aren’t veering too far off track.  Being able to have those dialogues is so powerful in putting out those proverbial fires and 

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Helping the person re-engage in the plan.

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Now, I know that a “GPS” is probably a more contemporary example versus a compass, but how many times have you used a GPS to get someplace that you’ve driven to a hundred times and you still couldn’t get there without the GPS, because you just blindly follow the GPS and there’s no actual learning that occurs?  And I find that to happen sometimes in clinical practice too. We talk about “getting your reps in” in terms of how to improve your clinical practice, but you can get a lot of reps/see a lot of clients, and not necessarily learn from those experiences. Learning has to be an active process.   

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Which is why I like the compass analogy, because with a compass you tend to pay more attention to what the hell youre doing and you start to identify familiar landmarks and actually learn more about the route and territory, but… I know that’s an aside and we’re “veering too far off course now…. Ah see what I did there.  But, seriously the point here is that we want to learn from the process.  When someone has a set back, for example, as frustrating and unfortunate as that is, it’s a learning and growth opportunity for both sides. When we have to go back and revisit those checkpoints - client’s goals, buckets of need, it’s deliberate practice for you as well, as the clinician. 

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And, not only can you think of this as a way to keep things on track during someone’s plan of care, but even after it’s done to see if there were any 

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leaks in your process that could be potentially cleaned up for the next case.  You’re like, oh damn, we never really addressed this particular bucket of need, or I didn’t realize this person had a trainer outside of the clinic, and they were already doing pretty similar stuff, so our program was kind of redundant, or that person with a 5 year history of low back pain came in with a goal of wanting to be completely pain free in 6 weeks and maybe we could have done a better job of defining what successful rehab could mean with more realistic expectations.

Having a process allows for some repeatability and a more effective means of actually learning from each case. Especially, if you were to share the details of your case within the CALU+ Community, we’d get to very constructive discussion sooner because you’re able to lay out your rationale, and you’re even able to identify and describe where you thought there was room for improvement.

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Another reason to take a process-based approach, is so that we don’t get stuck in the trap of “resulting”.   The “Resulting Fallacy”, is equating the quality of the decision with the quality of the outcome. 

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Here’s a visual matrix to help to with this.  We’ve got bad-good Process and bad-good Results.  

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We all want to live here, good process, good results.  

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And not so much here, bad process, bad results.

But getting stuck in the resulting trap, is assuming that because there was a good outcome, the correct decisions must have been made.  

LIke down here, with bad process, good result.   But of course, a good outcome can happen despite poor or risky decision-making.  We might call that

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“luck”. 

And, on the flip side, the resulting trap can also trick us into thinking that because the outcome didn’t turn out well, 

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we must have made poor decisions.  Good process, bad result - except in our resulting minds, we think that because the outcome was bad, we must have made a bad decision. Which we know from the nature of complex systems, that this isn’t necessarily the case, as there are many things outside of our control.

You could do everything in your power to prepare someone for their activity and checked all the boxes, and they could still get reinjured.   

Getting stuck in the resulting trap describes our human tendency to create “too tight a relationship between the quality of the outcome and the quality of the decision”, and this can hinder our ability to learn from our clinical experiences. With a process-based approach, instead of being so attached or blinded by the outcome, we can instead look back at our process and audit ourselves, like we talked about before.  And, in your dialogues with the person, poor outcomes or setbacks can often be seen less as “failing” and more as 

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valuable information, valuable feedback that can help us with blind spots, that can help us update our strategies to get back on track.  

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So, to summarize - why have a process?  Why have a mental map of your exercise prescription reasoning? 

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To decrease the sense of randomness in our prescriptions, to have a rationale

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Which, in turn, improves our confidence & communication with sharing and discussing that rationale with clients and with colleagues

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We have a process to be able to consistently apply certain principles to all clients as a general framework, to help with organizing our thoughts and creating a starting point, no matter what type of patient you’re dealing with.

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Which allows us to go back at various times and audit things, to revisit certain checkpoints during the course of care.

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And to help us not fall into the trap of resulting too often.

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And, going back to this excerpt from earlier, all of these things, having a process, helps us both manage and communicate 

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uncertainty more effectively.  

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As we close, and as we wind down these general discussions of complexity, and start to layer in more clinical context, I find it appropriate to provide some meaning behind the term uncertainty. We talked about how the word “complexity” is often used, almost as a throw-away statement, without much discussion of what it means, which hopefully the term complexity is becoming a little more clear now.  This is a similar case with the term “uncertainty”.  It can be hard to describe what this term actually means, other than how it makes us feel. We tend to just use it when we don’t know something.  And the “knowings” is part of the story.  

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We’ll use this matrix as an aid in understanding. You’ll see different ones out there with funny little descriptors here, but, here we have the “knowns”and the “unknowns”.  

Now, medical science & sports science, rehab science is trying and will continue to try to help us improve upon that with which we know.  Or, help us understand better what we don’t know, but that can be accounted for.  So, common science practices tend to be really good in these realms up here.

Where we know all the knowns, and we can account for all of the unknowns - this is a world where we can calculate things like 

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Probability and risk.  

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Think Chess - and you don’t even have to know how to play to understand the analogy - the chess player knows the rules of the game, he can see the whole board, and knows his options if X happens - these are the known knowns.   Now, he doesn’t know what the other player will do exactly, but because he knows the rules of the game, and he sees the same board that the other player does, he knows there’s only so many options - and can be much more difinitive with calculations, predictions, and probabilities. 

But we don’t just live in the world of risk and probability, the known knowns and the known unknowns - we live in a world where there are also unknown knowns - things that we’re sure are out there, but aren’t yet at our disposal, and unknown unknowns.  Things we don’t even know about that have an effect on the system.  

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And this is the world of uncertainty.  And for those of you who appreciated differentiating the definitions of “complicated” and “complex”, will appreciate the differentiation between the terms “risk” and “uncertainty”.  Risk, being the world of “known unknowns”, where we can model the possibilities and get cleaner answers (while of course making lots of assumptions along the way) - and the more “real world” of uncertainty - the world of ‘unknown unknowns’ - where we have to make decisions without a super accurate picture of the exact probabilities and with multiple blind spots. 

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Which is much more like the real world of clinical practice. 

And because we live and work with our people in the world of uncertainty, we will likely never have full control of the outcome. There are just too many possible factors that could affect it, many of which we either can’t calculate, isolate, or don’t even know exist.  And that’s uncertainty in a nutshell. 

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BUT we do have some control of the process, which will help you manage that uncertainty. 

The more you’re able to talk through your process and with each clinical rep, 

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“skill” and “luck” start to become more easily differentiated.  You’re able to better identify a relationship 

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between process and outcome. 

So, let’s keep building towards THAT.

Loops

Ok, we start where we just left off.  We’ve hammered on the importance of having a “process” for your exercise prescription - a mental map of the journey with your person.  That journey will include certain 

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mental checkpoints for you to revisit with yourself and with your client at various points in time - these checkpoints may include 

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creating a needs analysis for the person, 

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Having an agreed upon idea of what “successful completion of care” or “done” is going to mean, 

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Having clearly defined your role.  This one sounds so obvious, yet is so commonly not explicitly addressed. What exactly is the person expecting of you?  From their perspective, what are you bringing to the table, and does that jive with what you can bring to the table, your skillset, your clinical philosophy, your expectations of care compared to the person’s expectation of care. And if there are other coaches, trainers, a program they are doing on the side - how do you fit in? These things greatly affect the strategy of your exercise prescription.  

These checkpoints may also include

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identifying limitating factors in this person’s situation, or in other words, the bottlenecks that stand between the person’s current status and successful completion of care, as well as the leverage points - or places to intervene that will provide the most bang for buck.  

These are all things we will discuss in more detail, but all things that, if maintained as anchors within your process - as in, revisiting these concepts from time to time, even like a checklist, you will have already created a very solid foundation for your exercise prescription process.  You’ll feel more confident and consistent with your prescription and less like you’re floating in the random ether, because you have those checkpoints to fall back to - to help you with your process audits. 

Now, what’s important to consider about all of these principles or checkpoints - is that they are dynamic.  The buckets of need and limiting factors for the person at one point in their plan may change over time, and we could say that for each one of these.   And, of course, we know that, and hopefully they’re different because things are changing for the better over time.

But, although we know that change is inevitable over the course of care with our people, it’s that change still trips us up sometimes - the fluctuations in status, not knowing if a certain intervention is going to have an effect - all those things.  And, even though we have these checkpoints, we can still get lost sometimes, because we’re constantly making decisions in real time, and interacting with the person. Responding to a change in their status on the fly, deciding when or how to progress, regress, or modify an exercise, trying to answer their tough questions in the moment, that we may not have great answers to. 

But we mentioned in a previous lesson,

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that we have a compass on this journey to help with this. To help keep us on track. 

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Let’s think about a compass for a second.   A compass provides feedback.  It helps to orient you.  

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Now, in order to be oriented, it really helps if you know where you’ve come from and you know where you want to go.  Think about that in relation to clinical practice, I’ll give some more specific context later, but, just ponder that notion for a second - in order to be oriented to the current situation, it helps to know where you’ve come from and where you want to go.  In other words, you consider prior information, and you consider the destination, and along with the feedback from the compass - you decide and you act.  When you make a decision and act, based on the feedback, and that action influences subsequent feedback, 

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that’s called a feedback loop, because your action will feedback to the original mechanism.   If the feedback tells you that you’re headed in the right direction, and thus, you continue in that direction based on the feedback,

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that’s called a positive feedback loop.  Now, it’s not “positive” in a moral sense of “good” or “bad”, but just that the loop encourages or amplifies more of the same behavior. This can also be referred to as a ‘reinforcing loop’. A self-reinforcing mechanism.  The compass could also be leading away from the destination, and if my goal is to get lost, or purposefully go in the wrong direction, or I just don’t know how to use a compass, I’ll keep walking in that wrong direction, the compass will keep pointing away from the destination, and that’s still a positive feedback loop, encouraging, reinforcing, or amplifying more of the same behavior. 

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To use an overly simplified exercise example 

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if someone does bicep curls at a sufficient dosage, physiology will adapt and 

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give feedback in the form of bigger gunz and increased ability to produce force, which will increase the person’s capacity to do more biceps curls and probably increase motivation as well because gun show, so then more bicep curls leads to more physiological change - and feedback in the form of bigger gunz, ability to do heavier weights, decreased perceived effort with prior weights, this leads to the person doing more curls, and so on.  

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A positive, reinforcing loop.

Now, let’s say the person got a little too excited, overdosed the bicep curls a little, 

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and now the feedback is pain, well that might now lead to a decision or temporary behavior to do less bicep curls. 

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Creating a negative feedback loop.  Again, negative is not in a moral or normative sense of ‘good’ or ‘bad’ - but rather, meaning a counteraction of change instead of an amplification. A self-correcting mechanism. Often called a ‘balancing’ feedback loop.   Then, hopefully, in the short term, less curls leads to 

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Less pain, back to a reinforcing or positive feedback loop.  Again, positive, because the feedback reinforces or amplifies the behavor and vice versa.  Now, hopefully this would just be a short-term strategy, since after all, our goal was bigger gunz, but now with less symptoms, and with some thoughtful programming, learning from the past, our feedback mechanism can be what it was originally

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more curls, leading to more hypertrophy and ability to produce force, leading to more curls and motivation, etc.  And we’re back on the Gunz Gainz Train. 

Now, don’t worry too too much about the “polarity” of the feedback loops here (which is the positive / negative / reinforcing / balancing terminology), and moreso, just understand that feedback loops are everywhere in systems.  They are the basic operating unit of a system. 

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Think back to the human body and the systems hierarchy, and think about all of the balancing and reinforcing feedback loops that must be present to maintain order and function of all of these systems. 

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Now, our bicep curl example, when looked at through a clinician’s lens, was one of a certain type of loop.  A type that I want to spend the rest of this lesson discussing with you, and something that we’ll be adding to our process from here on out.  Because what did we do here? We used feedback from the system to inform future decisions. In this case, 

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that feedback could have been tests and measures of hypertrophy and strength to ensure what we were doing was having the desired effect, perceived effort at certain weights to inform dosage, pain was a form of feedback that had a potential effect on subsequent behavior.  

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And all of this feedback is analyzed to some extent, and informs the next action or decision.

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Now, is that not a representation of the clinician client complex system?  This feedback-based decision-making loop, as we’ll call it 

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with an information flow 

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that informs future decisions & actions, 

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is the compass that we’ve been talking about.  What type of feedback and information flow goes into this loop?  Everything.  All the tests and measures, the person’s objective and subjective response to exercise, and any other new information that could inform future decisions and exercise prescription.

As we probe and explore the person’s biopsychosocial landscape with exercise strategies, the more feedback and information we’ll receive, allowing us to more accurately chart the territory and establish their current boundaries.  

As we continue to outline the exercise prescription process, you’ll become better at identifying where feedback loops and information flows occur and how to leverage them to make more informed decisions and have more constructive dialogues with your people. 

But start thinking about this now, in your current practice.  Think about how reinforcing and balancing loops play out over time with your clients.  Think about whether there’s room for improvement in terms of creating more effective information flows in order to strengthen your decision-making loop.  

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And speaking of decision-making loops - and in the CALU spirit of considering multiple models on a particular concept,

I want to introduce you to some formal decision-loop models, just to expose you to them, and I think it will help you further internalize this concept.

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PDSA plan-do-study-act:

Christoph Roser at AllAboutLean.com

I lump these two together bc they are just iterations of each other. But, here we have the Plan-Do-Check-Act or Plan-Do-Study-Act feedback-based decision loop models, the latter of which, plan-do-study-act is attributed to engineer Edward Deming, who is often considered the father of quality control. Makes sense. So, we plan based on the information that we have, carry the plan out by doing, we check or study the outcome and the feedback that we got along the way, and then we act based on this new information, 

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and the loop continues, until some end is met. You’ll see the word ‘adjust’ in place of ‘act’ sometimes as well.  Plan-Do-Check-Adjust, Plan-Do-Study-Adjust.  Same idea. 

So, again, just a visual, sort of a brain-tangible example, a mental model, of the concept of a feedback-based decision loop.  So, think about where this would be embedded throughout the exercise prescription process. Certainly in the beginning when creating an initial plan, and then pretty much constantly, to some extent, over the course of working with the person. 

Another example or mental model of a feedback-based decision loop that might resonate with you is the OODA loop.  If you’re familiar with Scot Morrison and PhysioPraxis (which you should be if you’ve gone through Foundations 1) or have taken his course Sloptimal Loading (which you should), you might be familiar with this one as well. 

The OODA loop was developed by the US fighter pilot and military strategist John Boyd.  But it has very similar tenents to the PDSA loop - we gather and filter information by observing and orienting to it, we decide on a hypothesis or action, then we carry it out.  Whatever response that action creates will create new feedback, and the loop continues

Then we have the Build, Measure, Learn loop popularized by Eric Reis in his book, The Lean Start Up.  This decision-loop model comes from the chaotic and fast moving tech world.  In this model, we build a Minimum Viable Product, which we’ll change to Minimum Viable 

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Exercise Program (more on that later), measure and gather data and information on how the person responds to it, learn from that information and iterate the program accordingly. 

And the final model I’ll show you in this realm is part of the Cynefin (Kuh-nav-en) Decision Making Framework, which is a Welsch word, meaning “Habitat” and developed by David Snowden - who’s known in the decision-theory field.  But here, we probe the system and try to make sense of and interpret the response, to formulate our own response.  Probe-Sense-Respond

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Now, please don’t stress out with trying to memorize the terms they use or anything like that. Now, I do encourage you to look at and ponder them, do a little Googling, you’ll find lots of free reading and videos on each of these decision loop models. And you may find that one just resonates with you more.  But I care less about which one you adopt, or if you adopt any of these specifically, and I care more that you see the overall similarities, the overall concepts, the overall principles of what all of these models are trying to express - which is that whatever process that they are applied to, in our case, exercise prescription is a dynamic & fluid process.  It’s an open system where we’re constantly receiving new information that we need to filter and decide what to do with, if anything.  And if we can mentally frame the constant change and flow of new information in clinical practice as simply a necessary part of the 

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Navigation system, then it’s less overwhelming and viewed as actually something that we encourage, that we need in order to help the exercise prescription journey with our people.  

So, I encourage you to try and start implementing that perspective in your practice right now.  Next time one of your people has a set back, as frustrating as that is, it could also be looked at as valuable feedback to help inform the process.  

Whooo, your foundation is getting STRONG.  Let’s keep building.

The Drift

So, we just discussed the idea of feedback-based decision loops being embedded within our exercise prescription process. 

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We take any new information presented to us - feedback from the client, objective & subjective info, and

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Use that to inform future decisions. 

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But remember what we said before, that a compass or our feedback-based decision loop is most effective when that flow of new information is considered in the context 

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Of prior information, or where we’ve been.  As well as,

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Where we want to go.

In other words, all of that feedback and new information that we’re constantly getting over the course of care, should be considered in the context of the bigger picture, in the context of prior information - what you already know about the person’s situation, what the person has done up to that point, how they’ve responded to things so far - and, the overall goals. 

So, what happens when that isn’t the case?  What would that look like?

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Where we don’t consider new information within a greater context

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And where our feedback and decision loops just aren’t utilized in a way that guides the process effectively

SLIDE - silhouette taking compass away

Because what happens when there’s a broken feedback loop? When our compass is broken or when we don’t know how to use a compass? In other words, when we don’t know how to filter or act upon the information that we’re getting. Or the information isn’t useful.

Well, from our perspective as the clinician, that might be an instance when we get those feelings of randomness and lack of direction with our ExRx.

Consider this scenario, and ask yourself if you can relate.

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Let’s say your person comes in, 

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and they’ve had a flare up, a little unexpected set back. 

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You get that panicky feeling, that feeling that you need to do something, fix something, change something, make the person happy again, and those thoughts and feelings cause you to 

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Forget where you had planned to go and the overall goals in general

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You don’t think about this set back in the context of what you had previously done or what the person had been doing outside of the clinic, 

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and so you don’t effectively communicate with this person what options there are to address this set back, as part of an informed consent process,

And you just completely change the plan as kind of a knee jerk reaction.  Actually better yet, you say, “Oh ok, well we’ll work on it, go ahead and lay on the table” - and you proceed to do an impromptu manual therapy session for the entire time. 

Now, is an entire session of manual therapy or manual therapy in general, the problem itself? Absolutely not.  The problem is not thinking a little more critically about how you got to that place - the problem is using an entire session of manual therapy or just a complete switch of the program as a panicky knee-jerk reaction to a flare up or plateau, the problem is not having a conversation with the person about what the flare up might mean in the context of the entire plan and what you have done up to that point.  The problem is not discussing viable options of how to navigate this set back and move forward, as part of the informed consent process.  All of those things represent breaks in the feedback-based decision loop. Not using your compass.  Now let’s say you get done with that entire session of manual therapy, the person feels a little better, and you say to yourself “phew, got through that session”.  

But what about the next time. It’s going to be that constant feeling of starting over. 

Effective use of our feedback-based decision loop doesn’t just mean “reacting as quickly as possible and drastically changing things” every time we get new feedback. If we get stuck in the trap of constantly changing the plan without a rational or switching to a completely manual session because someone had a flare up - pretty soon we forget where we came from.  It’s no longer a loop that feeds back into anything. You drift along this pattern, and before you know it, it’s been 6 weeks, and you couldn’t explain how the exercise plan ended up where it is, even if you wanted to.  

Personally, I’ve fallen into this trap many times in the past, ‘chasing’ symptoms for example. Switching up exercises every session because the person is not noticeably better after 48 hours or still has pain or has a minor set back. Being lured by the next shiny new exercise seen on social media, without asking why or how that would fit within our model for this person.  All the while, not really making progress in any one area, drifting along with no direction, while the person’s progress maybe stagnant or at worst, even regresses. 

Then, you feel even more pressure.  Both sides are a little frustrated. And that sense of panic just feeds that spiral and frantic search for the next quick fix. It’s a positive, reinforcing loop, but not in the direction that we want. .

Now, effective use of our feedback-based decision loop does mean we can take something like a symptom flare up and consider it as useful information, as useful feedback, 

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within the context of everything that’s been done up to that point, considering possible factors that may have contributed 

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and in the context of everything you might have had planned for the person as part of their overall goals. 

When you do that, 

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now you can have a useful dialogue with the person going over options, in light of the current situation - maybe that means not really changing anything and just proceeding with the current plan with a bit of caution, maybe it means making tweaks to the program, but maintaining your mental connection of how those modifications relate to where you’ve come and where you still want to go with the program. It’s not just a blind short-term bandaid just to get through the session so you don’t get yelled at by your client.  And you know what - one of those potential options might just be an entire session of manual therapy.  The difference is, you’ve discussed it with the person, within the context of the other options, and within the context of what you think the flare up means in the grand scheme of the plan.  Maybe you’ve discussed that the aim of that manual therapy might be to just knock down the acuteness of the symptoms, hopefully providing a nice short term reprieve for the person, but that it will still be important to maintain the overall direction and goals of the exercise program. And you do just that.  A well maintained loop, even in the face of the chaotic ups and downs of clinical practice.  After all, navigating the peaks and valleys is why you have a compass in the first place. 

“Because of the nature of the industry, we spend more time creating and fine-tuning solutions than framing and exploring problems” (quote from Houda Boulahel)

I feel like this explains a lot in terms of how we often frame our care and interventions. And related to why we put pressure on ourselves to be the “fixer”.

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And what about from the other person’s perspective? What does it look like 

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when their feedback-based decision loop is out of wack, and they’re stuck in a reinforcing loop going in the wrong direction.  

I often have clients that seem to be in a never-ending “rehab” phase.  

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Many times, they’re stuck in these all-or-nothing boom or bust cycles where they take enough time off for their ‘thing’ to calm down, hop back into hard training or full blast with their desired activity, have a setback, and take another period of time off of training. 

In the CALU Community, we’ve often called this

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 “Rehab Purgatory”, where the person comes to us just feeling stuck in this never-ending cycle. 

What’s interesting, is that in systems theory, this is actually a thing too.  

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Environmental scientist Donella Meadows called this The Drift to Low Performance in her book, Thinking in Systems that we referenced before.  

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Systems Researcher Sidney Dekker coined this as a “Drift into Failure”.  

So, we’ll call it the “Drift into Rehab Purgatory”, floating within unmanaged uncertainty, where perceived fragility and athletic mediocrity awaits. I know that’s hyperbolic, but maybe not for those who have experienced it, and if you’re one of those people, then you know.  I am. 

And the thing is, The Drift is often slow…

The person may not even realize how far their standards of performance have dropped.  

Dekker calls this decrementalism, where the person makes small concession after small concession, adding up to

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More

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And more loss in ability over time.  With my clients, I’ll often see it manifest as them trimming away components of their exercise programs that they once thrived on, but they now consider too “risky”.

*Deadlifts hurt my back, so I don’t do them anymore.*

*I loved running trails, but the downhill hurt my knees so much, I only do flat ground now, and even that is becoming an issue*

Donnella Meadows would say 

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that the person’s Plateau of Resilience is shrinking.  They have less and less room or options in which to roam around and explore their functional landscape.  Each concession shrinks the person's plateau 

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More

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And more.  until they are standing on a razor’s edge. 

And I know for the people that I work with, the feeling of FOMO and competition often exacerbates this:

“I have a meets coming up, so I need to be able to rehab while I’m peaking”

“I see everyone else training hard, and I just got tired of rehabbing and jumped back into training hard, but I got hurt again.”

Maybe these people even start increasing the use of external ‘support’:

“𝘐 𝘸𝘦𝘢𝘳 𝘢 𝘣𝘦𝘭𝘵 𝘧𝘰𝘳 𝘢𝘯𝘺𝘵𝘩𝘪𝘯𝘨 𝘢𝘣𝘰𝘷𝘦 60% now 𝘵𝘰 𝘱𝘳𝘰𝘵𝘦𝘤𝘵 𝘮𝘺 𝘣𝘢𝘤𝘬”

“𝘕𝘚𝘈𝘐𝘋𝘚 𝘸𝘦𝘳𝘦 𝘵𝘩𝘦 𝘰𝘯𝘭𝘺 𝘵𝘩𝘪𝘯𝘨 𝘵𝘩𝘢𝘵 𝘨𝘰𝘵 𝘮𝘦 𝘵𝘩𝘳𝘰𝘶𝘨𝘩 my sessions”

Donella Meadows would say these means of “support” 

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are like rigid walls surrounding the person’s shrinking plateau of resilience.  They don’t allow the plateau to expand and they’re brittle.. 

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They often crumble, causing the person to 

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shrink their plateau of resilience even more, 

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drifting further into rehab purgatory

Somewhere along the way, their compass broke or they didn’t know how to use it or they didn’t know how to adjust and act on the feedback that they were getting.

And there’s rarely a single solution to these situations and ones like them, but this is exactly why we’re here. Exactly why we’re putting in the effort to build a strong exercise prescription process 

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to help our people pull themselves out of Rehab Purgatory or avoid The Drift all together.   

Let’s keep building your process. 

Assignment

Did discussing “The Drift” hit you in the feelz a little bit?  Were you able to relate to that scenario from either the clinician or client perspective?  Maybe even both? 

We want to hear about those experiences..

Describe at least one instance when you felt like you were stuck in The Drift - a reinforcing feedback loop headed in the wrong direction..  This could be you as the clinician, struggling with a difficult case. It could be you as the patient, dealing with an injury or issue yourself. It could also be any other life scenario, in which you felt you were stuck in a reinforcing cycle that you wanted to turn around. 

What was the situation? Describe it from your perspective along with the roles of anyone else involved (to the extent that you’re comfortable sharing).

Where/how do you think the feedback loop and information flows went awry? 

What did or can you learn from that experience to improve your process in the future? 

Checkpoints Intro

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Ok, back to our homebase meme, just to be reminded of what gives us the scaries and why we’re here.  But, we’ve actually made some really good strides with this already.  

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We defined your exercise prescription process as your mental model, your mental map of the plan. 

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It’s how you guide the journey to help your people get to where they want to go.  

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We discussed Decision loops that are based on any subjective and objective feedback you get along the way, as being your compass - helping to inform and guide your next moves and your dialogues with the person, and helping us to steer clear of rehab purgatory. 

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But we also discussed having certain big-picture principles to act as checkpoints throughout the exercise prescription process - things that you can always come back to and check-in with periodically, as part of your ongoing process audit, as part of your monitoring system.  These checkpoints help to ensure that the overall vision and direction of the plan is still headed in the right direction.

These checkpoints are what we’ll be detailing in these next few lessons.  So, let’s go

Define Your Role

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As we talked about in Foundations 1, exercise planning often starts with the end in mind. What are the person's desired activities and what is their current status in terms of being able to perform those activities to the degree that they want?   

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They’re often coming to us some level removed from that end, and are looking for guidance from us to help them carve out a path to hopefully get back to the things that they wanna do.  Keeping these two bookends in mind, where are they now in relation to where they want to go, this is going to be the start of our framework and 

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we’ll just replace these bookends now with the two things that we're gonna start to talk about. And they're two of the most important things when you're working with someone because they set the tone for expectations.

The first one that we’ll discuss is “Defining Your Role” in this person’s journey. 

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This one sounds so obvious, and because of that it’s also commonly not explicitly addressed or discussed with the person.  Like, well I’m a Physical Therapist and this person is coming to see me, so my role is to provide them with Physical Therapy, silly PFFFHPFH.  But what does that mean?

Forget professional titles for a second, what exactly is the person expecting of you? From their perspective, what are you bringing to the table, and does that jive with what you can and are willing to bring to the table - your skillset, your clinical philosophy, your ethical compass, your expectations of care compared to their expectations of care. 

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First of all, are there other stakeholders involved? A stakeholder being anybody who's also invested in any way into the person’s journey or plan of care. Would exercise planning not change if they're also seeing a school athletic training staff or strength and conditioning staff, or if they have a trainer on the side or if they have parents that make them run sprints every day to keep them in shape.

Or, what if they are their own trainer - meaning, what if they’re doing some type of exercise programming on their own, already - are they going to continue that, are they looking for you to compliment that, or work around it, revamp it - any one of these things could affect how you approach the plan and your exercise prescription.

We’ll use some common scenarios as examples:

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the person might be an indefinite performance or training client post rehab, maybe this is somebody that is just gonna be your client and you're gonna program everything for them indefinitely from this point forward, that's awesome. Some of you might have clients like that now, I've had clients like that, but that's not gonna be the majority of you, or at least the majority of your clients, for many of you. Many of your clients are probably going to fall into one of the next two categories,

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which is maybe you do have the skill set, the confidence, and the bandwidth to program their entire training or exercise regimen, but there's going to be a stopping point, there's an expected endpoint.

They either expect to go back to their coach or trainer, or they expect to go back to whatever program they were on before, or just go back to living their life and doing their activities without your guidance. There's some expectation that your role with them will end.

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And then you might work with someone who has an expectation that you're gonna help them with the parts of their programming that are relevant to their current issue, but then the other stuff is still gonna be taken care of by their trainer or some other stakeholder, or themselves - maybe they want to continue doing some other type of program on the side. But again, there's some type of expectation for an end in terms of you all working together. So if you fall into one of these two categories working with these people, this comes with some other considerations. 

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It comes with hopefully communicating with any other stakeholder, because if there's some expected end, then that other stakeholder should be made aware of what that end is, if at all possible. Updates of how close you are to that end. And especially if you're going to be tag-teaming the program in any way, you have to talk about who's taking what and to make sure that those things jive with each other and that they're not confusing for the client.  

So, imagine a case where you’re working with a runner who’s dealing with achilles tendinopathy and this person just wants us to help them get back to running and is open to any recommendations on all modes of training.  So, the person is just like, I don't know what this is going to entail, but I just want you to help me get back to running.  And let’s say they are also completely open to you making recommendations on running dosage, they’ll pull back as much as you recommend.  So, think about how your exercise prescription or recommendations might be in that scenario versus that same person with achilles tendinopathy, but they have a running coach.  And their idea of physical therapy is that you’re going to give them certain exercises and also provide recommendations that they can take to their running coach in terms of milage and running frequency.

So now you have somebody else in the mix that you might have to take into account with your programming to not be redundant with what their other coach or stakeholder is giving them. And to potentially open a dialogue so that the client isn’t hearing contrasting voices. 

Or imagine another scenario in which you have a collegiate lacrosse player that you’re helping to rehab after shoulder surgery.  Their season starts in 3 months.  Imagine how your approach and exercise prescription might differ if you have the entire 3 months with the athlete, versus 6 weeks and then they are going to go back and work with the athletic training staff at the school. 

Because, what we’re trying to avoid, 

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but what often happens is we get stuck in these silos of death, as we call them, 

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where we dichotomize rehab and training or rehab and their normal exercise routine, both professionally and the client starts to dichotomize their rehab and their exercise as just two separate things that they do, in their mind.

The person's getting different opinions, maybe even getting different or redundant exercise programs.  

I give them 5 exercises and then the trainer gives them 5 exercises and they're mostly the same and the person's just stuck in the middle.   

Or it’s the classic scenario where the person comes in with their past three PT rehab programs that they've been given and they tell you, yeah, I do my rehab an hour a day 2-3x a week and then I do my normal exercise routine and it's just completely dichotomized, it’s completely compartmentalized and separate in their minds. We wanna try to integrate these things because it's all one process. So if we can actually show that by communicating with all stakeholders involved, then the person isn’t in the middle of a game of tug of war.  Because, what we want are programs that are complementary rather than redundant or contradictory.

Now, I am fully aware that if there are other stakeholders involved, that is it not always possible to communicate with them, that even if you are able to open a line of communication, the quality of that communication may not always be great.  That doesn’t minimize the importance of defining your role and how you fit within the bigger picture of the person’s journey, and what the expectations are.  Even if the “team” of stakeholders is just you and that person, make that clear, have that conversation.  The sooner and more explicitly this can be discussed with the person, the more clear and more intentional you can be with your exercise prescription approach and the goals of the program.

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Now, we put this checkpoint item of “Defining Your Role” at the beginning of the journey here,

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Because it just makes sense that you would do that as part of the initial encounter. But remember, this checkpoint and the others that we’ll discuss soon are principles that you can, and I encourage you to, revisit periodically throughout the course of your working with the person, as part of your monitoring, as part of your process audit.  Because these things might change or evolve over time. 

SLIDE - Define your role scenarios

Going back to this idea here, with different scenarios and practitioner-client dynamics, maybe the scenario shifts for whatever reason and you’re now going from programming only a specific piece of their plan to more or less, or you have a model where you take on long term clients and what was meant to be temporary arrangement has now turned into an indenfine relationship, or vice versa.  

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So, with that in mind, 

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think of “Defining Your Role” as a check point or big picture principle that you revisit periodically over the course of care - and even after your done working with the person, when you’re reflecting back on the case, regardless of the outcome, you can ask yourself:

"Did the person and I explicitly define my role?"

"Did I communicate adequately with other stakeholders?"

"Was there ever a point where any of this was unclear to either myself or the person? How and when was this addressed? 

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Or if you prefer the visual or mental model of a checklist, think of it like that.  Same idea. 

So, in summary, consider where you fit within wider context of the person’s journey and any other stakeholders, and when possible and appropriate, make those dialogues explicit with your client and anyone else involved, in order improve clarity around expectations and the intentions and objectives behind your plan.

Let’s keep building.

Defining Done

Ok, so in the last lesson, we talked about the importance of “Defining Your Role” at the beginning of the process of working with someone, as a way to set expectations and intentions for your exercise prescription.

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And we talked about how this is an ongoing checkpoint, that you can and should revisit, as needed, throughout the course of working with someone, in case your role evolves in a way that would affect your exercise prescription.

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Now, let’s talk about the other checkpoint you see here, and one that is so so important for setting and maintaining appropriate expectations for both you and the client, for giving you direction and intention with your exercise prescription, for giving meaning to the entire plan, we could go on and one about this one. And that’s what we’ll do now.  Defining “Done”

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Let’s go back to this slide, from the last lesson on Defining Your Role.  We’ve discussed the different practitioner-client scenarios that might happen - maybe this client is just going to be an ongoing performance or wellness client, but more likely you’ll be addressing all or part of their exercise prescription, and then there will be an endpoint.  We talked about how we want to try to avoid siloing the concepts of “rehab” and “training” or ‘rehab’ and their regular ‘exercise’, and instead, think of those concepts as all just one process, and we want try to get all parties/stakeholder/agents, whatever term you want to use, on the same page with communicating the intentions of the program.  All good with that, makes sense.  But let’s go back to these two scenarios down here, in which you’re either programming all or part of someone’s exercise program.  There’s an expectation that there will come a time where hopefully the person successfully “graduates” from your care and they’re off doing what they want to do independently, or the program is going to be passed off to another stakeholder.  “Passing the baton” so to speak. 

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So, that requires that we add an element here.

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And that is, Defining “Done”.  

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“Done”, “Successful Rehab”, “Discharge” what are those things actually going to mean for this person?  As an example, let’s say it’s an athlete or a person that wants to get back to some type of specific physical activity:  some of the goals that you might see in your intake from the client or said to you during your initial encounter, might look like this:

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Set PRs

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Win 1st place

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Win a championship

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Earn a scholarship

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Run a marathon   These are awesome, I want these things for the person too. I love a good outcome-based goal. But you have to ask yourself as the practitioner, how relevant are these outcome-based goals for our current situation right now? Am I even still in the picture during the person’s realization of these goals? If the person’s actually achieving some of these things, then I might have been long gone, out of the picture by the time these things actually happen. Think back to our college lacrosse player from the last lesson, who was recovering from shoulder surgery.  I’m sure that athlete wants to go on to win a conference championship with her team, but she and I have 6 weeks together, so what’s going to define success for us during that relatively brief amount of time? So we've gotta start to actually whittle down what done and success means for the expected time frame that’s relevant for you as the practitioner and the client, which might actually only be a stepping stone to their true “end goals”, like this. Now, you might wonder if things change with the non-athletic population, and I would say this principle still holds true - defining what success is going to mean for that person.

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Let’s say it’s someone with longstanding back pain and this is their goal that they initially state. “Be able to play with my kids again.”  Which is awesome, beautiful, I want that person to be able to play with their kids too.  But we still run into the same issue, in terms of, well what’s stopping you from doing that right now?  Are you literally, physically unable to play with your kids even just one time (which is usually not the case save for a pretty severe acute flare up or a post-op scenario).  Or is it fear around not knowing if it’s ok to feel some discomfort during that activity, or not knowing if some activities actually should be limited in the short term, which is sometime very appropriate, but maybe we can help the person become more capable and confident with those activities over time.  Those are the meaningful dialoges and bits of information for us as practitioners, because it gets at the potential limiting factors and allows us to start formulating ideas for the direction and intention of our interventions. 

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Now, in the pain, injury, and rehab space, it is inevitable that we will get something like this, as someone’s initially stated goal in working with you.  So, think about this for a second, and just think about the expectations that come with a stated goal like this.  Think about the unpredictable and complex nature of pain, and especially, imagine if it’s someone coming to see you who’s had a longstanding issue for months or even years, maybe they’ve been stuck in rehab purgatory during that period, and you know you’re not likely going to be working with them forever - yet they come with this as their goal in working with you. Realistically, what are the chances that the very last time that they ever feel their thing again is during the relatively brief period that they are under your care?  That’s a lot of pressure right?  I get anxiety just thinking about it. 

Now, to be clear, I am not saying that we should invalidate this as someone’s outcome-based goal.  I want this for them as much as I want the lacrosse player to win a conference championship.  But, in that same vein, the more that an outcome-based goal is affected by factors outside of our control, the less influence we can have, and the more difficult it becomes to define success. And it can absolutely affect the way that we prescribe exercises, if you’ve ever gotten caught in the trap of chasing symptoms, trying to throw at them every exercise under the sun, or switching up the plan significantly every time someone has a little set back, versus seeing symptoms as definitely something to manage and work towards improving, of course, but also tying success to function that is meaningful to them.  So, I’m going to challenge you, us, as professionals, to acknowledge this if it’s someone’s outcome-based goal, but to continue the explicit dialogue over the course of working with this person, to try to come up with a criteria that defines ‘success’ that is maybe a little more actionable, meaningful, and realistic for the time that you’re going to have with the person. 

And this is both from a qualitative and quantitative standpoint.  And we’re actually going to lean on that qualitative side pretty strongly in this lesson. 

So, here’s some examples that came from actual clients of mine. 

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This is something I see a lot as someone’s initially stated goal on the intake form - “Train pain free”. But over the course of time working with the person, we’re able to continue revisiting what done is going to mean for the person, in a way that ties it to their meaningful activity, but in a less dichotomous way. 

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Something like this for example: be able to train the competition lifts at 75% so that my coach feels comfortable programming for me again.  We've got something measurable, we've got something now where the expectation is, yeah, I don't have to be in tip top shape for this stint of care to be considered a success, but I'd like to feel like I've got enough momentum that myself and my coach feel safe enough to just start training again independently. It also takes some of the onus off of the clinician to be the complete fixer and the healer.  Now this is a real example of something that a client and myself came to, but a couple of things about this - you might ask, well what’s special about 75%? Are you taking that from a research study?  No.  It’s arbitrary.  As is any goal.  Even if your goal is to win a championship? Well why just one?  Why wouldn’t you want to win 7?  And especially looking at this as an outsider having not worked with the person, it definitely seems arbitrary.  What this is though, is the product of multiple dialogues with the person over time, as they are progressing through they’re exercise program, coming to a mutual agreement of what “success” will mean, with some type of reasonable, actionable criteria.  So, don’t get too caught up on the specific number that we ended up landing on, but rather, focus on the process that got us there, which was revisiting the concept, talking about it, with respect to how they were doing with the program.

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Here’s another one. A real client, coming in with this stated goal on their intake form. “Prevent this from happening again.”

Now, I want this for them, but because we can’t predict the future very accurately and there are many factors that could affect this outcome that are out of our control, plus what if they were to have a minor recurrence in the future, does that mean our time together was a complete failure? So, here’s what we came up with over time:

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“Have a better understanding of what’s going on and how to modify my training when I have a flare up”.  So now, this person wants to take ownership and wants to learn about the process, which is awesome. They’re actually conceding that they may have some future flareups, but they just feel lost currently. They don't have a plan and they would like to understand how to navigate these things better. Now, this one’s very qualitative right?  “Have a better understanding”.  This will probably involve more dialogue to know when the person has reached that threshold, but this at least gives us something to work with.

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So, back to the nonathlete population example:  “Be able to play with my kids again.”  Maybe this can evolve to something like this,

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 “Understand when and if symptoms are ok to feel during certain activities”, where we’ve addressed the person’s uncertainty in terms of whether or not it’s ok to feel some symptoms during certain activities.  Now, this understanding, when and if sxs are ok to feel during certain activities, is developed over time, but maybe in this scenario, it’s if the person feels radiating pain or numbness and tingling, then that’s where you draw the line and they should modify the activity, but if it’s just a dull ache in their back, then they’re ok to continue.  You provide recommendations on what “modifications” they can try, they implement that system on their own to demonstrate understanding, they return  with feedback and tell you if it helped them manage things and feel more confident in making decisions, and if so, great.  

This is, again, obviously very qualitative in nature, so our definition of “done” for this person could also turn into something like this:

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“Be able to play with kids on the floor at least 3x/week on average and know how to modify positions if needed.”  So, we still have our symptom monitoring system in place, but now we’ve got something semi-measurable - but still allows for some flexibility.  The “on average” piece here let’s us know that the person acknowledges there might be some fluctuations week to week in terms of what they can handle, and that that’s normal.  Similarly, let’s say this person has a successful stint of care with you, and they are ready to go off on their own, but there is definitely still more potential for improvement - you might also have something layered on like 

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this, to define successful graduation of care:

“Be able to play outside on feet 1-2x/week on average and know how to modify if needed, with a plan to continue progress independently towards running.”  So, maybe you send them away with a walk-run program that they can progress with on their own.  So these are all examples of how we've modified some of the initial outcome-based goals that were very dichotomous - be pain free, prevent future injury, which we have less control over, and evolved them to, still outcome-based goals, but things that we have a little bit more control over and that set more realistic expectations for the process, AND that will give you a more clear direction for your interventions. So, I know I’m saying it over and over, but these are explicit conversations. Because, if, implicitly, your expectation for a person, from a clinician’s perspective is this

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like we saw earlier - Knowing their history and you'd say, hey, it would be awesome if they just understood the process a little better - but you don't actually have that conversation…And their implicit assumption for this whole thing remains, this 

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Or

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This -  you might run into a difficult conversation later on, if and when they do have a flare up, or set back or progress isn’t moving as fast as they’d like, in which they didn’t expect that to be part of the journey because that was never really talked about, they thought it was just going to be this linear path . So I challenge you, this is a challenge that I have for myself, to have these conversations early so that we limit surprises, set realistic expectations as soon as possible, and have something to work towards.  

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Now, here’s a slide showing some of those outcome based goals that we evolved to, in order to define “done”.  You saw all of these in the previous slides.  You might be wondering, are we supposed to just wait for the person to come up with these types of evolved goals on their own, or can we nudge or suggest them as options early on?  And the answer is, yes, to all of the above.  I’ll show you an awesome example here in a minute, where the client is expressing some angst during the process when we’re already several weeks into care, that actually led to some of the most meaningful dialogue that we could have had, in terms of defining what success was going to mean. But, even during the initial encounter, after you’ve defined your role, it can be really helpful to at least start planting the seed, that “Defining Done” is also going to be something important to revisit and shape over the course of care. 

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Again, let’s say someone with a longstanding issue initially states their goal in working with you as this - Be pain free.  You acknowledge that they said it, wrote it in the intake, you acknowledge that you want that for them as well.  

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But you also present an alternative scenario to that person, one in which there’s an acknowledgement that they might still deal with this from time to time, to some extent, even after we’re done, but regardless of that, they’ve regained control over their meaningful activities.  And that might sound something like this, with me as the provider talking to the client:  “I know you wrote or said that your main goal for care is to be pain free, and I want that for you as well, and definitely think we can make great progress towards that - but let me ask you this, imagine a scenario in which you feel your thing [insert whatever issue they are dealing with] every now and then, it pops up every so often, but when it does, you know how to handle it much better and it doesn’t completely stop you from doing what you want to do. What if we were able to at least get to that point? Would you in any way, consider that a success? Would that be an acceptable scenario?”  That right there, CALU peeps, I’m sure I’m biased with my patient population and everything, but I am sincerely having trouble recalling a instance in which someone pushed back and said that would be an unacceptable scenario.  Instead, they say often something like, “Oh yeah, I just want a plan.” 

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Regardless, what you’ve done by having that initial conversation, is you’ve opened the door to revisit that idea, to start narrowing down what that will mean specifically over time. What “successful discharge”, what “done” will mean.  The seed has been planted. 

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And now here is an example of how the definition of “done” can be revisited and refined even several weeks into care. The questions that your clients ask are often a perfect opportunity to dig into that. Here’s an example - this was the question a client asked me while we were several weeks into care. “What’s the end game here?”  This client was a powerlifter that was dealing with some pretty gnarly low back pain and radicular symptoms down his leg, also while working full-time as a nurse. Which if you know anything about that, the work schedule is not always conducive to the most optimal sleep and recovery.  To top that off, his initially stated goal was to “compete pain free”.  But he was just so far removed from that end goal and his symptoms were so acute in the beginning, that “defining done” was a conversation to be had later, after we had gotten him to a baseline in which he’s, first just able to handle work, try to get him on the most basic, non powerlifting exercise program in the beginning, just to build some habits again, while we wait for the acuity of the symptoms to calm down, then reintroducing some semblance of a powerlifting program, just getting a bar in his hands again.  Then, thinking about what “done” was going to mean has a whole lot more context. Now, if you don’t work with powerlifters that’s ok, this example is relevant to any client interaction.  So, it took us 3-4 months for the radicular symptoms to settle, to balance an exercise and work schedule that was sustainable for him, which all allowed us to start getting the barbell in his hands pretty regularly.  So, one day, this is his question:  “What’s the end game here?  What are we shooting towards?” And this was awesome because even the fact that we're having this conversation, and he’s asking this, is a sign of improvement because before it all seemed so far away, but now there’s light at the end of the tunnel.  So the questions that I posed to him were:

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what would things look like if you were training normally or uninhibited? Meaning would you have a coach writing your program (another stakeholder)? Would you be writing your own program? Would you be just going in there and doing whatever you wanted, but not having any movements that you had to be careful about? Think about where you are right now, physically and mentally, and compare it to whatever training that you would normally do - the future you. Our end goal is filling that gap. So, how big is that gap right now?  I’m asking these questions.    And again, their ‘normal’ may or may not mean 100% symptom free, but symptoms are no longer a limiting factor to doing the things they want to do the way they want to do them. 

Then . . . 

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After he describes that scenario, what ‘normal’ might look like, I might ask something like: “What's stopping us from doing that tomorrow?” Saying, hey, you're doing great. I'm here if you need me, and being done with me.  This is actually what I asked him.  In other words, and also questions that you can ask yourself as the provider - Are there still movements and activities that you’re not confident in or that we're still working towards being able to do to their fullest extent? Are you confident communicating to a coach now (if another stakeholder is involved) who's not a healthcare provider per se, but communicating with him or her in terms of keeping the momentum going? If you're going to program for yourself, have you learned enough through the process with me that you're able to take that on confidently to include independently managing any setbacks that might happen in the future? So, when having these dialogues with the client, determining our end goal for each other, determining done, or what successful discharge looks like, it’s helpful to have them reflect on these things, so that we, as the providers, can have a better understanding of their perspective, to be able to compare to our perspective and discuss.  So, for this particular person, he had decided that he was going to try to program for himself after we were done.  And after this conversation, his biggest remaining concern was not really knowing how much training he could actually handle, as his work schedule had caused him to miss some recent sessions, and we were still spacing barbell work out, moreso than he would probably do on his own.  

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So, we came to an agreement to revamp the program to a consistent 3x/week schedule where we could easily see how much training exposure he was getting, his side of the agreement was hitting 90% of those sessions, and decided that if he was able to handle that amount of work and that schedule for an entire training block, while coming up with his own solutions for minor set backs - simple things like going lighter or reducing range of motion in the short term as needed, then he’d feel confident taking that on independently.  And, fortunately, that’s exactly what happened.  He left me 4-6 weeks later, not in absolute peak powerlifting competition shape, and not even completely sxs free 100% of the time, but with a much clearer understanding of the process and the path to get to where he wanted to go. 

Now, I hope this is not taken to mean things are always smooth sailing or that these conversations are always this smooth, because they aren’t. But, at least we’re having them.

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Ok, so now we've got our book ends of the process.

Defining, establishing what our role is going to be, and also what success or done is going to mean for the person - a mutually agreed upon state, in which the client feels ready and confident to carry the momentum on their own, and where you, as the provider, feel they are safe and equipped to do so as well.  And as we said, with defining your role - that even though it’s shown here at the beginning of the process,

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It’s something to revisit throughout the course of care, as it can evolve. 

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We can say the same for Defining Done - although it’s shown here at the end, it’s certainly something that can evolve over the course of care, and even something that we said is useful to at least begin to discuss on Day 1, or as soon as possible.  So, now you have another checkpoint to refer to, as part of your process-audit - has my role been clearly defined and have we been seeking or established a mutually agreed up on definition of done?  These concepts aren’t fancy, but they are oh so powerful.  Ok, let’s keep building your process.

Buckets of Need

Ok, so in the previous lessons, we talked about the importance of these two checkpoints as a means of setting expectations and intentions for your exercise prescription.  “Defining Your Role” and “Defining Done” - establishing these two things as best you can, as soon as you can, and revisiting both, as needed, throughout the course of working with someone, in case your role or the person’s goals evolve in a way that would affect your exercise prescription.

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Now, it’s time to add another checkpoint to our journey of exercise prescription excellence and client success.  And to do that, we’re going to revisit a notion that we’ve mentioned before.

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That exercise planning often starts with the end in mind. What are the person's desired activities, 

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and what is their current status in terms of being able to perform those activities to the degree that they want?  They’re often coming to us some level removed from that end, and are looking for guidance from us 

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to help them carve out a path to hopefully get back to the things that they want to do, the way that they want to do them. In order to carve out that path, i.e. devise and guide the person through an effective exercise program, we need to consider the person’s goal activities, and

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determine the person's buckets of need, which is the next step in our process - another checkpoint for us.  

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So, 

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if we go back to our definition of Exercise Prescription - Applying a physical stressor to a complex system in order to elicit a reaction and (hopefully) subsequent desired adaptation.

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What types of stressors do we need to subject the system to, in order for the person to be prepared for their desired activity?  Said another way…

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What qualities does the person need to develop or redevelop, in order to get back to their meaningful activities?

We can think of all the things their desired activities require of them through a process that’s often referred to as

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a “needs analysis”.  We do this in order to ‘bucket’ or categorize our exercise interventions.  You might also see this called a “Gap analysis”, which makes sense, since we’re trying to figure out - where the person is compared to where they want to go - and determining how big that gap is, and what “needs” make up that gap.  And again, a “need” in this case, can be considered the difference between the current state and the desired state or outcome. 

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And because we’re all about defining terms, here are a couple of definitions of the concept of a Needs Analysis from the peer-reviewed literature. You’ll see all different kinds of iterations, but I think these two constitute the jist of it:

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A systematic process that helps to establish priorities and guide decision making to facilitate program design and allocation of effort and resources.  And, 

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A preliminary assessment of the specific demands and unique characteristics of the sport / activity being prepared for.   And that’s how we’ll frame this lesson, what is their goal activity or sport going to ask of them. Where is it that they need to be able to go to complete this rehab journey. 

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So,

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What positions do they need to get into for their desired activities? What shapes do their bodies need to assume? 

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What forces are they going to encounter - and in what manner with respect to time? A power lifter is dealing with high forces, but doesn't have any time constraints. They can grind a back squat as slow as they have to, as long as they complete the task.   For a sprinter, they're also managing high forces with the ground, but are doing so across much shorter timescales.  For reference, in high-level, maximal sprinting, the ground reaction forces at top speed can be upwards of 5x/weight, with ground contact times being around a tenth of a second or less, just think about how crazy that is.  So those two force-time requirements, between the powerlifter and sprinter are obviously very different, which might influence your exercise prescription.

A field sport athlete might be somewhere in the middle, or need a bit from both ends as deceleration and change of direction also become very relevant.  Not to mention, a back squat, linear sprinting, and multi-planar change of direction are all just different movement skills.  

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Speaking of which, taking those same examples, you might think about your buckets of need for a particular person, just based on the end goal activity.  A sprinter coming back from a hamstring strain is going to need to be prepared for sprinting again, so, sprinting itself might be a bucket of need that you make sure to address. You might still use a back squat during that rehab process for the sprinter, but in that case, the back squat is probably just one of many methods to fill the very general bucket of need of lower body strength, for example. Many of you might decide to fill that bucket with a different method of exercise. In contrast, for the powerlifter, the back squat is a sport specific skill, so you’re much more likely to bucket the back squat as a specific need for that person. And, the same with multi-planar change of direction for the football player, soccer, basketball, tennis, etc. Change of direction would probably be a specific bucket of need that you’d want to address with those people, whereas that might not be something you touch at all for the powerlifter or competitive sprinter. 

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And for a baseball player returning from shoulder or elbow injury for example, a return to throwing progression might get its own bucket of need, to go along with others that you feel are important to fill, like range of motion, external rotation strength, etc. Now, deciding which buckets are important to address and when for a particular person, is part of the fun when we discuss these things together, because we all might have some differing thoughts in that regard.  What’s more important though, for our purposes right now, is just a baseline understanding of what a needs analysis is and the principles behind it.  

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Are there metabolic or energy system demands? You can imagine, for example, that the energy system training may differ between a volleyball player and a soldier who has to ruck 15 miles carrying 75 pounds worth of gear on his or her back.  What’s also cool about all of this, is that you could potentially address multiple buckets with a single exercise method, depending on where the person’s at in their rehab journey. Could repeated 10-15m sprints potentially address some energy system needs for a soccer player, as well as addressing the general running or ‘sprinting’ bucket that you might have had for them? Sure, very possible.  Side note, when I was thinking about how to word this particular part, I thought of the old saying, “kill two birds with one stone” - and I got curious about alternatives to that saying, so I googled it. There’s a lot of funny ones, so I’ll let you do that on your own, but I’ll use one here - with those repeated sprints, we could potentially “mash two potatoes with one fork”.  So, there you go.  So, again, for a needs analysis, think about the qualities that the person will need to develop or redevelop and what their desired activities will demand of them, and those will inform the buckets of need and subsequent exercise prescription.  So, you can use these four general buckets, as an initial template or mental model that you can filter a sport or activity through, in order to generate some ideas about what they’ll need from an exercise prescription standpoint. 

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We’ll move our general ‘buckets of need’ that we just described over here for a second.  One of my favorite parts about this course is when we get to loop back, and tie in concepts that were previously discussed.  

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Remember the systems hierarchy?  

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And this hierarchy model in particular that looked at the various levels of systems contributing to a task.  Well, you might use the systems hierarchy as a mental model to help categorize and bucket your exercise interventions. We’ve talked about how you might consider your exercise selections based on the range of motion, force application, energy system, or coordination/skill demands.  And as you see over here in this model, with the tissue level, you might find it useful

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to class a component of the exercise program based on the desired adaptation of specific tissue

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maybe hypertrophy or strength of a specific muscle group, or tendon or bone adaptations, which we’ll have specific lessons on.

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And then, you might have a bucket that is on the other end of the continuum of specificity, that’s 

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Filled with exercises meant to just get someone moving, and it’s not super important how stringent you are with execution of intensity, at least not in the beginning of the journey. Maybe this is someone who’s deconditioned and/or experiencing longstanding issues that have caused a bit of apprehension to movement in general. 

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So, let’s say we’re rehabbing someone after a knee surgery, and have decided that a tissue-level bucket of need 

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of ‘quad strength’ is important.  And we’ve decided that we’re going to 

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use a bilateral goblet squat as a method of addressing that bucket of need. Now, a bilateral goblet squat could be a solid quad exercise, but kind of depends on how it’s executed and position - in which case that particular movement pattern or method may or may not be addressing the level or bucket of need that we think we’re intervening on.  And if we feel a certain degree of specificity matters, maybe

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we modify how the movement is performed or 

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pick a different exercise method altogether to better ensure that level or bucket of need is being addressed.  And in other cases,

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maybe the squat is more at the task level - where we care more about exposure to the “skill” of the movement, like with the powerlifter, and trying to isolate a specific tissue doesn’t matter as much.  Or 

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maybe I’m just using that bilateral goblet squat for general lower body tolerance to exercise for someone who’s been experiencing chronic low back pain for example, where again being specific to a certain tissue or the level of skill proficiency may not be as important.   So, you’re beginning to see how these mental models can help you to start organizing your thoughts around the categories of exercise prescription you plan to give someone.  

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Ok, so we get the jist of a Needs Analysis I think.  Considering the goal task or tasks, and what they require of the person.  And where is the person currently at in terms of being able to meet those requirements.  And what qualities or buckets of need do we want to try to develop through our exercise prescription to help get them there.

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Now maybe you don’t have a great idea of the requirements of the goal activity.  Or, whether you do or you don’t, maybe you just want to learn a little bit more about what it is they want to get back to, so that your needs analysis can be more direct and accurate for the plan.  So, how do you learn more about what it is they want to do?

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Well the first strategy is to just ask them about it.  I almost feel silly saying that, because maybe it seems super obvious.  But there were times as a younger clinician where I was a bit embarrassed or self conscious when asking about the person’s sport or activity, because I felt like it would make me seem incompetent or that I didn’t know what I was doing.  When really, it just shows that you’re engaged and really interested in learning about the person and what they like to do, so that you can help them as best as possible.  So, ask specific questions that go right in line with our previously mentioned buckets of need - what positions do they have to get into, how long and how often are they in those positions, does the activity involve moving fast, jumping, running, cutting, lifting something, throwing something, moving something.  If it’s a position sport - what position do they play and what’s the relevance of that compared to other other positions. 

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Have them show you pictures or videos of the thing they are trying to get back to.  Go on youtube and watch the activity or sport to get a feel for it.  And then, a really effective way to get a feel for the demands of various physical activities and sports is to 

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google the name of the sport or activity

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Along with key phrases like time motion analysis OR kinematic analysis OR kinetic analysis OR energy system demands, and you will probably get some really useful insight into the demands of that sport or activity. Not to mention, just seeing how a needs analysis is conducted in the literature, is really helpful to solidify the concept in your mind. The more you see how it’s done elsewhere, the more you’ll start to develop your own model of doing it. In addition, especially for popular sports, you can get a feel for the common training practices with key phrases

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like this.  Now, this is obviously going to be helpful if you’re looking for exercise selection ideas, and want to see what buckets of need are often addressed in the training, but also, it kind of gives you a feel for the culture of the sport, to get to know the common training practices.  Like american football for example - the power clean is deeply rooted in the fabric of the training methods of most football strength & conditioning programs.  Even in high school, it’s a whole culture thing, the entire team will crowd around as their teammate goes for a max.  You might not be programming power cleans for your high school football player in the clinic, but that person is probably going to do power cleans at some point outside of your clinic time with them, sometimes even in conjunction with your plan of care, whether they are prepared for them or not. So, it can be helpful to at least be aware of those common practices. That specific example aside, the point is, it may be relevant to know the demands of the training program the person is possibly going to return to for their chosen activity, not just the activity itself.  So, let’s pop one of these key phrases into google scholar and pick a sport to go with it.  I’ll choose “time motion analysis” and 

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Volleyball. Let’s say you have a volleyball player rehabbing from lower extremity injury.  You’re like, I’d to just brush up on the physical demands of volleyball, so that my needs analysis accurately represents what I should help this person prepare for.  

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You google, “time motion analysis AND volleyball, and this is one of the first papers that pops up.  An analysis of playing positions in elite men’s volleyball: Considerations for competition demands and physiologic characteristics. 

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Now, an important consideration when you’re performing these searches is trying to match the demographic of the population in the paper with that of who you’re working with, when possible.  And in a sport like volleyball, even playing surface might change the demands - like with court vs. sand.  But for the sake of this example, we’ve decided this paper is relevant enough for us, so we take a look.

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And right off the bat, we see some pretty interesting things in terms of the differences between jumping demands based on position, which I’m sure will make sense for those of you who are familiar with volleyball. So, looking at this figure, we’ve got 3 different position groups being compared (setters, middle blockers, and outside hitters), the different style of jumping demands in a volleyball match, and the frequency of each type of jump that’s performed by each position group.  And if we look at the significant findings, we see that middle blockers performed significantly more block jumps than the other two groups, but that all three groups perform a decent amount of this type of jump.

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And let’s just look at the nature of that type of jump - upright torso, knees tracking forward.  You also notice that it’s a pretty quick/reactive countermovement.  So, while jump height is still important, you’ll sacrifice a little bit of that for the sake of getting up quick and reacting to the hitter on the other team - potentially turning into repeated block jumps, one right after another. Now, if we come back to this figure, middle blockers also performed significantly more attack jumps than outside hitters, and both of those groups performed way more attack jumps then setters.

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And when we look at an attack jump, they are often coming in from an approach, generating horizontal momentum that they stop on a dime to send vertically.  Ground contact time is increased compared to the block jump, there’s a big arm swing, all in order to maximize jump height for one big jump - and of course, a subsequent landing from that higher position that might sink them down into deeper joint angles. 

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So, that volleyball player comes in with that lower extremity injury, and you’ve determined that this athlete is going to need to prepare for the jumps they do in their sport, and so that becomes a bucket of need that the athlete will fill with some progression of exercise over the course of care. I labeled it Jumps. We could call it lower body ballistic exercises whatever general term you want to use. I’m going to refrain from using the term “plyometrics” as a blanket term, because we might just get a little more specific with that one in a future lesson.  So, we’ll just call this the jumps bucket for now. Now, depending on the injury, your entry point to fill this bucket might be the same, regardless of position.  As in, early on in care, distinguishing between these two jump variations that you see may not be relevant, because the person just needs to get comfortable with some semblance of jumping at all.  

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So,

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That might be something as basic as a snap down to get comfortable with managing a countermovement or 

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this thing here that I refer to as a pseudo jump. I’m not actually leaving the ground here, just getting comfortable with the rhythm of a stretch shortening cycle.  

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Now, for all 3 of those positions, setter, middle blocker, and outside hitter, we know we have to prepare for the block jump, 

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so maybe our pseudo hop turns into actual countermovement jumps where we’re leaving the ground progressing intent, as tolerated, 

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taking that and our previous snap downs, into something like this snap down jump, which looks a lot like what we’re seeing in this block jump. And of course, also just having the athlete do blocks jumps with the same technique that they would do in a volleyball match, with control of volume and intensity as tolerated. Bucketing the sport skill itself as something to directly address. 

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But 

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if they are a hitter, then you know they need to be prepared for an attack jump as well, which requires managing horizontal to vertical momentum, a deeper countermovement, and higher landing forces because it’s a higher jump.  So, now, the classification of the jumps bucket of need, 

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might need to have a bit more resolution, be a bit more granular, as we make sure to prepare the athlete for both kinds of jumps. 

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You might even think of it as two separate skill buckets that you want to address. Remember, these are just mental models to help you organize your thoughts, so set them up whichever way your brain prefers. 

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We’ll go back to the single bucket just for simplicity sake. 

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But, what this might mean, is that in addition to the exercise progression we mentioned previously for block jumps, we might also have a certain progression for the attack jump.  

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That could include variations that involve deeper countermovements, deeper joint angles, and increased ground contact times to prepare for those things during the attack jump and subsequent landing. 

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Progressing to variations where we’re managing horizontal momentum into vertical force application

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and most certainly, practicing the approach in a graded fashion - one step then jump, two steps then jump, and then the full 3 or 4 step approach, with increasing intent and entry speed.   Now, the sport of volleyball and these exercise examples were presented more to illustrate the principle of a Needs Analysis and how it might affect your exercise prescription.  I purposely didn’t make this a detailed case with diagnosis or anything like that, so as not to detract from the bigger picture checkpoint that we’re talking about.  With that said, if your brain wheels were spinning on ways you would have approached something like this, that’s awesome. That’s exactly what we want at this point.  Brain dumpz all day. 

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Ok, that was quite a bit, so we’re going to leave it for now.  But this concept of a needs analysis, is going to underpin everything that we do moving forward.  

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And in the same way

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That defining our role and defining done have become checkpoints that we revisit throughout the course of working with someone, so too does performing a 

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Needs Analysis become a crucial ongoing checkpoint. Where does the person want to go, where are they now, and what buckets of need should we fill to help them get there, that falls within your defined role and coincides with your mutually agreed upon definition of done. 

We’ve still got a lot of work to do, but we’re really building something special now. Well done. See you soon. 

Brain Gainz

Ok, for your next Brain Gainz exercise, you are going to do exactly what we did with the volleyball example, and you’re going to learn about the ‘buckets of need’ for a particular sport or activity.  Said another way, you’re going to do a general needs analysis on that thing. Now, the activity or sport you choose, can be anything you want, but try to pick something that’s really going to move the needle for you, going forward.  As in, pick a sport or activity that you anticipate seeing more of in the clinic or want to see more of.  Maybe a sport or activity that you’ve wanted to learn more about that you feel you have a gap in your knowledge.  Or maybe it’s something that you’re already interested and knowledgeable in, and you want to test or solidify that a little bit.  Again, this is for you, so choose something that is going to help your practice in the future.  

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How will you go about gathering the resources for your needs analysis?  Exactly how we talked about before 

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Ask people - current clients that do the thing, friends, colleagues

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Watch videos of the thing

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And use the peer reviewed literature, just like we did with the volleyball example,

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Using key terms for both the demands and/or common training practices.  Now, before you start gathering this information, create an initial hypothesized needs analysis for the thing.  Before you do any digging, let’s pull out what’s already in your head.  

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You can use our general buckets here as a template.  

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What do you think would be required of this activity? The positions, the forces with respect to time, energy system demands

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What type of training program or exercises do you think would be beneficial, based on your hypothesized buckets of need?   If you think you have no idea, guess anyway.  It’s such a beneficial habit to pull out what’s already in your head, your current working mental model of the thing.  Not only will you surprise yourself a lot of time with how much you actually know about something, but you’ll now have an established model to be able to compare to when you go digging.  And any contrast that you find compared to your previous mental model will really help things stick.  Also, don’t look at the other responses first.  It’s ok if there are repeats.  That will just strengthen the resource library that we’ll have for that sport or activity. This will turn into a pretty sick resource for all of us. 

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Ok, to summarize the steps:

1. Pick an activity or sport to do a needs analysis on. 

2. Create your initial buckets of need hypothesis first, without consulting any resources - you can use our general Buckets of Need template. Let’s reach deep for what’s already in that beautiful brain of yours. 

3. Then, go digging - ask clients, friends, colleagues you know who participate in the sport or activity, watch videos of the thing, and dig into the peer reviewed literature to learn about the demands and/or the common training practices

4. Share!

1. Topic 

2. Initial hypothesized buckets of need

3. The resources you used

4. Brain Gainz - what did you learn? Anything new or surprising regarding the demands or training practices?

Ok, this will be a fun one.  I’m really looking forward to your responses and learning about lots of new things!

BCs: Threshold & Entry Points

So, in the last lesson, we discussed the importance of implementing the concept of a needs analysis as one of our checkpoints, to guide your exercise prescription. Which, at its core, is a practice in 

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determining the demands of the person’s desired activity, and 

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establishing where they currently are, in relation to where they want to go. Two sides of the same coin - A Needs analysis being the consideration of the demands of the desired activity, and where the person currently is in relation to that. We mentioned that a useful mental model when determining the demands of the person’s desired activity is 

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‘Bucketing’ certain characteristics of the activity, to help organize your thoughts and categorize your exercise prescription.  

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So, we’ve got all of these potential ‘buckets of need’ that we could try to fill with our exercise prescription. You might consider the positional or range of motion demands of the activity, the forces the person will experience with respect to time, the energy system demands, the coordinative or skill demands, maybe even considering specific tissues or parts of the body that are involved, and/or you may prescribe exercises to fill some very general bucket of just getting someone moving again, without much regard to how ‘specific’ you are being to certain tissues or movement skills. 

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And you might use a model like the systems hierarchy to help you organize your thoughts around this as well. Thinking about the task itself, the environment in which the task is often performed, and then the various subsystems that are involved, potentially creating buckets of need around some of these things. Now, the fun part, is that you might try to fill all or some of these buckets within the current exercise program that you write for a person, or you might categorize your exercise interventions with different buckets or categories than these, as part of your own mental model.  That’s great! I encourage you to explore different ways to think about exercise categorization. That’s part of building your own process. The beauty is that now we’ll be able to have a conversation about it, because we’re all coming in with the “first principle” understanding of what a “Needs analysis” is in the first place.  

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So, you start to think, well we’ve established various buckets of need that we might use for the person, we can start to 

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fill in the ‘workout calendar’ so to speak, of what their program is actually going to look like, and how we’re going to fill some of these buckets or slots within the week. 

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We’ll use some color coding to help visualize this. Let’s just say we’ve decided to give this person

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a 3 day per week program, and we’re going to address 

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range of motion on all three days, 

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maybe some force production or general strengthening on Day 1 and 3 with 

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some extra hypertrophy focused dosing here on Day 1, and 

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some cardio action on Day 2 and 3.  And it starts to look like a decent plan. 

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So, what we’re doing is 

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thinking about the characteristics and requirements of the desired activities, 

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and creating slots or exposures to address those buckets of need over time. But, that’s only addressing half of the needs analysis process, right?  One side of the coin. This addresses the ‘where do they need to go’ part.  We still need to continue working backwards in order to determine 

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“where they are now”.  Where they are in relation to where they need to go.  

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It’s one thing to start filling in those slots to address each bucket of need that 

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you think is relevant to their desired activity, but it’s another thing to find an appropriate entry point to begin filling that bucket. As in, where do we start? In order to determine that, we need to establish 

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where the person’s level currently is, or said another way, we need to 

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establish their current boundary conditions.  The, “where are we now, in relation to where we need to go?” part of the needs analysis, which is the next step in our process.  Where are their current limits in relation to their buckets of need. In relation to the positions they need to get into, in relation to the forces they need to be able to express and manage, in relation to the amount of time and effort they are able to put forth towards their goal activity, before they begin to experience issues.  This, in turn, will provide you with the information necessary to establish an entry point, to work on things. And, just to be clear, the word “boundary” here, isn’t meant to have a negative connotation. Just think of it as shaping the person’s current capabilities. 

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If we go back to our lesson on

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Feedback-based decision Loops and also where we discussed the 

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dreaded Drift into Rehab Purgatory, we also talked about the idea of a person’s

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Plateau of Resilience - or their ‘functional landscape’. How much room do they have to roam around and explore their physical function, as it relates to their desired activities. So, this might be a useful mental model to come back to as we’re thinking about the idea of establishing a person’s boundary conditions.

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So, where does the information come from when we’re looking to establish where the person currently is in relation to where they want to go? Well, speaking very broadly,

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all of the things you’re already doing clinically in terms of obtaining information about the person via tests and measures, reviewing their history, your conversations with the person - is all information that for (1) 

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goes into our feedback-based decision loop, and (2) 

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are means of establishing where the person currently is. Establishing their boundary conditions. Where they are in relation to where they want to go.  Again, just thinking big picture - that is fundamentally, what we’re doing with all of our clinical findings - we’re attempting to establish the person’s current boundary conditions. Where they currently are in relation to where they want to go. Now, narrowing in, 

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thinking about the person’s specific desired activities, can we establish certain boundaries or thresholds within those activities that will both inform us of their current level of function and inform our exercise prescription entry points? Let’s dig into that and then use some examples, because this is an extremely useful and practical means to base much of your exercise prescription off of. 

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So,

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Is there an intensity threshold at which they start to feel their issue? We’ll qualify the definition of this term with some examples here in a minute, but let’s just think of it broadly as the application of force. And of course that doesn’t just mean lifting weights in a gym. Is there some type of tipping point or threshold that we can establish in this regard, relevant to their desired activity?

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Is there a range of motion threshold? As in, do they start to experience their issue at a certain point in the movement. 

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Is there a speed or a velocity threshold where they can do something slow and it feels okay, but when they have to do it quickly, then it starts to become a problem.

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Is there a positional intolerance? So, within the execution of their desired task or activity, are there certain movement strategies that are more or less of a problem when executing that task. Is their issue affected by any environmental factors - like the terrain the person is performing on, for example.

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Is there some threshold in which the person experiences their issue at a certain proximity to momentary muscular failure, or with a certain amount of fatigue or exposure to the activity, i.e. volume.  Now, a couple of things. (1) Again - how are you getting all of this information? Well the easiest way is to ask. And certainly taking someone through a series of movements or testing could help you establish these thresholds or boundary conditions as well. But isn’t that just going back to the general idea that what we are doing with our clinical findings and client history review, and our conversations with the person, is attempting to establish where the person currently is. Their current boundary conditions. Just imagine how useful it would be for you when attempting to establish an appropriate entry point to exercise with a person, if you had some of this information at your disposal. If you had an idea of how much intensity and volume they could handle or couldn’t handle. If you identified what positions or ranges of motion they began to feel their issues, and if performing their desired activity at speed makes any difference. So, I challenge you to try and uncover this information whenever possible, to the extent that it’s relevant to the person’s situation.  On that note, and the second point I wanted to make before continuing, is that, like everything else we’ve done up to this point, what you’re seeing on the screen right now is simply an example model to carry out the principle of establishing boundary conditions. You might see a lot of overlap between some of these categories, like intensity, velocity, and effort.  Or you might see some overlap with positional and range of motion thresholds. And that’s totally valid, and clinically, you may only use one or two of these categories that are most relevant to your person, in order to establish where they currently are and to be able to devise meaningful and appropriate entry points for their exercise and return to activity programs. So, based on all of this, after having established some tolerance thresholds for the person, getting an idea of where their current boundaries lie,

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You might now start to have a better idea of what versions of certain exercises or movement options that we have at our disposal, as appropriate options to program, in order to start addressing the person’s buckets of need. And here’s a little mental model for you to help conceptualize this idea. 

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We might have a ‘proceed with care’ list. These are movements that are meaningful to the person, and they’re still on the table, but you need to proceed with care with one or more of these boundary conditions. We can do it, but we have to be mindful of how we dose it and it might need to be modified in some way. We need to put some ‘boundaries’ around this list of movements. Now, I say list, and that can mean literally. I find it to be a valuable use of time to go through this with the person, to get their feedback and thoughts, include them in the decision-making, all as part of the informed consent process. So you can literally make a list of those movements and the modifications that you recommend based on these established thresholds, and have this conversation with the person.

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Then, you might have a full go list - So these are meaningful movements or activities, but they don't affect the issue that the person is coming in to see you for. They can train them or perform them as hard and often as they want, as regularly as they want and there's no adverse effect on their chief complaint. And this is a great list, because the more things we can fill it with, the faster we can begin ‘normalizing’ the person’s situation. Like, “Yeah, we’ve got some things that probably need to be modified (i.e. they are in the proceed with care list), but look at the stuff that you still can do right now without any issue”. And this is one of our ways to help the person get out of, or avoid 

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the Dreaded Drift into Rehab Purgatory. Showing them all of the options of related movements or activities that are still available to them, and that don’t really need to be modified. 

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And then, 

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there might be a no-go list. It’s a meaningful movement, but we just can’t get any appreciable intensity, volume, frequency, range of motion without a significant set back.  We just need to build a bigger foundation and take this movement or these movements out of the rotation for now. The more obvious scenarios here would be post-operative cases, where you potentially have more clear restrictions, but there will be plenty of times where you feel it’s appropriate or at least worth having a conversation, to put movements in this list, even in non-op scenarios. Now, let’s talk through some examples to build some context to help these concepts stick.  

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Let’s say this person is a runner, swimmer, or cyclist. Three very different things I realize, but they’ll share some commonalities for what we are doing here.  So we have the desired activity in mind, the end in mind. Running, swimming, or cycling. However, the person is unable to perform those activities to the extent or level that they want. So, we try to establish their current thresholds, their current boundary conditions in relation to those activities. An intensity threshold in this case might mean pace, with which we might be able to lump this in with the velocity threshold category as well. So at a certain pace of running, swimming, or cycling, the person begins to experience issues. Try to extract that information from them if possible. For these examples, I’m also going to lump range of motion and positional thresholds together: So, perhaps a certain running style provokes their issue - heel striking versus forefoot, or a specific swimming stroke is more of an aggravator versus another.  Perhaps for the cyclist who’s having hip issues, for example, the deeper the hip flexion angle, the more they experience their symptoms. Or maybe the cyclist is experiencing back pain that’s provoked with spinal flexion - which is inconvenient, considering that’s the position that they are often in for cycling. Maybe there’s a certain environmental threshold - our runner may be fine on flat ground, but maybe they experience their issue more during trail running or vice versa.  And just maybe, there’s no problem at all for our runner, swimmer, or cyclist, until they reach a certain volume of work, fatigue level, or effort.  Maybe our cyclist can handle spinal flexion just fine up to a certain duration of time or distance. They say, “yeah I ride for 10-15 miles before I have problems”. Maybe our runner can run at a certain pace just fine up to a certain distance. And maybe our swimmer can handle that specific swimming stroke just fine, but only up to a certain distance or volume.  Another way that a volume threshold might manifest, is with their symptom or recovery pattern over time. Maybe you also find out that these people experience their issue more towards the end of each week, as training volume accumulates. And maybe sometimes they even have to cut the training week a day or two short to allow for extra recovery. Just enough for their issue to calm back down to do it all over again the next week. So, all of this information can inform what exercises or activities are “on the table” so to speak, and where modifications, if any, need to be made to them.  For the runner, you might consider all of this information and say, “you know what, trail running is something that’s just really difficult for you to handle right now in any capacity, and it seems to flare you up to the point of not being able to do anything else for a few days and even a week. What do you think about pulling that completely back in the short term? But, we know you can handle running on flat ground at X pace for X volume a lot better, so we can keep that in but just have to monitor how you’re recovering. And, the other good news is you can still push your cardio and go ham on the bike, rower, or elliptical, because those things don’t seem to affect the issue negatively at all. Not to mention, there’s a lot of resistance training options that we can supplement with in the meantime. What do you think?”   So, in that scenario, trail running might go in our red, no-go list for a time, with flat ground running going into our yellow proceed with care list - we can continue doing it, but at modified dosages based on the person’s current thresholds that we’ve established. That movement or activity is still something that can potentially light up the person’s issue if one or more of these thresholds are exceeded a bit too much. And then, things that are still relevant and/or meaningful, that don’t seem to affect the issue, can go into our green Full-go list. Same process for our swimmer with different swimming strokes, and with the cyclist in terms of riding hills, trails, flat roads, and with respect to any of these established boundary conditions. 

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Now, let’s say, we’ve got a lifter or barbell sport athlete. So, a person who either resistance training is the end-goal, desired activity; or it’s an important adjunct to what they do. And you as the provider know that resistance training is likely to be part of the plan. Same process here - and for the sake of this example, we’ll just say it’s a powerlifter.  Someone whose life revolves around the back squat, bench press, and deadlift.  Intensity could be a pretty straight forward threshold to establish - at what absolute external load or % of 1RM do they begin to experience their issue?  Do they tell you something like, ‘my thing only happens at around 80-85% of my one rep max.’ So there's some tipping point in external load. That's really valuable information because you as a clinician can say, Okay, that's gonna help inform our loading because there's 79 other percents that we could load this bar potentially.  Is there a range of motion threshold, and at what point in the range of motion? At the bottom of the squat or bottom of the bench press, at the top?  Right off the floor during the deadlift, when the bar is passing the knee, during lockout of the deadlift? Maybe there is an interplay between external load and the velocity at which they move.  As in, they can lift a certain percentage of their 1RM, if they deliberately slow the tempo down.  But trying to move the same weight with maximal intent and velocity triggers the issue. Are there positional thresholds? Maybe they are experiencing some back pain with low bar back squatting which is their competition technique, but they can high bar back squat or front squat, just fine. Perhaps something similar with deadlifts - their competition conventional style deadlift, which is just feet somewhere around hip or shoulder width apart and hands placed outside of the feet, is causing issue. But a sumo stance feels ok. Or a trapbar or hexbar deadlift feels better, because they have more control over how ‘hip hingey’ or ‘squatty’ they make the movement. With bench press, maybe they are having a shoulder issue with a wider grip, where they are also able to lift the most weight, but a more narrow grip feels more comfortable right now. Or decline bench press feels more comfortable than flat bench press right now.  In terms of volume, maybe the lifter tells you that they are several weeks into a high volume training block, in which they are doing high repetition sets of 8-12 (that’s a lot for a powerlifter), and they are experiencing their issue more towards the latter reps in each set and/or towards the end of each week; as training volume accumulates. So, taking all of this information into account, it starts getting your wheels turning into terms of viable, appropriate entry points. Possible volume, intensity, or range of motion modifications. Thinking about different exercise variations, and what’s going to go into our no-go, proceed with care, and full go lists.  What you’ll often find in practice, is that there is an interplay of some of these variables. They can lift relatively heavy, but not full range of motion. They can go full range of motion, but they have to go slower or lighter. They can handle more volume with this variation of a deadlift, than with that variation. And we can replay this process over and over and over for different populations.  And I encourage you to do that. 

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Could be climbers

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Field or court sports

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Could be the parent who just wants to be able to play with their kids, like in the example we gave in a previous lesson.  Think about the populations that are most relevant to you, and imagine scenarios in which you are taking into account the demands of their end-goal activities and trying to determine where they currently are in relation to that. Trying to establish their current boundary conditions. Even better yet, if you can, think of a client that you’re currently working with or have worked with, and take that case through this process, based on the information that you know about them. I find this especially helpful during times where maybe we’re struggling a bit with someone’s exercise prescription in terms of either where to start, or what direction to go. Ask yourself, have we established where they’re currently at? Is there potential to glean a little bit more of this information by some combination of explicit dialogue with the person or considering the feedback you’ve gotten from them on the program up to this point, or from their history, or any recent tests and measures?  So, this can all be crazy helpful in terms of determining appropriate entry points or progression forward with your exercise strategies, but what’s also pretty darn cool and clinically useful is that these boundary conditions or thresholds can act as measurables or 

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as potential key performance indicators. Think of key performance indicators or your KPIs as part of your dashboard for the person. Relevant, meaningful metrics that ideally you can associate with a standard. The standards a lot of times, can be the person’s prior performance or function before the injury. It could also come from normative data that you find in the literature, or maybe it’s a new standard that you and person come to an agreement on together, part of your “Defining Done” checkpoint. So, think of this like, if you were gonna pull up a dashboard on a certain client, what is some information, that you can snapshot or just at a glance, see the trends, see if things are trending in the right direction.  For example, are meaningful movements or activities going from the no-go list to the proceed with care list to the full-go list over time? And every one of these other boundary condition categories can be potential measurables or information that helps us to know if things are headed in the right direction.  Is the person’s intensity threshold rising? Are they able to run at a faster pace or lift more weight before they start to feel their issues? Are they handling loads at greater ranges of motion than they were before? Are they able to handle more volume over time? For example, now the cyclist can go 20-30 miles before that lumbar flexion intolerance creeps up, whereas when they first came to see you, it was only 10-15 miles that they could handle.  So, all of these things we can use as measuring sticks to track progress as key performance indicators or KPIs, that go into our

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Feedback-based decision loop, our compass, helping us to see whether we’re moving in the right direction towards done, and as some evidence to the client that we’re gaining some positive momentum. So, for example, if you had a meaningful movement in the no-go list to start, but now the person can do that movement, just with some modifications, you can say, “hey, we’re doing this now. Remember when you couldn’t do it at all?” This is ESPECIALLY helpful during periods where maybe the person is a little down or frustrated with the whole process, or maybe we hit a little snag in their recovery, they had a flare up. For them, especially, the person who’s living the experience every day, it can be tough at times, to zoom out and see how far they’ve come overall.  

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I liken it to a kid who’s growing. And you measure them, and say, “Wow look at that, you’ve grown 2 inches in 6 months!”.  And the kid’s like, “I have?”.  It’s difficult to feel those small gains when they occur, but they add up to something significant over time. It’s the same here. Incremental gains in 

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these boundary conditions accumulate to significant improvements over time, and it can be helpful to have this information to remind the person of how far they’ve come. Especially 

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during the seemingly “Down” periods. Because, a lot of times, if we

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zoom out to view the bigger picture, 

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We’re often able to see that the person has actually come a long way, even in the midst of this temporary set back.

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And establishing these boundary conditions can help serve as anchors for being able to see that progress 

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So, if we go back to this slide, where we began building a program for someone, based on these very general buckets of need that I provided as an initial template - we can now begin to consider the individual’s boundary conditions when thinking about how we’re actually going to carry out the needs of whatever categories we decide are relevant.  Let’s say this is a program for a runner who’s recovering from a meniscus repair in their knee. Their 6 months post-op and they’ve been cleared for all activities by the surgeon, but they're still missing a little bit of both end range flexion and extension and just want some direction in terms of helping them get back to running. So, let’s go through those same training slots that we had made earlier, but now with the lens of keeping the person’s boundary conditions in mind. 

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We had said we were going to be challenging that range of motion threshold on all three days, which will be fun to see some measurable changes there, 

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that can act as a KPI for us; not only in just seeing improvements, but also if we see trends in the wrong direction. Like what if the knee starts to swell a little, and the person loses range of motion. Well,

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That’s valuable information. Valuable feedback that goes into our feedback based decision loop, our compass, and might inform our future exercise dosing. 

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And we had decided to do some general lower body strengthening on Day 1 and 3. And let’s say this person does enjoy bilateral squatting and would like to do that as part of the program, so you decide to fill one of these lower body strengthening days with bilateral squatting. But you learned that it’s painful for them at the very bottom of the squat and they’re apprehensive going all the way down there, especially with a barbell at a certain load.  So, it seems the squatting pattern 

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falls into our yellow, proceed with care list, and you decide to start them off with 

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a goblet squat, to a medicine ball to set boundaries around the external load and range of motion. So, it’s a start. And what’s cool is that we can use the person’s progression of this squatting pattern here as 

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a measure of progress. If this person is able to progress to a full range of motion bilateral squat, without the boundary, or are able to progress the external load, maybe even up to barbell squatting, and with no adverse effect on the knee. That’s all indication that the person’s body is adapting well.  And then, for the second slot of lower body strengthening here on Day 3, you’d really like something that you don’t need to set a lot of boundaries on, so that the person can train a little more unencumbered. You learned from your clinical findings (history review, dialogue with the person, test, measures, movement observations) that the person handles 

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trapbar deadlifts really well.  To the point that the movement is pretty much in our 

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green ‘full-go’ list.  So, you throw some trapbar deadlift action in on Day 3. Now with this runner who is post op meniscus repair, you did notice that his operative leg looks to have some atrophy.  And sure enough, when you did some circumference measurements, it was an inch, inch and a half less beefy.

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So, you decide to throw in some extra resistance training volume really geared towards getting him up to a high intensity of effort, to really challenge those leg muscles and hopefully drive a hypertrophy response. You really want to use a knee extension machine to target the quad for this. But you got some information about how he’s able to handle this machine - either you had him try it in your clinic or he tells you - that he has to go really slow at the bottom of the movement or else it is a little uncomfortable in the knee, similar to the squats. 

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So, maybe we just think of this as going into our ‘proceed with care’ list as well, where we’ve got some more boundaries to navigate. But, that’s no problem because you prescribe a nice slow tempo, and even maybe do something slick like prescribe a short rest period. So, now even though he can’t handle a lot of weight, the slow tempo and short rest gives him that niceee quad pump. Now, could his tolerance to this exercise, as well as changes in circumference of the leg over time act as measurables that we could track? 

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Sure they could. Now - this person is a runner. So, their most meaningful activity isn’t squats, leg extensions, or trapbar deadlifts, 

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it’s running. 

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So, we had mentioned before that we were putting our energy system work in Day 2 and 3, so we’ll stick with that here.  And, we actually got some information on how well this person is able to tolerate running right now, through our history review and dialogue with him during our consult. First of all, trail running is his thing. But, he tried a short trail last week, and his knee swelled up for 3 days after.  BUT, he said the week before that, he ran on flat ground at a certain pace for a certain distance, and that was ok. No increase in swelling. Ok, so awesome, you’ve got good baseline information then, that can go into your feedback based decision loop and inform your prescription. So, on Day 2 here, you know he loves trails, that’s ultimately what he wants to get back to, but you feel that the juice just isn’t worth the squeeze right now, and you think it’d be worth building up his tolerance to running on level, flat ground before trying to handle trails. You talk about this with him, and he agrees. So, right now, trail running goes into 

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our no-go list. But, you have some informative details on his ability to do level ground running. So, you take into account the pace and distance he told you he ran, and you decide to start him out with a 

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progressive walk-jog program, to build up his tolerance to both pace and distance. A nice entry point back into running with certain boundaries to consider in terms of dosing, and a watchful eye to see how the knee responds. Ok, so for this second energy system slot here on Day 3, similar to what we talked about with finding a lower body strengthening exercise that could be trained with less limitation, you’d both really like some type of energy system modality, where he could really push, without much concern for the knee. After some talk, you both decide that either the 

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elliptical or swimming can go here. The person likes both. And could our walk-jog progression here on Day 2 turn into a 

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Key performance indicator? Heck yeah. The person handling more volume, faster pace, the walk-jog program simply turning into an entire bout of running. Introducing trails again. So, an example of a “no-go” activity shifting over to proceed with care. And during that time, perhaps he handles level ground running well enough that we’re actually able to push his heart rate and cardio with that, instead of having to use the elliptical or swimming. So, now you’ve introduced a second day of running, 

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Which itself, is a sign of progression. 

Ok, gosh, this was a jam packed lesson. But, before we call for today, a couple of things about what you’re looking at right here. One, 

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Our mental model of here of no-go, proceed with care, and full-go activities - there’s going to be some blurry lines between these categories, some gray area. If you use this model, you don’t have to fill all 3 categories. And movements or activities might move back and forth.  In this example here, we may have thought that trapbar deadlifts were a Full-go movement, but if those end up blowing this person’s knee up, that information goes into our feedback-based decision loop, and we update our mental model.  Secondly, As far as Key Performance Indicators (KPIs) - not all KPIs may be created equal.  As in, you may not care about all of the ones we mentioned here or put the same weight on all of them.  For example, what if this person’s running is progressing well, but their leg circumference measurements aren’t really changing - or what happens sometimes, they always skip the extra volume of resistance training here that you were hoping was going to help with hypertrophy. They just hate that part of the program and compliance is hit or miss. Or what if their back squat numbers have plateaued? Does it really matter in the big picture, for this person, considering their goals? Versus if that scenario was the other way around? Their gym numbers were progressing, but their ability to run had stalled. So, again, just because we can track or measure something, doesn’t necessarily mean it carries the same importance as other things. But that’s on you and the person to decide what’s important. Lastly, if you’re looking at how we laid out this plan, and you’re already thinking about ways you would have arranged it differently or modified certain things, or in your mental model, you would have put the activity of ‘running’ itself as its own category or bucket and worked backwards from there - that’s great!!  That means you’re thinking critically, that means you’re thinking in systems and considering principles vs. methods, and developing your own process. 

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Ok, let’s summarize our process so far. We’ve got 3 big picture checkpoints that we’ve discussed. Checkpoints that we should revisit during a plan of care, to audit our process, and to help us stay oriented to the big picture.

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Have we clearly “Defined our Role” in this person’s plan. Is it clear how we fit and what we are bringing to the table? And is that the same now as it was when we started?

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Have we come to a mutually agreed upon definition of what “done” or “successful” completion of care will mean? Or are we at least working towards that? Having explicit conversations with the person about what that might look like?

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And, our ever-important needs analysis. That doesn’t just happen in the beginning stages of working with someone. It’s an ongoing analysis, of 

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Where the person’s level currently is, 

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In relation to where they want to go. Two sides of the same coin, that are informed by 

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The requirements of the desired activity,

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And the person’s current boundary conditions that you establish through clinical findings, that help to inform the entry points for your exercise prescription strategies.  Whoooo, we are building something special.  See you soon.

BCs: Leverage Points & Rate Limiters pt. 1

Ok, let’s start this lesson the way we ended the last one - regroup, reorient, and summarize some key things that we’ve covered so far:

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Our person has certain activities that they want to get back to doing, and are 

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currently some level removed from being able to do them the way that they want to.  And are looking 

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for guidance from us to help shape the path back to where they want to go via exercise prescription. In order to do that effectively while managing all of the uncertainty and ups and downs of clinical practice, it’s helpful to have 

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checkpoints or guiding principles that we can come back to in order to ensure that we’re on a solid path.

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Are we clear on our role in the person’s situation? What exactly are they expecting from us and how does that fit within their lifestyle and any other potential stakeholders that might be involved? 

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Have we, or are we working on defining what “successful completion of care” or “Done” is going to mean? A mutually agreed upon state in which they have progressed to some degree along this path. How far along the path and how that is defined is exactly what needs to be hashed out with the person, and what is represented by the checkpoint of “defining done”.  If you’re still a little unclear on those concepts or maybe you’ve forgotten some of the key points, I recommend you go back and re-watch those lessons. And, by the way, a really powerful Brain Gainz habit, in general, is rewatching and rereading things you’ve gone through in the past. Since we’re not in the matrix, where we’re just downloading information into your brain, just because we watch a lesson or read something one time, that doesn’t mean we’ve truly internalized the concepts to be able to use practically. It’s like when you watch a movie for the second time, and you pick up on something new. Every time we go back and rewatch a lesson here, we’re coming into it a slightly different version of ourselves. With more clinical reps in the tank, different experiences than last time, a different knowledge base as a whole. Those subsequent exposures to the same material will continue to bolster your understanding and ability to apply the information.  Ok, so that aside, aside… Defining your role, defining done.  And then,

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In some form or fashion, a “Needs Analysis” should take place. This is you, gaining an understanding of the demands of their desired activities that will be relevant to your plan of care. Biological and physical demands, psychological, social, environmental. That is, just trying to gain as clear an understanding as you can, in terms of where it is they want to go, and what it is that they need to be prepared for. And when you’re thinking about the demands of their desired activity, a useful mental model for you might be to 

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‘bucket’ certain qualities, treatments, movements, or exercise categories that you feel are relevant for those demands. These are buckets of need that you’ll look to ‘fill’ with your exercise prescription and plan of care.  So, that covers the, 

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“Where do they need to go” part of the Needs Analysis. And from that as a reference, the other piece of the needs analysis is determining the person’s current state, their

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Current boundary conditions

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where they are in terms of their thresholds for being able to handle those demands that were determined from the first part of the needs analysis - as best we can, we want to establish where those boundaries currently are, so that we know how far we need to go, and because establishing those current boundaries and thresholds provides us with useful information in terms of informing our ‘entry’ points for fulfilling those buckets of need.

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We provided some examples here of boundary conditions and thresholds that you can try to establish, with movements or activities that are relevant to the person’s goals and that coincide with their current limitations. And these thresholds can often be measured and tracked, acting 

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as ‘key performance indicators’ or KPIs. Information that will go into 

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your feedback based decision loop, to help you and the client see if things are headed in the right direction. As in, oh the person’s intensity threshold is rising, their range of motion threshold is improving, or we were able to introduce a meaningful movement back into the fold, albeit with modifications, but prior to that was unable to be performed in any capacity. — And of course, all those things could be spiraling the other way as well, which is obviously not the direction that we want, but still important information that goes into our feedback based decision loop and informs future decisions. — We look at all of this, and it seems like a lot of information that you could glean, and it is. It’s a good bit of info and very powerful in devising and monitoring the program.  But, of course, it’s not close to all of the things that could be intervened on, and not close to explaining all of the interacting factors that influence this person’s status and progress. After all, this is a reductionist model - categorizing each one of these metrics, nice and clean, progressing each threshold little by little.  Slowly increasing range of motion, or load, or volume. Maybe we even imagine it happening in this nice linear fashion and the client is just happy as can be the whole time. But, we’re systems thinkers. We know that practicing reductionism is important and even necessary at times, zooming in on certain facets of the program or the person’s situation. But, we also know that it’s important to zoom out, to see how things fit into the broader picture for this person. So, let’s do that now. Let’s zoom out and consider these factors that you see here, along with others, within a broader view.

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Let’s go back to our trailrunner who was recovering from meniscus repair 6 months ago, that we talked about in the last lesson.  

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Remember our web of determinants model? We’ve got all of these interacting factors, or system boundary conditions, that may help to explain a subsequent pattern, event, or behavior that might emerge from these interacting factors. That event or behavior loops back and influences those very same factors. A recursive loop. So for our trailrunner, we’re talking about all of the interacting factors that may have influenced (1) why they got hurt in the first place, (2) their rate of recovery from surgery, (3) how they are going to respond to your exercise program, and of course, your exercise program now injects itself as a part of this web of interacting factors.  And, if the “emerging pattern” so happens to be that this person’s knee range of motion and force production capabilities progress well, their tolerance thresholds to running are improving, and now they’re able to participate more in the things that they want to do, well that introduces a whole new dynamic to the system and greatly influences how these factors interact..  The web of interacting factors influences the behavior of the system, the behavior of the system feedbacks and influences the web of interacting factors. A recursive loop. And this is how things play out in the clinic a lot of times, when we really think about how this manifests in real life. The person’s progression through the plan introduces new questions, or opportunities, or obstacles that weren’t there before. Like, what if a person had previously canceled their gym membership because they were afraid to workout and just used some of their light equipment at home. You work with them for a little bit, they progress well, and in order to continue that progress, it’s like, oh shoot, we have to get a gym membership again. Or maybe this runner was starting to feel really really good, and just got a little too excited and went rogue and ran a trail that wasn’t part of the plan yet, and had a flare up from it. That emergent behavior, hitting that trail wasn’t even a thought before, because they felt so physically and mentally far from being able to do that. Similarly, a common thing that will happen with the athletes that I work with, is that over time their hard work and consistency is paying off, we’ve got a nice little system going, minor set backs are managed effectively, but then they might hit me with a question like  - “Hey since things have been going pretty well, I looked at some competition dates and wanted to get your thoughts on me doing a competition in the next 12 weeks. Which was something that wasn’t even on their mind before, heck maybe their initial goal was just to be able to train somewhat normally again. But, web of determinants interact, and when things go well, that might feedback into the system and manifest itself in the person getting a sense of feeling a little like they used to — thinking, dang, I want to compete again. And, that will open up some important dialogue, because our program to continue reconditioning without the pressure or boundary condition of a timeline or upcoming competition, might look a lot different than attempting to train for peak performance. So, I bet this will be something that you start to take notice of. How these recursive feedback loops manifest in real world scenarios. I believe this concept was described by The late Notorious B.I.G as - 

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Mo’ money, mo’ problems.  Also, in those examples I just gave, they all were in context of someone who’s progressing favorably, but of course, these recursive loops can and do spin out in the wrong direction too, including in people that I work with - which would be a complex systems way of explaining the 

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drift into rehab purgatory. — Ok, now, we said we were going to zoom out, so let’s just brainstorm some of the factors that might make up this trailrunner’s web of determinants. 

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Again, this is just a quick brain dump. We could fill slides and slides with factors that might make up this person’s web of determinants. All of the possible interacting factors that contribute to their situation. But actually this is a really useful practice for us to do. If you ever find yourself overthinking your exercise prescription, or feel like you’re stuck zoomed too far in, or your brain just feels stuck in general with how to move forward with somebody — perform this web of determinants brain dump. And a brain dump is just that, don’t think about the most “important factors” just yet, just brainstorm any and all potential factors that might be contributing to this person’s situation. You might uncover some things that were previously hidden from your mind. Now, as the provider, what we’re doing with our plans of care, is that we’re trying to manipulate factors within the person’s web in various ways to nudge the interaction in a certain direction, to nudge the system to ‘behave’ or ‘adapt’ a certain way. Specifically, in this course, we’re thinking about how we can leverage our exercise programs to do just that - using exercise to leverage some of these factors and nudge the system towards a certain behavior or adaptation.  Now, I’ve used that term twice now - leverage.  Because it’s going to be one of our principles when dealing with complex systems in the clinic. Think of these interacting factors as potential 

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“leverage points”. A leverage point is anywhere in a system that we can intervene and potentially influence the subsequent behavior or adaptation of that system. And what we can ask ourselves, is how much influence does a certain factor or group of factors have on the system, how much leverage can we gain by intervening on it?  How much “return” or ‘bang for buck’ will we get towards the person’s goals, if we intervene on that leverage point. Because we learned from the web of determinants model here, that some factors have a greater influence than others, depicted by darker circles. Meaning, hypothetically, if we can intervene on those particular factors, they might provide ‘higher return, or be a stronger leverage point in our plan. And then other factors might be modifiable, we might be able to intervene on them, but doing so might not provide much yield or return, or leverage towards the adaptation that we’re looking for or the person’s goals. For example, is upper body strength or upper body strength training going to give us a whole lot of return or yield if we spend all of our time intervening on that? Is that a strong leverage point for this person whose goal is to rehab a knee for trailrunning?  Maybe in the sense of being able to fill the green ‘Full Go’ bucket with movements that at least keeps the person exercising (if they want to do that), but otherwise, upper body strength training might be a weak leverage point. Spending time intervening there might not move the needle much for this person and their specific goals.  But what about manipulating the running surface and manipulation of training load? We talked about that in the last lesson for this person, setting parameters on running surface and dosing return to run. Potentially a lot of bang for buck there, a lot of return on investment. Strong leverage points. Now, what’s cool is that you might disagree or feel that some other factors provide just as much leverage, and that’s great. Again, what that means is that we’re all just working off the same principle of what a leverage point is in the first place, and then we can discuss from there. So, when it is the case, and it often is, that there are a lot of potential leverage points in the system that we could intervene on, we look for the leverage points that we think will provide the greatest return, the most bang for buck. The ones that will provide the system (the client) with the most opportunity if we’re able to make a change there. Think about that, what factor or factors, if we were able to make a change in, would provide the person with the most opportunity to move towards their goals. To take that further, are there factors that, not only do we think they are strong leverage points, but if we don’t modify that factor, then other things can’t or won’t have as much impact. As it’s often described in systems theory - the most important factor or factors of a system are thought to be the ones that are most limiting.  

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AKA - the rate limiting factors. The rate limiters. The bottlenecks in the system. That pretty much, by definition, are high-return leverage points, strong leverage points, where again, if we can create a change in that factor and sometimes even a small change, will provide a lot of opportunity for the person to move forward towards their goals. And on the flipside, if we don’t address that factor, then other things can’t or won’t have as much impact.  If we step away from the runner example for a second, - in any early post-operative scenario, we’re often prioritizing tissue healing and range of motion. That’s because those things are often bottlenecks - we can’t do a lot of stuff until the tissue heals, and we’ll also have trouble progressing exercise if the area that got the surgery is constantly inflamed and/or doesn’t move. And we could brainstorm other scenarios where the concept of rate limiters is relevant - if you’re working with a swimmer who’s trying to get back to doing the freestyle stroke, it doesn't matter much if they have a surplus of external rotation shoulder strength down by their side if they can't raise their arm over their head. So, again, in that case, range of motion would be the rate limiter or the bottleneck for their desired activity, but also a high-return leverage point. A strong leverage point. If we make a change there, we open up a lot of opportunity to continue making progress. In a performance example, let’s say it’s a football running back and they can run really fast and really hard for a couple plays, but then they have to sub out on crucial plays because they’re just gassed. So, all that speed doesn’t do them much good if they’re huffing and puffing on the sideline. So, in that case, the rate limiter of their performance would be energy system development.  You might have a person who just keeps flaring their issue up with whatever their activity is. And you could throw all of the rehabby exercises at them you want, but they’re just going to go out and go HAM and blow it up again.  In that case, the rate limiter is just their tolerance to training load, but also the management of their training load. Nothing we do is going to matter much unless we put some boundaries on what they’re currently doing, so that things can calm down. ACL rehab - stopping on a dime from a full forward sprint and changing direction becomes a lot more difficult when your peak knee extension torque is only 40% of your bodyweight. So all of those awesome high-level cutting and change of direction and deceleration progressions that you might be excited to implement might be halted right now because there’s a bottleneck in the system that needs to be addressed - in this case, peak muscle force output. 

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Speaking of ACL as just an example, this is a graphic from that same paper that gave us our web of determinants model, and they used ACL injury as the emergent event in two different examples here on the left and right. The difference being that this web of determinants on the left is for a basketball player, and on the right for someone in ballet. And what you’ll notice is that the profile of factors is different. Now, don’t get too hung up on the specific terms they used, like you know, what is “foot misalignment?”  But rather, consider that the importance of certain factors - whether they are strong or weak leverage points or rate limiters might depend on the activity, in the context of that individual.  The even put ?? marks here just to depict one of those factors that are influential, but that we either don’t know about or can’t measure or intervene on. An ode to our lesson on Process where we talked about the unknown unknowns within uncertainty. What this model also depicts, is that certain factors might have a greater influence if they are tied to other factors in certain contexts, which is represented by the thicker or thinner, and dotted connector lines here.  Fatigue might not be an issue, until the athlete is required to manage a very dynamic situation. The person might be able to get away with a lack of sleep, until training load increases, and then sleep starts to become a bottleneck. Same with something like force production or strength within a certain body part or movement - becomes more or less relevant depending on the task.  And, looking at these factors, there are many instances where what you feel might be strong leverage points or even rate limiters, are things that are less in your control as the provider, or are just more difficult to control, difficult to measure, difficult to intervene on, and maybe just downright beyond your scope of knowledge or practice. Think about things like sleep, nutrition, and other psychosocial factors. And if you do feel that any of those factors are within your scope of knowledge and practice and are able to be intervened on and will provide a lot of return, then that becomes a bucket of need, and you treat it like we do any other - what is the person’s current boundary condition around that factor, what’s your entry point to intervene, and how are you tracking progress for that leverage point - what’s the KPI?  Which brings me to an important aside, in the case that a factor that you deem important is not measured or easily measured, that doesn’t mean it’s not important, it just means it’s not being measured. So, a person’s fear of return to activity for example, maybe you use a standardized patient reported outcome measure to track that, maybe you don’t, that doesn’t mean that acknowledging fear avoidance isn’t important. Part of having a process and being able to audit yourself is knowing what components of your plan are more data oriented versus not, or knowing where you’re intervening directly versus secondarily.  So, with fear avoidance to activity, maybe you’re not sitting them down with cognitive behavioral therapy, but you’re grading exposure to fearful exercise, providing encouragement, answering their questions, asking them questions, etc. And now when we have discussions about your case, and someone asks how you’re addressing and measuring fear avoidance, you’re able to describe your process - whether you have specific interventions or measures for that factor or whether you feel it’s baked into what you’re already doing elsewhere. And, of course, there might be other pretty important or serious things that could become rate limiters - what if you suspect an eating disorder? Social abuse, depression. Things that could have very high return for this person if they are addressed, but you then also have to consider whether you have the knowledge, skills or scope to intervene on that and, if not, potentially refer out.  

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Let’s summarize some of the key points about the concepts of 

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leverage points and rate limiters. When we did our brain dump

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of all of the possible leverage points for this person, and some of the other examples that we talked about, you might have noticed that these factors fall 

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within various levels of the Systems Hierarchy. Some of these factors, these boundary conditions relate to the individual and maybe at certain biological levels - tissues, joints, energy systems. Whereas other factors here are describing boundary conditions within the environment or the task itself. We talked about how certain factors become more or less relevant, depending on the task or environment. So, you see how our two models here of the web of determinants and systems hierarchy are complimenting each other. And that’s why being a multi-model thinker is so powerful, because you can start to make those connections and use them to create an even more robust mental model. So, let’s just take a minute to play around with combining these models.

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We’ve got our systems hierarchy. And we know that various biological levels interact and self organize to create system within systems, all the way up and down the hierarchy, and the emergence of a movement is dependent on what the task requires, the characteristics and attributes of the person, and within the context of the environment that the person is performing the task in. So, we might be able to encompass all of that with something like this:

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Representing interacting factors relevant to the individual, the task, and the environment that we are considering in our plan of care.  

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And then, we’ve got the web of determinants, which helps us conceptualize the idea that certain factors might hold more weight, or have stronger influence on the system depending on the context of the task, environment, and the individual’s boundary conditions. 

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So, maybe we throw in the web of factors here in the middle of our individual-task-environment triangle.  So, now we have this little short hand model, combining the systems hierarchy and web of determinants, to represent the multi-factorial emergence of an outcome - an injury, an adaptation, a behavior or any event within a complex system.  So, let’s take this and use it to summarize some of the main ideas about, leverage points and rate limiters.  

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A leverage point is anywhere in the system that we might be able to intervene. That could be at the individual level, the task level, or the environment level. Some leverage points are stronger than others and more limiting to the system than others. The most limiting factors are known as 

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the ‘rate limiters’. The bottlenecks in the system. And we learned that not all leverage points are rate limiters. As we discussed, our trailrunners max bench press is probably not a limiter to their knee rehab, and thus, intervening on or leveraging upper body strength probably won’t bring us a lot of return. And, not all rate limiters are leverage points. As in, just because something is a limiting factor, doesn’t mean we can do anything about it. It might be non-modifiable. If we can’t intervene, then it’s not a leverage point. 

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Such as considering Shaquille O’neal’s potential as a champion jockey. We probably don’t have much leverage to intervene on the individual rate limiters - namely his size, to optimize his riding capabilities. We’d have to leverage task or environmental aspects of the system. Change the rules somehow, have them ride elephants, or a manipulation of some other modifiable boundary condition that would have made his size an advantage instead of a rate limiter. 

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So, when taking it back to our runner, and really any case that you’re working with, you’re considering 

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all of the possible leverage points, all of the possible places and ways to intervene, and you’re considering what factors are currently most 

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limiting to the system, and how much opportunity it would provide if change could occur there. Or in other words, you’re identifying what you feel are the most relevant or important 

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buckets of need at the current time. Because, of course, we can’t address everything all at once a lot of the time. So, it will help you prioritize, if you’re able to think about which factors or buckets of need are currently the most limiting and will provide the most return if a change is able to be made. What do we need to work on first, before we can get to X.

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Let’s revisit the program that we had written for our trailrunner with our new concepts of leverage points and rate limiters in mind, and build it out over a longer period of time, to see how things could play out. We’ll pick right back up here in the next lesson.

BCs: Leverage Points & Rate Limiters pt. 2

Ok, so we’re going to revisit the program that we had written for our trailrunner who was 6 months post op meniscus repair. We’re going to take things a little further and deeper into this program, and tie together a lot of the concepts that we’ve gone over thus far. So, here we go. Our initial process was to determine relevant buckets of need - and to 

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establish boundary conditions for those needs. What do they have compared to what they need? Where are they in relation to where they need to go? Our buckets of need for this trailrunner ended up being these:

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Kinematics - to represent knee range of motion, as this person was still missing a little end range extension and flexion. The energy system bucket representing general energy system development and it included the person’s return to run progression. The kinetics bucket represented our lower extremity resistance training that we felt would be helpful for this person. And the tissue specific bucket, represented the interventions that we threw in to provide some extra lower extremity hypertrophy stimulus, because we had determined that there was some atrophy present.

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And we would establish the person’s current boundary conditions for each bucket of need. Measuring knee range of motion, determining tolerance thresholds for running - pace, distance, tolerance to running surface, weekly volume, if you were going to do something like an aerobic capacity test on a bike or something like that, that would all be included in the current boundary conditions for that bucket of need. Any and all clinical findings relevant to that bucket. Our kinetics bucket or lower extremity strength could be measured by any other formal strength testing that you deem relevant, having them perform resistance training with a certain weight to a certain rating of perceived exertion and noting any symptoms, that could act as a baseline resistance training tolerance test.  Our tissue specific boundary condition could be determined by circumference measurements comparing side to side to indicate any changes in muscle hypertrophy.  And everything I just mentioned, could be a measurable to help track progress. 

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or a Key Performance Indicator. Changes in range of motion, changes in the person’s ability to handle more intense or longer runs, changes in your strength testing, to include the ability to move the same amount of weight at a lower rating of perceived exertion, move heavier weight for the same # of reps at the same rating of perceived exertion, changes in lower extremity circumference. So, this is actually a nice, broad overview of our process so far. What buckets do you want to fill with your program, what’s the person’s current ability, current status, current condition, in relation to that need, and what are you using to track progress. Now, let’s go back through what we decided to do for this person, using our new concepts of 

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Leverage points and rate limiters. So, what did we do? We considered this person’s 

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Web of determinants. All of the interacting factors pertaining to the individual, the task being performed, and the environment in which it is performed, that might contribute to their recovery and response to the our program, and we identified leverage points that we felt were relevant to helping the person achieve their goals of trailrunning again. We decided that regaining full knee range of motion would provide a lot of return for this person to tolerate running, that it would be a strong leverage point, so we decided to fill that bucket with some sort of range of motion intervention 

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3 times per week. One slot for each day on the program. We also decided that addressing energy systems for this person would be a strong leverage point to help them achieve their goals, so we put that down 

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2 times per week. But, if you remember, this person couldn’t tolerate trails at all. Trailrunning went into our 

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No-go list for the time being. We were bottle-necked, by the person’s tolerance to trailrunning, to the point where the juice just didn’t seem worth the squeeze. But, he could handle flat ground running, so we decided to do a progressive flat-ground running program, starting with a walk jog progression, which because we had some boundaries around that running progression, we considered that in our 

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proceed with care list. On this second day of energy system work, we wanted an energy system modality in which the knee was not a rate limiter, where we were not bottlenecked by tolerance, which would allow us to push true cardiovascular thresholds a little more - we decided that was going to be the elliptical or swimming, which went into our green

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Full go list. We also decided that lower extremity strengthening was a beneficial leverage point to spend time on. For at the very least, to supplement some mechanical load through the legs, while the person’s running volume was decreased. 

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So we threw that in twice per week.  Now if you remember, the person did like to squat, and would like to do those in the program, but they had some tolerance boundaries to range of motion and load. We were ‘bottlenecked’ a bit by the person's tolerance to the squatting pattern. Not so much that we couldn’t do it at all, but enough that we needed to put some boundaries around the movement. We can do the pattern, but have to 

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proceed with care with the dose and variation, a goblet squat to a medicine ball was what we landed on.  For the second slot of lower extremity training here on Day 3, we wanted a variation that wasn’t bottlenecked by the person’s load and positional tolerance, so we decided to do a 

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trap bar deadlift on that day, and assumed that we would be able to train and progress that movement more normally.   And then, because we noticed some atrophy of that surgical leg, we decided to 

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leverage some extra resistance training work here on Day 1 aimed at driving a hypertrophy response. Now, what you may have noticed is that just the frequency with which we address certain buckets speaks to what we think are stronger leverage points and potential rate limiters. If it’s a rate limiter, you probably want to address it more frequently than weaker leverage points. In this case, we’re hitting range of motion on all 3 days, which speaks to our thoughts of its importance and rate limiting qualities. Now again, this is us speaking hypothetically. If you have different thoughts about what the strong or weak leverage points are and what the rate limiters are, awesome. That’s what we want. Your program very well could look different than this, in terms of its structure. — But regardless, from here what do we do? We monitor progress - monitor KPIs, hopefully things that were once rate limiters are less so, movements are moving from red, to yellow, to green, the person is feeling more confident, on board with the plan — or some of those things are moving in the not so great direction, either way, that information goes into our 

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Feedback based decision loop and informs the next moves.  Alright, before we forward with this, can we first just appreciate this slide. Oh my, thank goodness for animations, because what if I had just hit you with this mess all at once.  I kind of like it though, because it’s got so many of our mental models in one place.  But let’s 

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clear a bunch of this for right now, just down to our basic skeleton of a Needs Analysis - what do they need and where are they in relation to that. I’ve mentioned many times now, that how we are structuring things is not set in stone and I want your creative juices to flow. But to help with that, I just wanted to show you how my brain would probably organize things in this particular case, just so you can see alternatives. The term Kinematics here, I would probably just categorize as 

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knee range of motion. That’s the specific leverage point and bucket that I want to address in the program, so that’s probably how I would categorize it. 

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So we’ve got that the same as before as far as where it lands in the program. i’m going to skip over energy systems for a second and go to kinetics and the tissue specific bucket. We mentioned that for this particular case, the term “kinetics” just represented our lower extremity resistance training program, so that’s just probably what I would call it in my mental model:

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Lower extremity resistance training, which 

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Looks the same on the calendar. Our tissue specific bucket, represented our muscle hypertrophy work, so I’d probably just think of this bucket as

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Hypertrophy. So, my brain maybe starts with those very generic descriptors - kinetics, kinematics, tissues (because forces, positions, tissues - it makes sense as a starting point), but then I move to categorizing things based on what they are specifically. This is not groundbreaking nor am I showing you because I think it’s ‘more correct’ this way. I’m showing you this because all of our brains think about things and visualize things a little differently. So, don’t hesitate to make these kinds of changes to make the process your own and to better jive with your mental model of things. Now, for this energy system piece, what we did was include our running progression within this broad descriptor of ‘energy systems’.  Personally, I would break this up 

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into a “Running” specific bucket and the original energy systems bucket. For a few reasons. 1. This person’s activity of choice is running, and so I just like to make sure that the goal remains the goal, and if I have a specific bucket for the thing it helps to make sure that we don’t forget what the ultimate goal is. 2. Because this person's running tolerance is pretty low right now, I’m not sure it would even be accurate to call the running they will do in the beginning as “energy system development” because it might be so low-level that it’s not actually stressing their energy systems enough for an adaptation. We’re bottlenecked by tolerance. And 3. Related to the two previous points, our return to run progression will be a very specific thing. It will be walk-jog intervals to sustained running, from flat ground to the introduction of trails, and separating those specific running progressions from the non-running energy system work - the elliptical, the swimming, the exercise bike, just helps me keep things organized in my mind. So, then our initial walk-jog program is what

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Would go here on Day 2. And our swimming or elliptical, where we were pushing cardiovascular physiology more, would be 

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here on Day 3. Ok, so nothing huge here, just what my personal mental model would look like — But ok, so, what might it look like when we’re progressing this person through the program and boundary conditions are changing over time. Bottlenecks are no longer as limiting or no longer bottlenecks? 

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Let’s say, we’re looking at our program in two week increments. So, this is just the same series of workouts, repeated 3x, in 2 week increments, for a total of 6 weeks.  Now, nothing is ever this clean in real life, but just for the sake of the example. Let’s say lower extremity resistance training and hypertrophy is just going to stay relatively constant for these 6 weeks, in terms of frequency. But let’s say range of motion progresses really well and quickly. You could keep it 3x/week, but the person thinks those slots are kind of tedious and range of motion on the surgical side is pretty much the same as the non-operative side now, so it’s not really a bottleneck anymore. So, you’re able to reduce frequency down from 3x/week

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to 2x/week to 1x/week. You keep it in there just for a little maintenance and as a weekly assessment to make sure it’s being maintained. 

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So, that range of motion bucket kind of gets faded out in our mental model here. It’s no longer a limiting factor and no longer a strong leverage point. Spending more time there is going to bring less return. All good things. And because the person’s range of motion boundary condition has been lifted, our squats on Day 1 no longer have to be modified by having him sit to a medicine ball. And so, we’re now able to program squats in a manner that we would for any client, not just someone with a knee issue, which means it’s moved from our yellow proceed with care list, to our 

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green full go list. For weeks 3-4, the client requested a second day of non-running energy system work, since that’s in our green zone and hasn’t caused an issue, and he just wants a little more work in that regard.

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So, you put that in on Day 2. The client also requested a second day of flat ground running. You think, well he’s done well with the work so far. Ok, we’ll add a second day of flat ground running, but only half of what he does on Day 2, just to err on the side of caution.

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So you put that here on day 3. Things go well and we get to Week 5, and a few things happen. First, he tells you that he just hates the extra hypertrophy work on Day 1 and never does it. Ok, fine.

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So, you take that out of the calendar and nix it as a bucket of need, but you tell him, if we end up having any issues in the future, this is a potential leverage point that could be helpful. He says ok ok, I get it. But what’s also cool, is that this run on Day 2 is turning into a pretty long one, that definitely gets his heart rate up, which is ticking the box off for our second energy system day as well.  Which he prefers, because he doesn’t really like swimming or the elliptical.  

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So, just as a visual here, I’ve made this a slot of kind of half and half to signify that it’s a longer or more intense run that covers our energy systems day as well. And I faded the energy systems bucket up here, not all the way, but a little, to signify that we’re beginning to shift to having this bucket taken care of by our running bucket. And by golly, wouldn’t you know it, 

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by Week 6, we introduced trails back into the fold for the first time, here on Day 1. A movement that was in our red no-go list, has moved into our yellow proceed with care list, and our guy is doin some version of the thang. We leveraged the fact that we could establish running tolerance through means of manipulating certain boundary conditions of the task - surface (we started with flat ground), intensity of running (keeping bounds on the pace), and volume (weekly volume of the runs). We did that for a sufficient amount of time, in this case 6 weeks with no major adverse effects, discussed with the person how they felt about a re-introduction into trailrunning as part of the informed consent process - and then we establish an entry point to that bucket, by manipulating certain variables, certain boundary condition  - starting with a trail with a low grade of incline maybe, putting distance and/or pace boundaries around the prescription, depending on what threshold is more of their rate limiting factor. Meaning - maybe pace is what really gets them in trouble, or it’s the overall volume, or it’s the incline going up or down that’s more of the rate limiter - and of course, it’s often a combination of factors, but you’re just thinking to yourself, which of these variables or set of variables are most apt to cause an issue and what we want to put some boundaries around. And then you can expand the boundaries a little bit for the variables that they can handle better. 

And because of all of that, I gave it it’s own bucket, for the same reason that I separated flat ground running from energy system work before, that’s just how my brain works - we’re going to have some relatively tight bounds around the dose of trailrunning so I just want to think of it as it’s own component of the program. So, you see how things can evolve over time, as boundary conditions change, leverage points change, rate limiters are no longer such, and human things happen, like him admitting that he just doesn’t do the extra hypertrophy work. You might still think it’s a leverage point, and depending on how important you feel it is, you might be a bit stronger in your dialogues and recommendations to keep it in the program. I just wanted to include that as a real life curve ball that happens. Because what if things don’t quite progress this linearly, and the person’s knee keeps blowing up with flat ground running. You look and the person hasn’t really been compliant with their resistance training work, it might be time (1) to re-assess how the flat-ground running is being dosed, and potentially for a ‘real-talk’ conversation, in which you can use some of our terms in your dialogue with the person - like “Hey, it seems like the knee’s ability to handle forces is the limiting factor right now”, and I think the gains we can make with the strength and hypertrophy components of the program can really bring a lot of high value and leverage there. Do you agree? If so, what can we do to help make it easier for you to get that stuff done?”   Along those lines — And, I know I don’t need to say this, but I will - in real life, things might and often do progress more slowly, there are might be set backs, or other modifications made to the structure of a program like this. There also might other 

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leverage points that you include in your plan of care, that don’t necessarily get their own bucket or slot in the program, but that you might still address. Or at least have a conversation with the person about. Things like

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Footwear

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Manual therapy and other modalities

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Running technique - cadence, step rate, or how their foot strikes the ground - heel vs. forefoot. So remember, if you get stuck with a case and think you might be missing something, perform your leverage point brain dump. You might also feel there are other 

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rate limiters for this person that we didn’t discuss here, that you feel are worth their 

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own spot in your plan of care. Things like

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Fear

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Pain modulation. Maybe it’s an acute case and the person’s symptoms are very reactive, to the point where things like manual therapy and modalities might make up a decent amount of time

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Sleep

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Nutrition. But, keep in mind our process. If you think it’s a strong enough leverage point to become an explicit part of your plan of care, then we do our best to 

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Establish where the person’s current status is, in relation to that need and try to establish some type of way to track or measure progress for that need. And if you can’t, then you just acknowledge that there may be some ambiguity with that particular leverage point or aspect of the plan. Regardless, we are building a stellar process. See you soon.

Entry Points pt 1:

Ok, let’s regroup again, and run through our process so far, from the top:

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Our person has certain activities that they want to get back to doing, and are 

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currently some level removed from being able to do them the way that they want to.  And are looking 

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for guidance from us to help shape the path back to where they want to go via exercise prescription.  Now, in order to do that effectively while managing all of the uncertainty and ups and downs of clinical practice, it’s helpful to have 

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checkpoints or guiding principles that we can come back to in order to ensure that we’re on a solid path.

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Are we clear on our role in the person’s situation? What exactly are they expecting from us and how does that fit within their lifestyle and any other potential stakeholders that might be involved? 

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Have we, or are we working on defining what “successful completion of care” or “Done” is going to mean? A mutually agreed upon state in which they have progressed to some degree along this path. How far along the path is deemed “successful” and how that is defined is exactly what needs to be hashed out with the person, and what is represented by the checkpoint of “defining done”.  And then, in some form or fashion, we perform a 

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“Needs Analysis”. This is you, gaining an understanding of the demands of their desired activities that will be relevant to your plan of care. Biological and physical demands, psychological, social, environmental. That is, just trying to gain as clear an understanding as you can, in terms of where it is they want to go, and what it is that they need to be prepared for. This will help you create a mental model of the things that you want to address in your plan of care and exercise prescription. You might create 

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‘Buckets of need’ in your plan. Creating categories that represent the qualities, treatments, or exercise modalities that you feel are relevant for the person and their desired activities. You’ll look to fill these buckets of need with your exercise prescription and plan of care.  So, that covers the, 

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“Where do they need to go” part of the Needs Analysis. And from that as a reference, the other piece of the needs analysis is determining the person’s current state, their

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Current boundary conditions

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where they are in terms of their thresholds for being able to handle those demands of their desired activities - as best we can, we want to establish where those boundaries currently are, so that we know how far we need to go. 

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If this helps, you’ll remember that a 

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Needs Analysis is sometimes referred to as a 

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Gap analysis. Describing the gap between where the person currently is, and where they want to go. Their current conditions in relation to their buckets of need. And if there is a gap, we’re obviously looking to help the person fill that gap. We also mentioned that, in order to know if we’re making progress, if possible, it’s helpful to attach some type of measurable to each bucket of need. 

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A Key Performance Indicator, or KPI, as part of your dashboard for the person. Relevant, meaningful metrics that ideally you can associate with a standard, even if that standard is just their prior performance or condition. 

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We provided some examples here of boundary conditions and thresholds that you can try to establish with the person. These would be thresholds within any movements or activities that are relevant to the person’s goals and that coincide with their current limitations. And these thresholds can often be measured and tracked, acting 

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as one or more of your ‘key performance indicators’ or KPIs. Information that will go into 

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your feedback based decision loop, to help you and the client see if things are headed in the right direction. As in, oh the person’s intensity threshold is rising, their range of motion threshold is improving, or we were able to introduce a meaningful movement back into the fold, albeit with modifications, but prior to that was in our Red No-Go list, unable to be performed in any capacity, and now they can do a modified version. — And of course, all these things could be spiraling the other way as well, which is obviously not the direction that we want, but still important information that goes into our feedback based decision loop and informs future decisions.

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Now, sometimes you might get stuck and think, gosh there’s so many potential buckets of need for this person I don’t know which ones to try to address, or we’ve established some current boundary conditions for the person, but I’m not sure which ones to prioritize. This is where we encouraged you to zoom out, 

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and brainstorm the leverage points in this person’s web of determinants. Leverage points being - what are all of the possible ways in which we could intervene. What are the modifiable factors that we have some influence on? 

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And which of these factors do we feel are most limiting? What are the rate limiters, the bottlenecks. Can we identify or at least hypothesize which factors, that if we don’t try to influence or modify, will significantly limit the client’s potential. Or said another way, can we identify or at least hypothesize which factors, that if we can influence or modify, will provide lots of opportunity for future gains. And at minimum, which factors do you feel won’t have much bearing on the system.  In doing this - in identifying the most relevant buckets of need based on the person’s boundary conditions and hypothesizing which factors are most limiting, we have useful information in terms of informing our 

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‘entry points’ for fulfilling those buckets of need, which is the next step in our process. As in, we’ve established where they are, and where they want to go. Well, how do we get our foot in the door, so to speak? What's our first step to get them towards those desired activities? What’s our first step in fulfilling that bucket of need? An entry point could be the first version of the thing, if you’re just starting with the person, and that probably makes the most intuitive sense when you hear the term “entry point”.  But you can also think of the concept of an “Entry Point”, as the next version of the thing, if you’ve been working with the person and are looking to progress.

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