Sprinting Down Mountains, and Other Speed-Based Fun

As most parents will attest, we are constantly amazed by the things our children attempt/accomplish, especially at an early age. My latest experience of amazement came on our trip to Maine, as I watched (and attempted to chase) my daughter running down Blue Hill Mountain, with reckless abandon.

This activity only allowed for a brief video clip, as I feared for my life/livelihood while chasing her on the rest of the descent! If this is Amelie descending a mountain, you can imagine the speed at which she pursues her flat terrain activities. Hooray speed work!

As I reflected on my potential for loss of life or limb, it got me thinking: When do we stop sprinting down hills? And for that matter, when do we slow down in all aspects of our daily movement practice?

Many of us would probably say that we notice this change as we get older.

My next question: Do we slow down because we age or, do we age because we slow down? Who says we have to stop running down the mountain just because we are not 4 years old?

Why Speed Work?

In my previous blog post, Running Away from Running, we dove into the benefits of speed training (or HIIT), as it relates to endurance training. Here are the Speed Endurance highlights^1,2:

1. HIIT causes a dramatic shift in the rate of energy depletion in the body, when compared to steady state cardio.

2. Both intensity and duration of training impact the body’s adaptation response.

3. Intensity of the stimulus is more important than the duration of the stimulus.

4. HIIT recruits more muscle fibers into the exercise – causes the muscle to use up available fuel sources faster. HIIT requires use of both fast and slow twitch muscle fibers, whereas endurance training primarily recruits only slow twitch muscle fibers.

5. HIIT increases mitochondrial density in muscles (improves the energy production/utilization capacity of the muscles)

6. HIIT is important for cardiovascular health – it improves the heart’s ability to pump blood (expressed as our VO₂ max) and improves the structure of the heart.

7. HIIT is safe for people with pre-existing conditions, such as cardiovascular disease and diabetes.

 

In an attempt to build on these principles of endurance training, why not incorporate more speed work into our entire plan of care?

 The Movements:

Speed Work Warm Up:

Why don’t we program more speed work as a warm up? The goal of the warm up is to efficiently prepare the body for activity. Per the American Heart Association, a warm up achieves this goal by dilating your blood vessels, ensuring that your muscles are well supplied with oxygen³. It also raises your muscles' temperature for optimal flexibility and efficiency³. The Amelies of the world spend their days bouncing off of walls in a perpetual state of "warm up," so their preparation time will be brief. The rest of us desk jockeys may want to take 5-10 minutes to knock the rust off of the joints with some speed work warm up movements.

Here are some examples of speed-based warm ups:

 

Jumping Jacks:

 

How about 30 seconds of Amelie Jacks to start the session and put a smile on your face? This movement provides an introduction to jumping that paves the way for the higher impact movements to come.

 

Hopping:

Next, try a couple of passes with the Amelie hop. Next stop, The Washington Ballet!

Medicine Ball Tosses:

 

The movements in this medicine ball series should warm up the upper body, trunk, and lower body. Start with 2 sets of 6 repetitions for each movement.

Speed Strength:

Utilizing speed as a component of strength training can be beneficial, as it improves your ability to produce power with your movements. Power is defined as the rate at which work is done. As it relates to exercise, power is the ability to generate lots of force in a short period of time².  As it relates to life, power is the ability to keep up with your 4-year-old daughter!

3 Pillars of Speed-Strength Training²:

1. Plyometrics – Involves the rapid stretching followed by shortening of a muscle (or group of muscles) to improve power.  Use of this stretch-shortening cycle (time to transition between eccentric phase to concentric phase) allows for greater contraction force than you would normally be able to produce during a movement. The delay between the stretching and the shortening phases needs to be very short – no longer than about ¼ second. Just remember - The quicker the eccentric contraction, the greater force generated during the subsequent concentric contraction⁴. Examples of plyometric activities include hopping, skipping, bounding, jumping, throwing, and swinging.

The kettlebell swing (shown above) incorporates the stretch-shortening cycle to engage the posterior chain (muscles on the back side of the body). This type of movement should be performed in sets of 5-10 reps in order to maintain maximum speed.

2. Speed strength^2,5 – Involves tailoring your strength movement to a speed focus, by scaling back weight and reps (similar modifications are made with our injured patient-athletes). Modifying weight and reps allows you to focus on maintaining maximal speed of movement across the entire set. Recommended volume is 3-5 sets of 3-5 reps @ 40-60% of your 1 rep maximum². The following example is a deadlift, a hinging movement similar to the kettlebell swing.

3. Complex sets² – Involves a strength exercise, immediately followed by a plyometric or speed-strength movement (ie deadlift followed by kb swing).  The rationale behind this approach is that the strength exercise primes the nervous system for explosive movement through the recruitment of more muscle fibers. Recommended approach – go heavy for 3-5 reps – rest 10 seconds – move explosively 3-5 reps – rest long (3:00).

The Speed Movement Principles:

1. The Warm Up is not your workout. It should efficiently prepare you for your workout.

2. When training speed-strength, less is more. Keep the reps low and speed high.

3. Rest long after each speed set. You want to completely recover between each set, in order to maintain speed across each rep and each set.

 

The Take Home:

Amelie has the world at her finger tips and plans to explore every nook and cranny, as quickly as possible. After taking a minute to admire her speed-based curiosity, I intend to do the same.

 

Addendum:

Please check out the References section for a list of the incredible books that have influenced my speed practice and this blog post. If you would like to learn more about how to incorporate speed training into your movement practice come hop, skip, and jump with me: https://thejacksonclinics.com/request-appointment/

 References: 

1. Gibala M. The One-Minute Workout. 2017.

2. Greenfield B. Beyond Training: Mastering Endurance, Health, and Life. 2014.

3. https://www.heart.org/en/healthy-living/fitness/fitness-basics/warm-up-cool-down

4. Wilk KE, Reinold MM, Andrews JR. The Athlete’s Shoulder – Second Edition. 2009 - Pg 751

5. Tsatsouline P. The Quick and the Dead. 2019.

Anti-Perspirant Integrity Test

My “Not-So-Baby” girl just turned four years old, so we decided to celebrate her pre-school status with a larger-than-life doll house.

While I was admiring my handiwork to assemble this monstrosity, I found myself marveling at Amelie’s determination to reach the tippy-top floor to put her Peppa Pig dolls in the attic.

This got me wondering: Why can’t many of us fully press our hands over our heads? Is it a fear of sweaty arm pits? We are in the midst of a DC summer, so I will not throw this theory out as a potential factor. Wait a minute…If this is the case, why do I also see this issue in the frigid, winter months? Is it a fear of exposing more of our bodies to the inclement weather?

Maybe, it is something far easier to explain: use it or lose it!  We stop trying to lift our arms over our heads, so we lose the ability to do so. Go ahead and try this test, I’ll be right here waiting (fully stretching my arms overhead):

Wall Flexion Test:

 

So how do we go from this:

My Muse:

To: “I can’t reach overhead, and I am moving all of the furniture to the bottom two floors of the doll house”?

 

10,000 Foot View:

People tend to fall into one (or more) of three camps – stiffness prevents overhead position, weakness prevents overhead position, pain prevents overhead position. Good news, we can treat all three, simultaneously! And, there is a ton of research that supports the utilization of overhead training in the presence of shoulder pain.

Many of my patients come in with pre-conceived notions that they should not be doing any resistance work over shoulder height. I find this puzzling, as many of the major muscles of the shoulder girdle work most effectively at progressive levels of shoulder elevation. For instance, the Serratus Anterior and Lower Trapezius muscles demonstrate improvements in activation with progressive levels of arm elevation^2-4 .  Additionally, the Overhead Press has been established as a movement that facilitates increased upward rotation and posterior tilt of the scapula, and reduced scapular internal rotation (all of these motions facilitate better reaching overhead)¹ .

What happens if I cannot get my arm fully overhead to effectively train these muscles? Train in the motion you possess! Numerous studies have shown the value of “partial range of motion” training, including a “training overflow” of 30 degrees beyond the training range^5-6. Just keep your eye on the prize, stretching ever closer towards that top floor of the dollhouse.

 

The Movements:

Broken record alert: A strong overhead game cannot be restored overnight – it will take MANY repetitions of purposeful movements, that are salient, specific, and build in intensity. ***As a dedicated reader of my previous blog posts, you may have noticed that I cut and paste this line from “Step Up Your Ground Game,” and replaced “ground game” with “overhead game.” I promise you that this is for the sake of reinforcement of principles, not the author’s laziness.

Principle of Movement – Mobility comes first! You cannot be strong in a position if you are too stiff to get there, in the first place. The following movements utilize weight/assistance to improve overhead mobility.

 

Pull Up Hold:

Haven’t hung from the monkey bars in a minute? Start with your feet on the ground. Let your body support the position and gently sink into the stretch.

 

Aspiring towards Amelie status? Pick up those feet and hold on for dear life! The longer you hold, the more time you spend working on your mobility (and strength, to boot!).

 

Dosage? Start with small sets (1-3 second holds) and progress in duration (20-30 seconds) as your tolerance improves.

 

Supine Pull Over:

Early stages of reaching overhead? Phone a friend for assistance!

Dosage? Start with small sets (20-30 second sets) and progress in duration (5:00 continuous) as your tolerance improves.⁷

 

How to progress? Sub out the dowel for some weights and repeat the process! 

Dosage? Treat it like a high rep strengthening exercise – sets of 12-20 reps.

Lat Pull Down: Doesn’t the top position look eerily similar to the top of a shoulder press?

Short on time and want to work on overhead mobility while building your back? Firstly, thank you for working on your back – even though you can’t easily see it in the mirror, a strong back is of huge importance. Secondly, here is the movement for you:

Dosage? Treat it like a high rep strengthening exercise – sets of 12-20 reps. Or, play up the tempo component, with sets of 6-8 reps with an 8-10 second eccentric. Not sure what I mean by tempo? I have a blog for that! Check out "A Not So Tempo-rary Training Tactic."

 

Principle of Movement # 2: Build strength and resilience in the range you possess. Start pressing on day one, within your good quality range of motion.

Towel Pull Apart: Early stages of reaching overhead? Phone a friend for assistance, part deux!

Dosage? Start with small sets (20-30 second sets) and progress in duration (5:00 continuous) as your tolerance improves.⁷

Sidelying Shoulder Press:

Dosage? Treat it like a high rep strengthening exercise – sets of 12-20 reps

 

Incline Press:

Dosage? Treat it like a high rep strengthening exercise – sets of 12-20 reps. Progress in weight and reduce the reps after one month.

 

Side Note – Pain is a big, hairy beast that is a separate blog unto its own. While slow, steady progression of these movements may help reduce your pain, you may need more guidance still. Suffice it to say, physical therapists thrive in the face of pain. If you have questions or concerns about pain limiting pressing overhead that cannot be addressed with these videos, schedule a consult with me and my friends at The Jackson Clinics!

 

https://thejacksonclinics.com/request-appointment/

 

The Overhead Movement Prescription:

1. Mobility is a dish best served daily. With this in mind, use the “20/20 Rule” – Every 20 minutes, step away from your work station and check the integrity of your antiperspirant (aka put your arms over your head) for 20 seconds.

2. Brush your teeth, brush your body – We brush our teeth at least twice daily to get rid of the gunk from our mouth. Why not do the same for the rest of our body, and undo the stiffness that we feel in our joints? Spend 3-5 minutes in the morning and evening exploring overhead positions.

3. Check your work – use the Wall Flexion Test after your movements and see which movements provide the biggest bang for their buck. Assess, don’t guess 😊

4. Check out my blog post, Balance the Shoulder, for specifics on exercise prescription for strength training purposes.

The Take Home:

There is a whole world of unused kitchen cabinets (and dollhouse attics) that are dying to be filled. Earn back the right to press overhead through restoration of mobility -> strength, and fill those cabinets!

 

References:
1. Ichihashi N, Ibuki S, Otsuka N, Takashima S, Matsumura A.Kinematic characteristics of the scapula and clavicle during military press exercise and shoulder flexion. J Shoulder Elbow Surg (2014) 23, 649-657.

2. Bäcker, H. C., Galle, S. E., Maniglio, M., & Rosenwasser, M. P. (2018). Biomechanics of posterior shoulder instability - current knowledge and literature review. World Journal of Orthopedics, 9(11), 245-254.

3. Bdaiwi, A. H., Mackenzie, T. A., Herrington, L., Horsley, I., & Cools, A. M. (2015). Acromiohumeral Distance During Neuromuscular Electrical Stimulation of the Lower Trapezius and Serratus Anterior Muscles in Healthy Participants. Journal of Athletic Training, 50(7), 713–718.

4. Ekstrom, R., Donatelli, R. and Soderberg, G., 2003. Surface Electromyographic Analysis of Exercises for the Trapezius and Serratus Anterior Muscles. Journal of Orthopaedic & Sports Physical Therapy, 33(5), pp.247-258.

5. George Davies - A Master Clinicians Approach to Advanced Concepts in Examination and Treatment of the Shoulder Complex – 2016.

6. Clark, RA, et al. The influence of variable ROM training on neuromuscular performance and control of external loads. JCSR. 25:704-711, 2011.

7. The role of anterior deltoid reeducation in patients with massive irreparable degenerative rotator cuff tears Ofer Levy, MD, MCh(Orth), Hannan Mullett, FRCS(TR & Orth), Sarah Roberts, Bsc(Hons), Bed(Hons), MCSP, and Stephen Copeland, FRCS, Reading, United Kingdom - J Shoulder Elbow Surg 2008;17:863-870.

Step Up Your Ground Game

The potential for falling is a constant threat in our daily lives. From the wet spot on the bathroom floor, to the missed step at the base of the stairs, and the pesky cat that is always underfoot, it is amazing we can make it through the day unscathed. While my daily struggle with my wife’s beloved cat is a nuisance, these threats become more serious with age, as our balance, strength, and mobility to overcome these falls decreases. 

10,000 Foot View:

The threat is real, folks: In the United States, 1 in 4 adults over the age of 65 fall each year and it is a leading cause of fractures and injury-related deaths, in this age group^1-4. Additionally, falls in this age group account for approximately 60% of all injury-related emergency department visits.² When do we lose the ability to safely and efficiently get down to the ground? More importantly, can we relearn this skill?

My Muse:

As per usual, I look to Amelie for guidance on all of my burning questions. My nearly 4-year-old daughter accumulates an astounding number of reps navigating the ground each day. I marvel at the effortless manner in which she lowers herself to the ground in a seemingly endless variety of Calisthenic movements. Through hundreds of daily repetitions, Amelie has developed a virtuoso ground routine that includes seamless transitions between splits and squats, rolls and crawls. As I admire the proficiency of Amelie’s movement, I reflect on how much she has developed and on my lessons learned from the world of motor learning. ***Check out my previous blog post, Coaching and Life Lessons from Amelie, for the skinny on this topic.

A strong ground game cannot be restored overnight – it will take MANY repetitions of purposeful movement, that are salient, specific, and build in intensity. Why not use this approach in the clinic, while simultaneously addressing the impairments associated with our patients’ most common injuries?

 

The Movements:

In an attempt to channel the growth mindset of the toddler/preschooler, The Jackson Clinics-Skyline utilizes a daily movement practice that encourages you to get down to the ground, improve your body control, and reacquaint yourself with all of the dust bunnies in the corner of the room and lost Peppa Pig paraphernalia under the couch.

Ground Transition Options: ***All of these options can be performed with use of upper body support on a secure surface, for additional support. Rule # 1 - No falls. Rule # 2 - Don't break rule number 1!

Lunge Strategy:

Squat Strategy:

Four Point Transition:

Two Point Transition:

While you are down there, why not spend a couple of minutes mobilizing your whole body with the following movement series? We use some variation of this sequence with virtually every patient in the clinic. Whether you have knee pain, hip stiffness, back pain, shoulder weakness, this movement series does not discriminate! The ground rocker sequence is a veritable “Swiss Army Knife,” of movement practices. So, without further ado, here it is:

Ground Rocker Series:

Quadruped Sit Backs:

Adductor Sit Backs:

Z Sit Rotations:

Z Sit Stretch:

Lunge Rockers 1-3

The Prescription:

1. 20/20 rule – Every 20 minutes, step away from your work station and practice one of the lowering options for 20 seconds.

2. Brush your teeth, brush your body – We brush our teeth at least twice daily to get rid of the gunk from our mouth. Why not do the same for the rest of our body, and undo the stiffness that we feel in our joints? Spend 3-5 minutes in the morning and evening exploring the ground rocker sequence.

3. Progress the demands – Seek out ways to make these movements more challenging. Schedule an appointment with us if you need help!

 

The Take Home: Falling is Scary Business!

1. Actively work to mitigate the risks associated with falling by reacquainting yourself with one of the first skills you learn as a child – lowering and rising from the ground.

2. Restore lost mobility, coordination, and body control through daily exposure to a ground-based movement practice.

3. Check the work of your house cleaning crew through daily, under the couch inspections!

 

References:

1. Tromp AM, Pluijm SMF, Smit JH, et al. Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly. J Clin Epidemiol 2001;54(8):837–844.

2. Bergen G, et al. Falls and fall injuries among adults aged ≥ 65 years—United States, 2014 MMWR Morb Mortal Wkly Rep 2016 65 37 993 8

3. Centers for Disease Control and Prevention. Welcome to WISQARS (Web-based Injury Statistics Query and Reporting System). 2018. https://www.cdc.gov/injury/wisqars.

4. Bhasin S, et al. A randomized trial of a multifactorial strategy to prevent serious fall injuries. New England Journal of Medicine. 2020;383(2):129-140. doi: 10.1056/NEJMoa2002183.

 

 

Reconciliation with Bench Press - A Beach Season Saga

Hello friends! Summer is officially here, which for Amelie means lots of bubble time, swimming lessons, and helping Daddy work on his bench press muscles! 

Given my prowess in the bubble blowing arena, it was a toss up to decide whether to write this post about a return to bubbles program or bench press program.

Tails – bench press it is.

The bench press is a foundation exercise of any upper body routine and it pains me to see the quivering lips of my patients when they tell me that shoulder pain has forced them to break up with the bench press. Quiver no more! The shoulder love doctor is here, and today, we win back the bench!

 
10,000 Foot View:

Begin With Why – It helps to understand why you cannot bench press. Putting aside the fact that some anatomic structure in the shoulder is probably pissed off (think rotator cuff, AC joint, capsule, labrum) let’s look at this from a big picture standpoint. If you are having trouble with the bench press it is most likely due to limitations in mobility in the bottom of the bench press and muscular control pressing out of the bottom of the movement. So come along with me, as we highlight some exercises to improve mobility, muscular control, and some strategies to reduce stress on the shoulders during the bench press. 

Side note – if you are interested in learning in greater detail about the anatomy and treatment of the injured bench pressing shoulder, come check out our Movement Systems of the Upper Extremity Course this Friday and Saturday!

On to the Return to Bench Press Progression:

Low Hanging Fruit:

Step 1 – Mobility – Do you have the mobility required to complete the bench press? Most people with bench pressing issues have trouble getting into the bottom position, which requires large amounts of humeral extension and internal rotation. Before trying to load up a barbell and work into this end range extension and internal rotation position, start with this unloaded version of the same position:

Use this exercise to improve your mobility/position for the bottom of the bench press. This is a low irritability position because the shoulder is “un-loaded” in this position and the scapulae (shoulder blades) are free to move with the arms. Try performing 10 repetitions of 3-10 second holds.

Once you can successfully achieve this position, try it with a barbell.

Step 2 – Muscular Control through Mobility – Once you have established that you have the mobility to get into the bottom of the bench press, it is time to restore muscular control of the bench press motion.

1. Eccentric Push-ups are a great way to load the bench press motion without adding a large external load (Side note - Check out my blog post on Tempo Training to get the skinny on eccentrics). The beauty of this movement is that you are building body weight strength/control, and focusing on the eccentric contraction can lead to 10-40% greater force production compared to concentric contractions¹.

Try 10 repetitions with a 3-5 second eccentric and then build into your regular push-ups.

2. Isometric holds in the bottom position allow you to spend more time in the position of limitation, while forcing the muscles of the shoulder complex to actively stabilize the joint.

This plank hold can be performed as a body weight movement and progressed to adding external weight. 

Try 10 repetitions with a 3-10 second hold

3. Short Arc of Motion with the rack press can allow the lifter to continue training at similar volumes from their pre-breakup program, while avoiding the painful bottom position of the press. Limited range of motion training also has the benefit of improving strength outside the range of performance, due to a strength overflow of about 15 degrees of motion on either end of the short arc of motion^2,3.

**Note – weight plates have been removed from bar to improve visibility of the movement. Subject in video is much stronger than he appears!

 4. Control Full Motion with different implements – Using db instead of a barbell allows for a change in arm position. Try rotating your hand position to a neutral grip in the bottom to reduce the internal rotation demands on the shoulder.

Step 3 – Reduce Shoulder Stress with the Bench Press – One of the challenges of the bench press is that your shoulder blades get stuck between your rib cage and the bench, reducing the freedom of motion that is required to maintain a stable shoulder position throughout the duration of the lift⁴. This problem becomes more evident as the weight on the barbell increases. I would like to thank One Life Super Coach, Joe Helein, for this little pearl of wisdom:

Creating an arch in the back unlocks the shoulder blades and improves their excursion during the bench press. The key with this position is to drive through your legs in order to maintain this position under load, while transferring the force from your legs into the upper body and bar.

Thanks for the shoulder saving tip, Joe! Sorry folks, he’s married. But he is free to help you set personal records!

Other considerations – change the bench angle and arm angle. Consider implementing a decline press, which will alter the angle of shoulder flexion and potentially reduce stress on the shoulder. You can also change your grip width on the barbell, finding a comfortable position between shoulder width and 1.5 x shoulder width.

The Real World Application:

Just because you have shoulder pain does not mean that you and the bench press need to start seeing other people, but rebuilding your relationship will take time. You can make subtle modifications to your relationship, while working on your weaknesses, and come back together as a stronger couple (hopefully spicing up your relationship with some healthy pulling – see my Name of the Game is Progress post)!

References:

1. George Davies - A Master Clinicians Approach to Advanced Concepts in Examination and Treatment of the Shoulder Complex – 2016 

2. Clark, RA, et al. The influence of variable ROM training on neuromuscular performance and control of external loads. JSCR. 25:704-711, 2011.

3. Barak Y, et al. J Electromyogr Kinesiol, 16:403-412, 2006 – from George Davies 2016 course

4. Kaselj, R. (2006). Exercise Rehabilitation of the Shoulder. Course Manual.

Coaching and Life Lessons from Amelie

A little thing happened since we last chatted…

Just when we were starting to think that Amelie was going to scoot across the stage to receive her high school diploma, Amelie proved yet again, that she marches to the beat of her own drummer not ours. In doing so, she taught me a valuable lesson about motor learning that greatly impacts how I engage in this process in the clinic.

**Special thanks to Joe Hannigan (Skyline's student-extraordinaire) who helped lay the foundation for this blog post with his incredible motor learning in-service!

10,000 Foot View:

What is motor learning? Motor learning is a relatively permanent change in the ability to execute a motor skill as a result of practice or experience¹. In our Amelie case study, the motor skill of interest is walking.

Amelie (and Joe) helped me realize that there are 3 crucial tenets of motor learning that must be addressed in order to achieve a successful outcome: salience, specificity, and intensity².

1. Salience – importance to the person. Amelie was not going to engage in the process of learning to walk unless she found it important to her. Judging by the look on her face while scooting, she was in no rush to give this form of locomotion up.

Salience is crucial. If the learner does not connect with the perceived importance of the task, then they will not be willing to put in the work (and it is a lot of work) to master the skill.

2. Specificity – the proverbial steps on the journey to walking must be specific to the end goal – walking – not scooting, not crawling, not climbing. No matter how beneficial these tactics might be in the development of strength, mobility, and endurance (more on these to come), task specificity is walking.

3. Intensity – motor learning requires the learner to push themselves out of their comfort zone, over and over again.

Precursor to motor learning:

Capacity (mobility, strength, endurance) is a precursor to motor learning – establish capacity first³. Or, in the words of our fearless leader, Richard Jackson: Stretch -> Strengthen -> Functionally Retrain.

Even if Amelie decides that it is important to learn to walk, she must possess the requisite capacity to engage in the learning process.

I have spent a lot of time reflecting on capacity as a foundation for learning. What are the metrics that I can use to track mobility, strength, and endurance? Do these metrics directly relate back to the end goal of the motor skill? Remember, two of the keys to motor learning are salience (importance to the person) and specificity. If you are building a foundation of mobility, strength and endurance that is specific to the movement of concern and is important to the patient, you are on your way!

Low Hanging Fruit:

We can challenge intensity through⁴:

1. Feedback - How does Amelie know if she is improving her walking? The ideal feedback is dichotomous – easy to determine pass vs fail. In Amelie’s case, fail equals falling. Everything else is a pass. This feedback is immediate and specific to the task.

I am constantly working to improve the feedback I give my patients. Is my feedback something tangible for the patient (don’t fall) or is it some nebulous cue to engage some deep muscle that they cannot identify or pronounce, let alone engage? As the learner improves, you can alter the feedback to enhance learning. This can come in the form of reducing the frequency of the feedback, changing the input of feedback (visual cue vs auditory cue), or providing summative feedback rather than feedback in the moment - just to name a few. The iterations of feedback are endless, but I try to make sure the feedback is dichotomous and salient to the learner.

2. Weight – Amelie worked to modify weight by first walking with a rolling walker. 

As she becomes a more proficient walker, Amelie will begin walking while wearing a weight vest. What are we without progress :) ?

3. Environment – Early in the learning process, Amelie practiced walking in a controlled environment, where we could limit distractions and obstacles to her performance (our house). From here, she progressed to environments that were less controlled and had more potential distractions (daycare). Eventually, she progressed to chasing every dog in Shirlington Village, screaming “bow wow wow” and giggling with glee.

Remember – just because your patient performs a skill in the clinic, does not ensure the same success in the outside world. Practice in the environment in which they will have to perform.

4. Dual task – Involves divided attention in the performance of the skill. In Amelie’s case, this most frequently involves singing Baby Shark while pushing her walker.

5. Speed/accuracy – This was best tested through chasing our cats around the house. Can Amelie catch the cats? To do so, she needs speed. Can she successfully grab their tails? To do so, she needs accuracy. These are parameters of intensity that Rebecca does not support nearly as enthusiastically as I do. 

*Disclaimer – no cats were harmed in the making of this blog post.

6. Practice – Our method of exploration. Practice the task. Learn the limits of your capabilities and improve them. In the book Peak: Secrets from the New Science of Expertise, Anders Ericsson describes deliberate practice as the gold standard to building new skills and abilities.

What is deliberate practice? Practice that is purposeful and systematic. Deliberate practice demands near-maximal effort, which is generally not enjoyable. This goes back to the idea that you need the requisite foundational skills (mobility, strength, endurance) to even allow yourself to engage in deliberate practice. Additionally, deliberate practice depends on effective mental representations of the task - make it possible to monitor how one is doing. This is critical! What does successful performance look like? The answer should be clear and concrete.

7. Error – We learn through trial and error. Amelie did not read any books on the mechanics of walking (despite my encouragement to do so) or listen to my futile attempts to lecture her on the importance of walking. She learned to walk through trial and error (once she decided it was important for her to learn to walk). This also ties back to the point about feedback - The error with Amelie’s walking is a fall. Anything else is a success. This is a clear method for assessment, did I fall? Yes = fail. No = pass. Amelie does not need me to tell her if she passed or not. Your goal with any motor learning task is to set up a clear dichotomy of consequences – pass/fail.

What Did I Learn?

I cannot force motor learning. It is something that I can only nurture when Amelie is ready and when it is important to her. Thank you Amelie, for yet another incredible life lesson.

References:

1. Haibach-Beach P, Reid G, Collier D. Motor Learning and Development – 2^nd Edition.

2. Motor Learning – An Application in the Orthopedic Setting. In-Service – Joe Hannigan, SPT – 3/19

3. Understanding Human Movement as a Dynamical System – Erik Meira (2018) – as part of the course: Complex Understandings for Simple Solutions

4. Mowder-Tinney and Streeter 2018: Translating Motor Learning into Practice: What is M.I.A. from your patient care?

5. Ericcson KA, Pool R. Peak: Secrets from the New Science of Expertise (2016)