Kettlebell Swings: harder than Circuit Weight Traning; easier than Treadmill? How can this be?

There's a new study in English of Kettlebells that shows 12mins of  two handed swings is tougher/harder than circuit weight training, but not as hard as treadmill work. That's probably a surprise for folks used to swinging kettlebells, and certainly how kettelbells have been promoted as an amazing, tough, cardio conditioning endurance tool, where more is more.  What this great new study does, therefore, is help us ask some questions about studying kb's. It also gives us new ways to think about where kb work might be situated relative to other activities. So this post is a wee overview of one of the first english language, peer reviewed articles on Kettlebells.


There's not a lot of english-based research on the effects of using kettlebells. In the latest Journal of strength and Conditioning, though, there is a small paper looking specifically at a 12 min 2 handed swing protocol. The authors credit this protocol as "Dept of Energy Man Maker" described in Pavel Tsatsouline's Enter the kettlebell. Just a note, however: the protocol from what is in Enter the Kettlebell is a wee bit different than what these sudy authors use - it's looser. Here's Tsatsouline's description:

The Man Maker is a painfully simple workout that was devised and implemented at a federal agency’s academy by Green Beret vet Bill Cullen, RKC. Its template is simple: alternate sets of high-rep kettlebell drills—swings in our case—with a few hundred yards of jogging. Do your swings “to a comfortable stop” most of the time and all-out occasionally. Don’t run hard; jogging is a form of active recovery. Senior RKC Mike Mahler prefers the jump rope to jogging, another great option.

Indeed, the protocol is even less specific in Bill Cullen's founding eponymous article describing it.

Do 10 to 75 snatches with each arm depending on your ability level, be sure that you use good form, dig your toes in, and at the top of your snatch or swing hold for a second. Breathing is important, get a good rhythm going. Once done with your snatches jog -don’t run! - quarter of a mile, jogging lets your heart and body recover, if you are running fast it means you didn’t do enough repetitions with your KB.

Continue this routine for 2 miles or farther or till you leave a lung on the ground. This is a fat buster and a cardio gut check but the great thing is you can always make it harder or easier by tweaking the number of repetitions. 

Note that the quantifier in Cullen's work is distance rather than time and number of snatches rather than time. The protocol tested in the study is, by contrast, more specific. It's 12 mins of 2 handed swings.  Not sure where 12 mins came from, but the version run in the study is described in three different ways. First, the abstract describes it as "a kettlebell exercise routine consisting of as many 2-handed swings as could be completed in 12 minutes using a 16-kg kettlebell." I initially thought this meant "continuous" swings. But, in the article itself - thanks to Mike Reid, RKC for pointing this out, it is described as "Subjects performed 2-handed swings, in accordance with
the routine’s published description, for 12 minutes in duration." Er, and that would mean? Sets of high reps with jogging? No, because later it reads:

Subjects completed a 12-minute exercise bout, known as the ‘‘US Department of Energy Man-Maker’’ (ETK). The bout consisted of performing 2-handed swings, using a 16-kg kettlebell (Perform Better, Cranston, RI) for 12-minute duration. A 16-kg kettlebell was used in this study because that is a recommended weight for beginning men (ETK). Subjects were told to work at their own pace, resting as needed, while aiming to complete as many swings as possible in the 12-minute time frame. Heart rate was monitored continuously and recorded every minute of the bout.

Ok, so what is not the man maker is that (a) time is fixed at 12 mins (b) there is no active recovery, one is "working at their own pace" rather than, in Cullen's case of this routine being a "smoker" as hard as possible. I'd nay be inclined to call this the man maker, then. More "swing at your own pace, stopping as often as necessary, to get as many swings in as possible for 12 mins"

Standard benchmark tests for max heart rate and vo2 were taken; then during the actual kb trial, VO2 and HR levels were recorded throughout the 12 min swing set. The study looked at just this one kb experience. Results varied pretty wildly among participants (10 "active" men).

Subjects completed an average of 265 plus or minus 68 swings during the 12 minutes, for an average work rate of 22 plus or minus 6 swings per minute.

Ok, looking at the numbers, 12 mins of swings, does this sound like a man maker to anyone who's focused on a "smoker"? Just looking at myself, a wee 5'6", 60kg female, i do 100 swings for recovery during RTK with a 12 or 16 - i just checked with the 16 - it's 2 mins and a bit. So i'm mystified at how non-manmaker'ish (ie "smoker") this protocol must have been run.

Even given that "active men" were doing this, the results seem to have a heck of a standard deviation in such a small sample size, eh? I'm curious about how many times people stopped. Did the person with the lowest score only stop once? Did the best score recover frequently? That would be interesting to know. 


Main results: during the kb effort, %HRmax was "significantly higher (p<0.001) than average VO2max. That's a bit of a surprise. One would usually expect that %HRmax would be strongly corelated to predicted VO2max. For instance, 85% MaxHR should connect with about 75% VO2max  (see calculation here). In this small study of "active men" however,

The equation describing the regression line to predict %V̇o2max from %HRmax was %V̇o2max = 0.714%HRmax − 4.57, with a significant correlation of 0.58 and an SEE of 6.6%. Figure 2 illustrates the relationship between %V̇o2max and %HRmax.

That resulted in an 85% max heart with 65% V02max

What the results of the study mean
These results show that, at least according to the ACSM, the KB 12 min swing circuit rates as "hard". Second, the respiratory exchange ratio (RER) shows that the 12min effort means that this workout is high in "non-oxidative metabolism." That means that these 12 mins are not primarily fat burning minutes - calorie burning yes, but where many of those calories are coming from sources other than fat. But these results do suggest, that at least in this protocol, this is not a hugely stimulating protocol for enhancing Vo2max.

So again, i'd say that the way this protocol must have been run was out for a stroll with the 16, it still shows a pretty durn good effect, cardio wise.


Where does this KB workout Fit?
In terms of other similarly tested workouts - circuit weight training (see description of cwt here, mid port) and treadmill running, amazingly, it's higher than circuit weight training but lower than treadmill running.

lance armstrong: two handed kb swing

The authors recommend that this particular protocol is good for cardio training, but that coaches should be aware that the HR cost relative to the VO2 demainds. Treadmill work (where speed and incline are used to push on cardio work).


Moving Ahead
The intent of this study the authors say "was to document the heart rate (HR) response and oxygen cost of performing a kettlebell exercise routine that is intended to improve cardiorespiratory fitness." That's a rather general claim to make about investigating ONE protocol - one way - of working with a kb.

It's also a protocol used in ETK specifically, as "a smoker" as bill cullen called it and as a "man maker" as its name implies. That's pretty much an all out effort for miles not time and "until you leave a lung on the ground." That's not, it seems, how this study ran the protocol. That's ok; just don't call it a particular protocol if that's not the test you're running.

On the high side, it's great to see the formal research running assessments of KB protocols in a comparative, peer reviewed study. A recent American Council of Exercise test shows that kb's are just awesome for Vo2max training in particular - they effectively paid to have Kenneth Jay's protocol for VO2max replicated and tested, but without standard research protocols for running a comparative analysis, or having the protocol peer reviewed.  Indeed, it's at the very least intriguing that the results in that article (shown in the image below) using the snatch got such different results than the swing - that's in 20mins, with 15 secs on, snatching, 15 secs off, as opposed to 12mins, swinging as many reps as possible non-stop.

Not saying there's anything wrong with these results - just that the benefit of the JSCR shorty gives us a way to situate a KB protocol relative to OTHER kinds of training, and the results are a wee bit of a surprise - we tend to think that all kb's all the time are the hardest ass whopping we can get. And, what seems to have been the case here, is that sure, if you're not swinging with intent to get smoked, you don't get smoking results.

But that's ok. Not all protocols, all the time. And that's actually a good thing. We need physiological variety. Now we're learning what kind of variety kb's can deliver - relative to other workouts.

Looking forward to more formal KB research, to learn more about this awesome fitness tool.

Related Resources

• b2d KB article index
• Review of KJ's Viking Warrior Conditioning (VO2max)
• Cardio, VO2max, Kettlebells
• Hill Workouts with Kettlebells
• Respect the Fat - the role of fat in energy metabolism
• 6 mins a week workouts?

Citation

Farrar RE, Mayhew JL, & Koch AJ (2010). Oxygen cost of kettlebell swings. Journal of strength and conditioning research / National Strength & Conditioning Association, 24 (4), 1034-6 PMID: 20300022

Football (er, soccer): best for coach potatoes seeking health, fat loss, muscle?

What to do if wanting to move off the coach and into health? If a guy - especially a guy just starting up a fitness program - wanted to do just one thing that would help drop fat, build muscle (and muscle mass), improve endurance, enhance bone mineral density, improve cholesterol levels and blood pressure, it's football (what north americans call soceer).

Really. Better than HIIT, than running, than resistance training alone, football seems to be the Big Pill solution. The only potential downside is that levels of injury may be higher than hitting the weight room or stationary bike. Overall, the cost/benefit analysis may make football the Healthy Choice. As the authors say in the abstract:

Taken together, recreational football appears to effectively stimulate musculoskeletal, metabolic and cardiovascular adaptations of importance for health and thereby reduces the risk of developing life-style diseases.

Let's take a look at the attributes the authors reviewed. To begin with, they considered studies of men who have been sedentary and then got into some kind of training protocol.

Blood Pressure and Heart Rate
Over 12 weeks, men who trained for an hour, two or three times a week, on the football pitch, comparable to endurance training of same lenght and duration. Football also showed up as better than strength training, to the level thought to have significant health benefits. Risk of death from heart attack goes down with bett blood presure too.

The footballers also have a lowered resting heart rate, and lowered heart rate during submax runs. They also have lower heart rates in intermittent exercise. Compared with groups who did resistance training alone, that didn't happne. This indicated both central and peripheral adaptations. That's great.

Vo2Max
A quality near and dear to the hearts of many people is VO2max. Playing football over 12 weeks had the same effect (13% improvement) as "using continuous training" (eg running) for the same time, or HIIT for less time. BUT what's particularly cool is that the football group continued to have an imporvement after the first four weeks of ball play. Runners did not. It also seems that just playing some extra small sided games had the same effect as additional interval running susseions for experienced players. Playing a game is likely more enjoyable than running repeats, too.

Fat Burning (& other metabolic impacts)
Here's the kicker. How does football do for fat burning? Fat oxidation during low to moderate intensity goes up. muscle enzyme activity up, muscle fiber conversion from IIx to IIA up (good). LDL/HDL ration changed signficantly - for the good.

Now here's an interesting comparison: neither low intensity aerobics for 12 weeks, nor high intensity intermitent running or strength training lead to changes in cholesterol. What does show benefit is higher intensity work. Football vs just running seems to hit the sweet spot. Runners do have similar weight loss - just not these other perks to the same degree.

A result i find peculiar is a claim that

12 weeks of intense interval training and short-term strength training, no changes were observed in fat mass (Fig. 2b), which may be related to the fact that the total energy expenditure was limited for the interval runners and that the strength training group had no changes in metabolic fitness as indicated by unchanged fat oxidation during exercise, lipid profile, capillarization and enzyme activities (Nybo et al., 2010).

Study design is interesting, isn't it? As i've written about before, in work by Trapp, intervals on bikes were the one thing that showed fat loss - especially in the trunk - where steady state did not - even without tracking diet. So hmm. I'll go for total caloric expenditure did not exceed caloric intake in these runners/lifters, but it did in the football case, but i'm not ready to say "football is better than intervals for fat loss" -with fat loss as the single factor of interest. That said, there's more good stuff for football

Lean Body Mass
12 weeks of football, not only does fat go down, and cholesterol change, lean body mass goes up. The study authors look at related work to say heh, this should be good for glucose tolerance. Indeed, there's one study the authors site that when 12 weeks of football & dietary advice was given to a bunch of 47-49 year olds with type 2 diabetes, glucose tolerance was "markedly improved" (a similar trial without that advice showed no difference. hmm)


Musculo-Skeletal fitness
Soccer is stop and go. I've written before about how such action has been shown to be good for bone mineral density. Seems its good for muscle too. Again, comparing with interval and steady state running where there was no muscle fiber change, football does it all. The cool result is that 12 weeks of football got similar results to "14 weeks of heavy resistance training in young men" These kinds of changes just don't seem to happen in regular endurance training. But they do happen across ages in football.

Bone Mass
I admit i am partial to work on bone mineral density. It's a big deal for gals in particular, and we know that muscle size plays a not inconsiderable role for keeping the bones working. But so does the type of axial loading on the bones.

Here's the latest: go lift or do stop and start sports

[T]he increase in leg bone mass following 12 weeks of recreational football training was of a similar magnitude as the gains observed following strength training of the same duration, whereas neither recreational jogging nor high-intensity interval running induced changes in total or leg bone mass. In accordance, both male and female football players have higher hip and spine BMD than equally fit runners (Fredericson et al., 2007; Mudd et al., 2007). Furthermore, meta-analysis of cross-sectional studies reveals that participation in non-weight-bearing sports or physical activities with monotonous and stereotypic movement pattern appears to have little or no effect on bone mass or BMD, whereas strength-based and high-impact sports are associated with higher BMD (Egan et al.,2006).

In football, small sided games with lots of turns, stops and starts seems to be optimal.

Perceived Exertion
How tired are we after an activity? A lot of this experience is assessed perceptually against physiologic markers. Guess what? footballers repport lower poop'dness, despite work done. Play is good.

Injury
All good things come at a price? After last week's exegisis on ankle injuriers in sport, this question of injury level is not inconsiderable: what happens when someone gets off the coach and wants to get back int the game?

Most of the comparisons about footbal are with other on-your-feet activities like running, or very different work like lifting. Alas, no comparisons have (yet) been done with Kettlebells. The point is, when looking at injury, these are the places of comparison: how does football compare with say running?

[One study ]Parkkari et al. (2004) "have reported an injury incidence of 7.8 injuries per 1000 h of football participation, which ranks football eight in 31 recreational and competitive sports. Running ranks 20 with an injury incidence of 3.6 injuries per 1000 h of participation, but no differentiation between the types of running has been made. ... In another study involving 31 620 inhabitants in a Swedish municipality, injury rates in persons attending a physician for an acute injury sustained during sports participation were reported (de Loes & Goldie, 1988). In this study, ice hockey and handball were found to have the highest risk followed by football. For males aged 15–59 years, the ranking was ice hockey, horseback riding, handball and football. If an injury incidence of 7.8 injuries per 1000 h of football participation is valid in recreation football in general, the implication is that the players would be exposed to one injury every 1.2 years if he carried out two 1-h sessions per week all-year round and one severe injury every ∼13 years as the severity of most injuries in recreational football is mild to moderate with approximately 9% categorized as severe injuries, defined as injuries that result in missing of work or a corresponding activity for at least 1 day (Parkkari et al., 2004).

It should be emphasized that the above-mentioned injury incidences in football are the incidence for training and match play analyzed together. However, it is well known that for elite and amateur football players the injury risk per hour of activity is approximately 5–10 times higher during match-play than training (Poulsen et al., 1991; Hägglund et al., 2003; Arnason et al., 2004) with injury incidence from two to five injuries per 1000 h of participation in training sessions.

Stay away from match play and risk of injury seems to be lower.

Just to put the icing on the cake, it seems the study authors would like it to be known that runners are sucks:

In the reviewed studies dealing with the fitness and health effects of recreational football and running, around 150 subjects have been followed over 3–4 months of training performed two to three times a week. During these studies, 5% of the footballers (n=3) and distance runners (n=3) contacted the in-house medical doctor regarding injuries, whereas 33% of the interval runners did (n=5) [note the small sample size -mc]. However, further studies are required to obtain more information about injury risk, types of injury, injury severity, etc. for various age groups playing recreational football organized as small-sided games among friends.

Ok, just go play ball, already. Getting into some frienly 4 a side games, a couple times a week, seems to have so many pluses going for it's hard to imagine the down side - if everyone is rather at the same level (So great, where does one find these games?)

Field Note - General recommendation before Getting Back in the Game: get one's doctor's ok first to start a new prorgam of action, then consider getting a movement assessment to check how you're moving to reduce the risk of injury. It's also immediately beneficial to  practice some sensory-motor drills to help field awareness so as to reduce likelihood of falling on self or colleague, and so actually getting more out of the game. Such drills can start with proprioceptvie awareness work. I like z-health's r-phase and especially i phase for this (overviews).

After R- and I- phase, the drills for fast turning, fast getting up off the ground, and just moving fast in the S-Phase Complete Athlete Vol 1 dvd are awesome - as are the drills for field awareness and quickness (review here). A colleague is using a lot of the z-drills to help the kids baseball team he coaches, from proprioception to visual acuity. Injury down, performance up, much?? oh ya.

Citation:
Krustrup, P., Aagaard, P., Nybo, L., Petersen, J., Mohr, M., & Bangsbo, J. (2010). Recreational football as a health promoting activity: a topical review Scandinavian Journal of Medicine & Science in Sports DOI: 10.1111/j.1600-0838.2010.01108.x

Hypertrophy: More sets are Better than 1, from Day 1

In strength training, research has looked at the question of "how many sets" to make a difference for strength - does it matter if we train with 1 set or multiple sets?  Most research of late has put the strength question to bed: more sets = more strength.  What is less known is the relationship of hypertrophy to strength development. Strength is about at least two things: neural adaptations - muscle firing patterns - to be able to lift stuff, and structural changes to be able to support these loads without tearing ourselves apart. The latter is generally known as hypertrophy. So an open research question has been: are the changes in real strength more about the neural side of the fence than the structural?  According to work done to review a TON of studies that have ever bothered to measure hypertrophy along with strength, more seems to be better here, too. In other words, hypertrophy is playing a side-by-side roll in strength training. At least as far as we can tell from eligible studies. The juicy bits are highlighted.

This review is published in the April 2010 Journal of Srength and Conditioning Research. Here's the abstract:

Previous meta-analyses have compared the effects of single to multiple sets on strength, but analyses on muscle hypertrophy are lacking. The purpose of this study was to use multilevel meta-regression to compare the effects of single and multiple sets per exercise on muscle hypertrophy. The analysis comprised 55 effect sizes (ESs), nested within 19 treatment groups and 8 studies. Multiple sets were associated with a larger ES than a single set (difference = 0.10 +/- 0.04; confidence interval [CI]: 0.02, 0.19; p = 0.016). In a dose-response model, there was a trend for 2-3 sets per exercise to be associated with a greater ES than 1 set (difference = 0.09 +/- 0.05; CI: -0.02, 0.20; p = 0.09), and a trend for 4-6 sets per exercise to be associated with a greater ES than 1 set (difference = 0.20 +/- 0.11; CI: -0.04, 0.43; p = 0.096). Both of these trends were significant when considering permutation test p values (p < 0.01).

 Mean hypertrophy effect size for single vs. multiple sets per exercise. Data are presented as means 6 SE. *Significant difference from 1 set per exercise (p <0.05).

There was no significant difference between 2-3 sets per exercise and 4-6 sets per exercise (difference = 0.10 +/- 0.10; CI: -0.09, 0.30; p = 0.29). There was a tendency for increasing ESs for an increasing number of sets (0.24 for 1 set, 0.34 for 2-3 sets, and 0.44 for 4-6 sets). Sensitivity analysis revealed no highly influential studies that affected the magnitude of the observed differences, but one study did slightly influence the level of significance and CI width. No evidence of publication bias was observed. In conclusion, multiple sets are associated with 40% greater hypertrophy-related ESs than 1 set, in both trained and untrained subjects.

Correlation of Hypertrophy with Strength.  To get into the detail a little further, after the results are presented of comparing the various studies' methods, muscles, participants and periods of study, the author states:

In a previous meta-analysis on strength using an identical statistical model, a 46% greater ES was observed for multiple sets compared with single sets (²³) (Figure 3). A 40% greater ES was observed in this study. This indicates that the greater strength gains observed with multiple sets are in part because of greater muscle hypertrophy.

This is a nice finding: hypertrophy - structural changes in muscle - seems to go hand in hand with strength, and right from the start of training. This is interesting in no small part because changes in measurable muscle size seem to lag behind measurable differences in strength.

It is known that mechanical loading stimulates protein synthesis in skeletal muscle (³⁹), and increasing loads result in greater responses until a plateau is reached (²⁴). It is likely that protein synthesis responds in a similar manner to the number of sets (i.e., an increasing response as the number of sets are increased, until a plateau is reached), although there is no research examining this. The results of this study support this hypothesis; there was a trend for an increasing ES for an increasing number of sets. The response appeared to start to level off around 4-6 sets, as the difference between 2-3 sets and 4-6 sets was smaller than the difference between 1 set and 2-3 sets (figure 4)

Figure 4

Dose-response effect of set volume on strength from Krieger (23). Note similarity to dose-response effect for hypertrophy in Figure 2. Data are presented as means ± SE. ES = effect size. *Significantly different from 1 set per exercise (p < 0.001).

The key bony bit of the result above is that some of us (i count myself in here) may need to change our thinking about the role of hypertrophy especially in the early phases of training with untrained participants. Now, that finding does not mean that noticeable mass gains are happening from day one, but it would mean that structural adaptations are happening way sooner in the process than has been pretty much taken as given for some time. For instance:

It has been proposed that the majority of initial strength gains in untrained subjects are because of neural adaptations rather than hypertrophy (²⁸). The results of this analysis suggest that some of the initial strength gains are because of hypertrophy. Given the insensitivity and variability of hypertrophy measurements, it is likely that hypertrophy occurs in untrained subjects but is difficult to detect. This is supported by research that shows increases in protein synthesis in response to resistance training in untrained subjects (²⁴). Recent evidence also shows measurable hypertrophy after only 3 weeks of resistance exercise (³⁸).

What the studies do not discriminate about is whether these hypertrophic adaptations are more myofibrial or sarcoplasmic. And that rather makes sense as the main consideration has been (1) strength and (2) simply whether or not hypertrophy is more or less corelevant with the development of neural adaptations that lead to strength.

 Practical Application

A super attribute of the JSCR articles is their "practical application" section - what can someone do with these results. The first application Krieger suggests is to get behind the awareness that hypertrophy increases from day one from more sets. In other words the number of sets does make a difference whether a beginner or not. Cool. Move it move it:

Multiple sets per exercise were associated with significantly greater changes in muscle size than a single set per exercise during a resistance exercise program. Specifically, hypertrophy-related ESs were 40% greater with multiple sets compared with single sets. This was true regardless of subject training status or training program duration.

The second point is that those multiple sets make a statistically significant difference in terms of the amount of hypertrophy. More is more (at least up to 4-6 sets) for strength and structural development.

There was a trend for an increasing hypertrophic response to an increasing number of sets. Thus, individuals interested in achieving maximal hypertrophy should do a minimum of 2-3 sets per exercise. It is possible that 4-6 sets could give an even greater response, but the small number of studies incorporating volumes of ≥4 sets limits the statistical power and the ability to form any definitive conclusions. If time is a limiting factor, then single sets can produce hypertrophy, but improvements may not be optimal.

So while 1 set is certainly not useless, it mayn't be optimal (where that means before we hit a plateau). What remains to be done, according to Krieger, is to figure out that optimal set range:

More research is necessary to compare the effects of 2-3 sets per exercise to ≥4 sets. Future research should also focus on the effects of resistance training volume on protein synthesis and other cellular and molecular changes that may impact hypertrophy.  

Practical Awareness

For beginners interested in doing more sets, excellent. What to watch out for: fatigue. Stay fresh. Might be a grand idea to make sure to get a program that waves the volume so that there's ample recovery. Without that recovery, growth in strength/hypertrophy does seem to get retarded pretty fast.

For more experienced trainees, from what i hear among the folks i work with is: want to get bigger? lift more. More sets. more reps. more more more. The question this article nicely raises is what's an optimal more? Will be interesting to see if, when and how this question is formally explored in the future.

Related Links:

• What is the Pump, really? Do we know?
• Get Huge or Die?
• Occlusion training
• Supplement Curmudgeon: Does this stuff work? 
• b2d General Fitness Articles

Citation:

Krieger JW (2010). Single vs. multiple sets of resistance exercise for muscle hypertrophy: a meta-analysis. Journal of strength and conditioning research / National Strength & Conditioning Association, 24 (4), 1150-9 PMID: 20300012

90 Seconds or less to Bond: skills of social engagement

A bit ago i wrote about how Robert Sapolsky's Why Zebras Don't Get Ulcers describes a rich variety of animal case studies of coping with stress in these creatures natural habitats. A biggie of  stress seen among our non-human kindred is the effect on longevity and quality of life. A key factor in bringing down stress and increasing longevity? Good socialization. After looking at Sapolsky's work it became clear that the research i do on well-being which had been focusing on nutrition, movement and rest/recovery needed to add in socialisation. But how?

In nutrition, movement and recovery, i've been keenly aware that there are skills for each of these practices, and i've spent some time researching, practicing and writing about some of them. Socialization has been a bit of a mystery, though. What skills would one even look for? We're not talking about etiquette, but about how to connect and play nice with others. Thumbing through the material for the various management and leadership courses i'd been on didn't percolate up anything about basic human engagement. In coaching, the closest thing seemed to be motivational interviewing, but that's not developing peer-to-peer encounter skills.

And then, it - or at least a partial it - happened. I came across this fabulously concise (audio) book: how to make people like you in 90 seconds or less by Nicholas Boothman (uk cd | uk book|| us book | us cd).

In this wee book, Boothman presents a suite of skills to help us connect with people. These skills start before the first hello, such that the work of those 90 initial seconds (or less) in someone's company are richly prepared for optimal success.

The title sounds rather flakey, but in actual fact the skills are well founded in concepts like neural linguistic programming. That practice too sounds a little daunting as a controversial area of psychotherapy from the same era as TM. But whether one accepts the entire NLP package or not, the very pragmatic and specific application of it to human close encounters is both easy to grasp and to test with this simple question: do these techniques enable me to engage with other people more of the time and more successfully in more situations? For an introvert like myself, trying to add this Fourth Front of WellBeing to my skill set, believe me, this stuff has to be pretty robust if it's going to work.  And it does seem to be helping.

Boothman sets up a handful of concepts, from introduction approaches, to paying attention to the kind of language another uses (visual, auditory, kinesthetic) in order to successfully and quickly get on to that other person's wavelength.

Some of the techniques in the book will likely sound like simple politeness: be aware of cues from one person's conversation of where they want to go rather than pushing our own agenda/interests first. Other skills are more subtle: learn what to watch in body language cues for openness and engagement and where the body language matches words spoken - or does not.

And that's really it seems what these skills are mainly about: how attend with intent to an other in order to enable that person to feel comfortable. This comfort is achieved by having so modulating oneself to be on that other person's wavelenght that they feel safe, at home, we're sufficiently the same to share this exchange.

I'm looking forward to finding other books that map out more skills in the socializing space, but it seems remarkably appropriate that the first source that seems to fall into my hands (or ipod) is about these first steps to Making Contact.

If you too might like to improve the quality of your contact with Others, then i'd recommend this wee tome or cd set.

Eccentric Exercise - some cool ideas as to why it seems to heal certain tendinopathies (ps, ditch -itis and -osis)

Have you been suffering with some kind of sore tendon/jointy pain? Rotator cuff area, achiles, elbow, forearm, rsi etc etc? Guess what? First we're not alone, but second, just about anything that's been tried to address it has no real evidence to support it working, especially over time. Indeed, as the authors of a 2009 review study put it, "Tendinopathy is common although pathology of this condition is poorly understood." In other words, we don't really know how this dis-ease works. The point of this article is to consider why, as these authors see it, Eccentric Exercise (EE) which has seemed to have some good, some neutral results in research, may actually be successfully addressing the effects of that pathology. So much so, that it gets rated as a good "conservative" therapy for these kinds of common, awful and sometimes career ending, painful problems.

By way of context, in 2008, the year before these authors proposed why EE might be useful, another group reviewed pretty much everything under the sun applied to tendinopathies, from NSAIDS to shock wave therapy (and anything else one's GP may recommend). THe paper has the remarkably useful title "Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon"

They write of these therapies:

Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Thus, traditional treatment modalities aimed at controlling inflammation such as corticosteroid injections and nonsteroidal antiinflammatory medications (NSAIDS) may not be the most effective options. We performed a systematic review of the literature to determine the best treatment options for tendinopathy. We evaluated the effectiveness of NSAIDS, corticosteroid injections, exercise-based physical therapy, physical therapy modalities, shock wave therapy, sclerotherapy, nitric oxide patches, surgery, growth factors, and stem cell treatment. NSAIDS and corticosteroids appear to provide pain relief in the short term, but their effectiveness in the long term has not been demonstrated. We identified inconsistent results with shock wave therapy and physical therapy modalities such as ultrasound, iontophoresis and low-level laser therapy. Current data support the use of eccentric strengthening protocols, sclerotherapy, and nitric oxide patches, but larger, multicenter trials are needed to confirm the early results with these treatments. Preliminary work with growth factors and stem cells is promising, but further study is required in these fields. Surgery remains the last option due to the morbidity and inconsistent outcomes. The ideal treatment for tendinopathy remains unclear.

It's almost as bad as the common cold: ubiquitous and no idea how to cure it.

Aside: And if you have a type of rotator cuff tendinopathy, and your doctor is suggesting a steroid shot? I'm motivated here as this is me. You may want to point that caregiver to this 2007 review of the lack of proven efficacy of this approach.

This systematic review of the available literature indicates that there is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease.

It's interesting that from that mix of "current data" strategies that look promising in the 2008 survey quoted above, the authors of the 2009 BJMS article are interested in eccentric exercises. In 2007, another group of researchers concluded a literature survey about Eccentric Exercise and chronic tendinopathy with the sad claim that

the dearth of high‐quality research in support of the clinical effectiveness of EE over other treatments in the management of tendinopathies.

In other words, good quality studies that would be taken as being say clinically significant are thin on the ground. They're not as rigerous as these scientists would like to see in the presciption of a protocol to treat something.

By 2009, however, the UK group of scientists seems ready to say that EE is a good "conservative" treatment for tendinopathy. What's quite remarkable is why they're making this claim, and that's at the heart of this article.

Tendinopathy?
But first things first, just to be sure we're all on the same page, what is tendinopathy? Tendinopathy is the umbrella term that includes, among other considerations, tendinosis and tendinitis. As for the differences between these two, on a functional level, Mike Nelson puts it nicely:

TendonITIS is normally from inflammation (itis). TendonOSIS is normally from messed up connective tissue.

To get into a bit more detail, the intro to the 2008 survey is very helpful

Traditionally, pain in and around tendons associated with activity has been termed tendonitis. This terminology implies the pain associated with these conditions results from an inflammatory process. Not surprisingly, treatment modalities have mainly been aimed at controlling this inflammation. The mainstays of treatment have included rest, nonsteroidal antiinflammatory medications (NSAIDs), and periodic local corticosteroid injections.

There are two problems with this approach. First, several studies demonstrate little or no inflammation is actually present in tendons exposed to overuse [83, 96, 163]. Second, traditional treatment modalities aimed at modulating inflammation have had limited success in treating chronic, painful conditions arising from overuse of tendons. More recently, the term tendinopathy has been advocated to describe the variety of painful conditions that develop in and around tendons in response to overuse. Histopathologic changes associated with tendinopathy include degeneration and disorganization of collagen fibers, increased cellularity, and minimal inflammation [83, 163]. Macroscopic changes include tendon thickening, loss of mechanical properties, and pain [163]. Recent work demonstrates several changes occur in response to overuse including the production of matrix metalloproteinases (MMPs), tendon cell apoptosis, chondroid metaplasia of the tendon, and expression of protective factors such as insulin-like growth factor 1 (IGF-1) and nitric oxide synthetase (NOS) [10, 76, 93, 99, 154, 155, 174, 199]. Although many of these biochemical changes are pathologic and result in tendon degeneration, others appear beneficial or protective. Tendinopathy appears to result from an imbalance between the protective/regenerative changes and the pathologic responses that result from tendon overuse. The net result is tendon degeneration, weakness, tearing, and pain.

So for practitioners in the know, it seems the once-frequent diagnosis of "tendinitis" has gone down quite a bit - because inflammation may or may not be present, and when it is, may or may not be the main cause of pain. Also, there is an "imbalance" of protective/regenerative responses to overuse and pathological (diseease) responses. This is Mike's "messed up connective tissue."

Hence we circle back to the term tendinopathy to cover this not unusually mixed condition of perhaps some inflammation but in particular, "degeneration, weakness, tearing, and pain" Hence both osis (tears) and itis (inflammation) may neither be particularly pathologically accurate or diagnostically helpful. And so, tendinopathy is the new and more robust term for these conditions.

With that note in mind, let me also add that the following discussion is not meant to be a prescription of any course of action. Get yourself checked with your doctor before starting anything. In my own case i have been disappointed by the fact that the thing that has actually helped the most immediately has been taking NSAIDS - some inflammation, or -itis maybe?

After a month of other non-drug interventions, day one after finally breaking down and seeing the doc: bam - immediate reduction in the pain that was making putting on a jacket a painful experience. bugger. But ah ha, it ain't all better that's for sure. What to do next? My hope is that the following research may offer some insight into WHAT to do if not exactly how and when to do it.  


Eccentric Exercise and Tendinopathy
The authors of "Eccentric exercises; why do they work, what are the problems and how can we improve them?" J D Rees, R L Wolman, A Wilson write in the abstract:

Eccentric exercises (EE) have proved successful in the management of chronic tendinopathy, particularly of the Achilles and patellar tendons, where they have been shown to be effective in controlled trials. However, numerous questions regarding EE remain. The standard protocols are time-consuming and require very motivated patients. EE are effective in some tendinopathies but not others. Furthermore, the location of the lesion can have a profound effect on efficacy; for example, standard EE in insertional lesions of the Achilles are ineffective.

Until recently little was known of the effect of EE on tendinopathic tendons, although a greater understanding of this process is emerging. Additionally, recent in vivo evidence directly comparing eccentric and concentric exercises provides a possible explanation for the therapeutic benefit of EE. The challenge now is to make EE more effective. Suggestions on areas of future research are made.

So, the researchers are sitting with the 2007 surveyview that while there's some hints of promising evidence in the past about EE, it hasn't been super. They think that now, however, they have a better sense of what might be making it effective.

The body of the article focuses on Achilles tendinopathy (mid back of the leg - base of the calf muscles), Insertional Achilles tendinopathy (where the tendon inserts away from the calf muscles, down by the ankle where it attaches to the bone) , Patellar tendon (either side of the knee cap) in particular.

The authors' insight has been to look at where in the tendon the lesion is occuring. Is it where the tendon attaches to the bone or where it attaches to the muscle? The effects of EE in the small number of studies are all over the map, so it's hard to draw any conclusion except, it seems, that where the lesion is on the tendon seems to have a correlation between the degree to which EE will be successful. For insertional achilles, as opposed to "the main body" of the tendon, EE's not showing up as so great. With the paterllar tendons, while some studies have shown benefit, especially over CE or concentric, whether there's a difference around proximal or insertional hasn't been the focus of research in such a way as it's possible to make a distinction.


With respect to other tendinopathies - like forearms (RSI kinda stuff) and elbows, the authors write:

A small number of studies have examined the use of eccentric exercises in the management of tendinopathy of the lateral extensors of the forearms.26–28 There is some evidence suggestive of an increase in function using EE compared with ultrasound in the treatment of lateral extensor tendons,29 and a recent study adopted an isokinetic eccentric protocol in the management of lateral elbow tendinosis and reported promising results.30 No randomised study on the effectiveness of EE on the rotator cuff has been published, although a small uncontrolled pilot study of nine patients did suggest a significant benefit of EE (patients with arthritis of the acromioclavicular joint or significant calcification were, however, excluded).31 Further trials on both tendinopathy of the rotator cuff and lateral extensor forearm tendons are required in order to evaluate EE more fully.

Just my luck: shoulders with EE haven't been evaluated. Time to become an experiment of one.


What are Eccentrics Doing?
Despite this rather promising but still arid, partial research landscape for EE and tendinopathy, the authors have some ideas about the mechanisms that may be at play in eccentric efforts

The pathophysiology of tendon injury and healing is incompletely understood. It does appear, however, that in established tendinosis the tendon often does not progress into an active (or at least successful) healing cycle. EE may work by providing a mechanical stimulus to the quiescent tendon cells

The authors propose several interesting ways in which this "mechanical stimulus" may work. The first is on that all important building block for tissue, collagen

Physical training in general has been shown to increase both the synthesis and degradation of collagen,39 and in the longer term this may lead to a net increase in collagen. Recently it has been recently elegantly demonstrated by Langberg and coworkers, by use of the microdialysis technique, that a chronically injured Achilles tendon responds to a 12 week EE programme by increasing the rate of collagen synthesis.40 In this study 12 patients (six with Achilles tendinosis and six normal controls) performed EE over a 12 week period. The EE group had increased collagen synthesis (peritendinous type I collagen) without a corresponding increase in collagen degradation. There was also a corresponding drop in pain levels (in line with other studies).

That collagen production - to repair tendon degredation - is a huge and good deal. Especially that the exercise is not causing breakdown, but actual rebuilding.

Another factor the authors consider is blood flow. When we see tendons illustrated in anatomy texts, they're usually white-ish. That's the lack of a whole lot of blood going through them. This limit is in no small part why tendons can take longer than just about anything else to heal. So improving blood flow to tendons - blood being a nutrient carrier - could seemingly be a big plus. The authors write

The effect of EE on Achilles tendon microcirculation has also been studied. Achilles tendon oxygenation was not impaired by an EE programme but was accompanied by a decrease in postcapillary venous filling pressures, the authors suggesting that this reflects improved blood flow. Again this study looked only at eccentric exercise so it is not possible to determine whether this is a specific effect of EE.

In other words, concentric exercise may have the same benefit on blood flow as eccentric exercise - we don't know - but what we do seem to know is that exercise (in the studied case, eccentric) keeps the blood moving, circulating rather than sitting somewhere. The anti pump? in a good way?


Where using the Force Mayn't Matter. All this is cool, but it doesn't explain WHY these effects are occuring from EE. In particular, something the scientists can conclude rather strongly from the work that's been carried out is that the magnitude of the force has nothing to do with it. So lifting a big weight, or lifting a lighter weight faster (F=M*A) isn't what's getting the job done.

The key question the authors ask is:

If the efficacy of EE cannot be explained by the magnitude of force, then what is responsible?

Great Question. They have one very intersting finding about eccentric exercise - the shape of control of the muscle when it's lengthening and contracting at the same time:

Intriguingly, we observed a pattern of sinusoidal loading and unloading in EE which was not demonstrated in CE. The fluctuations in force probably reflect the difficulty in controlling a dynamic movement with a lengthening muscle; similar to the experience that it is easier to lift a heavy weight under precise control than to lower the same weight. We propose that these fluctuations in force may provide an important stimulus for the remodelling of tendon. Certainly in the remodelling of bone it is known that bone responds to high-frequency loading and appropriate mechanical signals can lead to a dramatic increase in bone density.

Frequency rather than Force. This is so cool - it sounds great too: that the sort of cycling on and off of the muscle (the sinusoidal loading and unloading) during the eccentric may be the biggie in stimulating that good collagen rebuilding in particular associated with EE and maybe the blood flow too. The other interesting part is that there is a possible parallel to bone remodelling here (and Woolf's law).

That is, as force is applied to a bone it will get bigger (the outer shell gets pushed out it seems, as the inner lace work architecture increases) and so stronger to respond to that demand. Davis's law on tissue seems a wee bit similar: "If soft tissue is placed under unremitting tension, the tissue will elongate by adding more material. "

Bottom line: the particular type of muscular demands to maintain control of a load in extension (force fluctuations not force magnitude) may play a particular role in remodeling tendons in these various opathies.


Whither, Voyager for Futuer EE / Tendinopathy Research?
The authors are now happy to say EE seems to have sufficient basis to be considered viable. Time to figure out how to optimize it. THey write in the Future Work section:

Little is known of the optimal protocol for EE. Indeed, fundamental questions remain unanswered, such as how fast the exercises should be performed and progressed. This is certainly an area worthy of future research. The specific location of the pathology within a tendon has increasingly been shown to have an effect on the efficacy of EE, and further study in this area is also suggested. Other potential areas of research include studying the effect of periodisation of training, a technique currently perhaps more familiar to athletes and their coaches than to sports medicine physicians.

Goodness, that's interesting. Periodization combined with frequency may be the sweet spot for rehab. Why not? It's excellent for anti-fatigue strength building; why not repair?

As an example of eccentric exercises that have been tried out among at least a small population of elbow-opathies,  Mike T Nelson's developed some nice eccentrics work with a kettlebell. Well worth a look and a go.

What i've been working lately for my shoulder/painful arc thing:

 put a wee kettelbell or light db in the hand of the sore side. bring hand up to chest (with weight in it), then lift elbow so it's parallel or close to shoulder height WITH NO PAIN - only go as high as you can with no pain
- slowly abduct the hand away from the chest, and potentially rotate wrist down (like pouring a jug) - if the load feels too heavy - brings on pain - bring hand in a bit; reduce turn in wrist; then lower the whole arm (not just the elbow but this L shape you're holding) so you're working the shoulder.

that lets one do the concentric pretty much unloaded and focus on a safe eccentric.
if you give that a go for a while let me know how that feels - just don't move into pain.

Concludium 
Perhaps the main take away from this summary of recent research reviews and primary work is that tendinitis vs osis is largely a non-starter; tendinopathy is where it's at. And saying that, the pathology or dis-ease of tendinopathy is not well understood, which may also explain why treatements - in particular long term ones - don't have much evidence to support their efficacy. There are some prospective treatements on the horizon, however, with eccentric exercise amongthem. This latest study on EE and tendinopathy seems to propose the best hypothesis so far as to why eccentric exercises is showing up as particularly effective for at least main body tendinopathy.


Citations:

Rees, J., Wolman, R., & Wilson, A. (2009). Eccentric exercises; why do they work, what are the problems and how can we improve them? British Journal of Sports Medicine, 43 (4), 242-246 DOI: 10.1136/bjsm.2008.052910

Andres, B., & Murrell, G. (2008). Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon Clinical Orthopaedics and Related Research, 466 (7), 1539-1554 DOI: 10.1007/s11999-008-0260-1

Woodley, B., Newsham-West, R., Baxter, G., Kjaer, M., & Koehle, M. (2007). Chronic tendinopathy: effectiveness of eccentric exercise * COMMENTARY 1 * COMMENTARY 2 British Journal of Sports Medicine, 41 (4), 188-198 DOI: 10.1136/bjsm.2006.029769

Koester MC, Dunn WR, Kuhn JE, & Spindler KP (2007). The efficacy of subacromial corticosteroid injection in the treatment of rotator cuff disease: A systematic review. The Journal of the American Academy of Orthopaedic Surgeons, 15 (1), 3-11 PMID: 17213378

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Ankle Sprains: Tape, Bracing - doesn't matter finds research - but how'd we get so busted up in the first place?

A recent paper has presented the results of a bunch of trials looking at interventions for ankle sprains. Main result? if someone's had an ankle injury - like a sprain - then tape or brace doesn't seem to show a difference: both seem to cut down reinjury. What's troublesome on a metalevel, is first how sort of accepted the notion of this level of injury seems to be, and second how nascent in the approach described here is the model that for folks who haven't been injured - as a preventitive - they maybe should be immobilised too. Aren't there other questions to ask - perhaps especially about the injury free staying injury free - rather than whether incapacitating natural function is a Good Idea? But perhaps more fundamentally, how did we get to this point where someone is so beaten up their joints are written off as so dysfunctional they must be immobilized to perform?

Here's the abstract:

Epidemiological studies have shown that 10–28% of all sports injuries are ankle sprains, leading to the longest absence from athletic activity compared to other types of injuries. This study was conducted to evaluate the effectiveness of external ankle supports in the prevention of inversion ankle sprains and identify which type of ankle support was superior to the other. A search strategy was developed, using the keywords, ankle supports, ankle brace, ankle tapes, ankle sprains and athletes, to identify available literature in the databases (MEDLINE, PubMed, CINAHL, EMBASE, etc.), libraries and unpublished papers. Trials which consider adolescents and adults, elite and recreational players as participants were the study of choice. External ankle supports comprise ankle tape, brace or orthosis applied to the ankle to prevent ankle sprains. The main outcome measures were frequency of ankle sprains. Two reviewers assessed the quality of the studies included using the Joanna Briggs Institute (JBI Appraisal tool). Whenever possible, results were statistically pooled and interpreted. A total of seven trials were finally included in this study. The studies included were of moderate quality, with blinding as the hardest criteria to fulfill. The main significant finding was the reduction of ankle sprain by 69% (OR 0.31, 95% CI 0.18–0.51) with the use of ankle brace and reduction of ankle sprain by 71% (OR 0.29, 95% CI 0.14–0.57) with the use of ankle tape among previously injured athletes. No type of ankle support was found to be superior than the other.

 This is when it's nice to have the whole article, because you'd think it just stops there, right? For previously injured, folks who were taped didn't seem to get reinjured. How does one predict the future like that? Well that's the toughie: only one study had a control group - so did they just get reinjured that many more times than the athletes who braced? No, it's of the populations taped or braced, how many did NOT have a recurrence in a given period.

So what's going on here that this is even considered a useful strategy?

Apparently, there's a lot of functional instability, mechanical and proprioceptive factors are also considered in some of the studies to be impaired. Mechanical instability (lax joint) can be a cause of functional instability.  These effects build up from - you guessed it - repeated ankle injuries. Where reflexes get slower, joints can get hypermobile, funtional loss of static and dynamic support of the joint has gone way down. Effectively, the ankle for a potential variety of reasons, is so beaten up and abused, it can no long function as an ankle, so, a greater degree of immobility is preferable to too much.

Um. what happened that a person gets to this point of so MANY repeated injuries they're beyond the pale of recovering normal function? Ah right: this is sport, not health. 

Intriguingly, there's a claim that some bracing helps proprioception:

 "they restrict range of motion to a certain degree and enhance proprioception of the injured ankle making them more useful in the prevention of possible re-injury." 

Wow, that's wild. How does that work? And can that awareness be re-trained rather than delivered only through a device? Where's it coming from? But there's not a lot of interest in the article in looking at say other strategies like rehab, movement assessment. Why not? There's a model here that says once injured, you're toasted:

As mentioned earlier in the discussion, after a sprain, structural damage occurs to the ligamentous tissues, nervous and musculo- tendinous units in the ankle joint. Functional and mechanical instability arise. For these reasons, the risk of injury to a pre- viously injured ankle is increased. his is the point where external ankle supports play an important role.

And that may have informed the authors' decision simply to look at what type of bracing is better to reduce re-injury, rather than to wonder if

• training that can find movement or other sensory-motor issues that may be related to WHY a person roles their ankles
• investigation of the stupid shoes that may be killing proprioception necessary to reduce ankle sprains
• anything else that may help the athlete perform with less likelihood of injury, better performance

What's kinda scary is a one line toss off in the conclusion:

This review provides good evidence for the use either ankle taping or ankle braces to prevent lateral ankle sprains among previously injured players. However, for those with- out previous ankle injuries this still needs to be proven. There is no evidence on which external ankle support is better than the other. Each has its own advantages and disadvantages.

You see it? These folks with this model of the weakness of the ankle - where "10-28%" of all athletic injuries occur - are already thinking MAYBE - we don't know yet - but maybe if we just brace the ankle up from the get go, we'll keep more ankles from being sprained.

There are alternatives approaches: perhaps we should ask, as indicated, what's causing these injuries in the first place? Is it a skills-on-the-field problem? turning skills? cognitive processing for field awareness skills? Is it lack of ankle flexion or hip/pelvis restrictions? Is it a sensory-motor disconnect with shoes or other gear killing proprioceptive awareness of foot placement?

Folks like Gray Cook working with NFL football teams have been looking at athletic mobility/stability. Eric Cobb has been looking more at sensory-motor approaches, and cognitive stress for field performance that's more effective and injury free.

Any solution assumes a model for which that solution is appropriate. The solutions proposed by these authors seems to presuppose a model where (a) the amount of reinjury that leads to such horrible dysfunction is taken as a given and seems to be ok such that (b) further bodily immobilization seems like a good idea to enable athletic movement seems problematic to me on a number of levels.

Strategies to understand why the injuries are so high in the first place - never mind acceptable - seems to be a more humane way to begin strategizing about enabling athltetes to play ball, no?

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Citation
Dizon, J., & Reyes, J. (2010). A systematic review on the effectiveness of external ankle supports in the prevention of inversion ankle sprains among elite and recreational players Journal of Science and Medicine in Sport, 13 (3), 309-317 DOI: 10.1016/j.jsams.2009.05.002

Some differences between Active vs Passive (Only) Work to Enhance Performance

Active? Manual/Passive? What's the difference when we hurt or hit a performance hurdle?  If we get a movement-oriented pain (low back, sore shoulder, hinky knee), our traditional, initial response after seeing a doc to make sure an alien is not about to pop out of our chest, is usually to seek out a manual therapist - a chiropractor, active release person, a massage therapist, an accupressurist/puncturist - to get us "fixed." If we're in acute pain in particular, these can be  great approaches to get out of that immediate pain place. Super. Likewise, if we sense we have a movement limitation, we might do the same thing: if stretching doesn't get it done, we go get it "worked on" by a manual therapist to help "open it up." While there can be benefit to these approaches in these cases, there may also be richer, sometimes faster paths to performance improvements that are active rather than passive.What does that mean though, to "go active" rather than passive/manual?

Manual therapies all have that one trait in common. They are the act of something being done to us, while we remain primarily the passive recipient of these ministrations. In some contexts this can be fabulous. Various kinds of massage enact a relaxation reflex that can help us - and our bodies - calm down - at least while we're on the table. And that may be sufficient for us to move past whatever effect it is we're experiencing to get to the other side.

Active approaches, in contrast, are when we do the work for ourselves. Active approaches have certain neurological benefits: they seem to require significantly great neurological engagement to be carried out. Models of motor learning that i've talked about before get engaged.

The differences between active and passive work might be expressed in the example of someone learning to swing a tennis racket. If a coach stands behind us, and does the swing for us, we get a sense of the feel of where the arc should be in our body - where our joints should move - but until we practice it for ourselves, we're not firing up all the muscle fibers in the correct sequences to hold the racket, and move the racket ourselves, through that arc. We certainly haven't coordinated the feel of that action while running one way and potentially looking another (blending in balance and visual acuity).  So, pretty obviously, carrying out a movement actively engages a lot more of our systems than passively being lead through the same motion. And that active engagement is a Good Thing for our well being.

As i've written about before (here's a list), a lot of performance limitations (stalling out in a lift, or a swing or whatever) and a lot of pain seems to come from issues in movement - poor mobility (control over one's movement) in one area requires compensations in movement (that may be uncomfortable after awhile) in others.

These kinds of movement/performance challenges are so well understood, Gray Cook and Brett Jones's entire "Secrets of ..." series deals with what they frame as mobility/stability issues. In their dvd on the Turkish Get Up, Kalos Sthenos, for instance, Cook and Jones talk at length about the effects of say restricted upper spine mobility and the negative consequences this has for upper body movement in general and strength work like pressing in particular.  Their functional movement approach to addressing these restrictions is not to get a person on a massage table, but to get the person active with what they term corrective drills that work with the thoracic spine and shoulders. 

Threat or No Threat In Z-Health, Eric Cobb looks at this kind of mobility (control of one's movement) as the fastest path to the nervous system that is the governor of the entire muscular-skeletal/sensory-motor system. I've written before how in this model, the only thing the nervous system cares about is threat or no threat. That a perceived threat (like jammed or  less independently mobile joints) causes a reduction in outputs like force production. Help address the quality of movement, threat goes down as quality of information to the nervous system goes up; performance goes up.

Recently i've talked about a wee hypothesis i'm playing with that the value of tons of movement reps with light weight has a huge benefit for moving to larger loads in a new move because the threat has been reduced. The body knows how to do the move, so the only new thing to worry about is managing the load.

To come back to manual vs active work, in manual work, with less of the nervous system engaged in translating the work done to into any active effect, it seems threat response may stay pretty high in that a real lasting change pattern has not been initiated. Trust has not been built, perhaps? And so the benefits of the treatment may not have an ongoing effect.  This lack of stickiness from manual work has been demonstrated  in a recent video by the Z-Health team. Here, Eric Cobb demonstrates the immediate after effect of passive work vs active.

In the example, the participant is first muscle tested - strong - is placed in a jammed joint position at the ankle, is muscle tested again - weak. He is manually maniupulated to fix the joint (Cobb is a chiropractor by license); re-tested, strong. Supposedly,  this person is now fixed. He gets up to take one step, comes back for a re-test, weak again. Goes away to do 3-4 reps of the toe pull drills for that joint that have been taught in the class, comes back after walking around post-drills, is tested again, and he's solid.


What we could draw from this example is 

• how little all the systems of the body are engaged in passive manipulation 
• how improved funtioning after a manual experience on a table is potentially very distinct from our experience in normal active movement
• how much more of our systems are engaged in even simple small but active movements
• how necessary that engagement seems to be for well being/performance
• how rapidly that engagement kicks in 
• how easy that active engagement is. 

What i am not saying at all is that passive therapy is inapporpriate. A number of the athletes i coach who have decades of trauma in their bodies find that mixed methods help them, and that in particular, when they combine their passive work with active z-health drills, for instance, during or immediately after their treatments, the benefits are far more sticky. Books like the well-regarded Anatomy Trains on the fascial system talks about the neural necessity of blending active participation with the manual manipulations of the fascia a therapist may carry out.

Indeed, one person has told me they've gotten through an intense patch of combined work of manual/active therapy and are on maintenance now with just the z-health drills. For most of my other athletes, combining the z-health work with their sport work has had significant benefit for their overall performance.

Give Active Work a Chance. What these demonstrations seem to show us is that there is a real both immediate and lasting benefit to carrying out dynamic active work around our own mobility - our own volitional control of our motion. In moves like the turkish get up, we see this control in the ability to exectute a high hip bridge when transitioning from back to kneeling, or being able to keep the chest high with the arm raised in lock out when in the upright seated position.

In a z-health drill it may be simply the ability to do a shoulder circle where say the left arm circles in front of the right side of the body without the left shoulder moving/torquing at all towards the right side to get the arm over to that part of the body - just for example. For some folks, one of the most challenging movements has been a wrist movement where the wrists, not the hands, lead the movements up and down.

The quest here is not hypermobility - it's not about doing the splits, per se. It's about at least in part having better control of independent ROM in our bodies in order to move better - to move as we are designed to move. That means that the hips can move independently of the pelvis; the thoracic spine can actually move back and forth and side to side independent of the lumbar spine; that there is an appropriate degree of ankle inversion and eversion, and so on.  To find out more about why that independence of joint motion also leads to greater "map clarity" and better performance, here's an article more about that.

Take Away In this context of active in relation to passive care, a ket take away, i'd say, is that it's ACTIVE work that builds up this capacity to enhance our performance, and that by deliberately practicing active mobility our performance improves - and likely incidents of tweaks go down as well.

Places to Start

Specific Work: I start my athletes with a movement assessment to see if they have any issues with particular movements (what Gray Cook calls "weak links") that if addressed may lead to improved performance. If you don't have access to a CK-FMS trainer or Z-Health coach in your area for an assessment, some of us (me included) do them online (here's some reviews). 

Anytime Work: At anytime it's a great idea to get an active mobility practice in your universe. There are all sorts of programs in this space, including traditional practices like t'ai chi. Fabulous. Here's a piece on where i see z-health being different from these practices and why i think the z-health progressions are valuable to know too.

My recommendation for the folks i coach is z-health drills because of the focus on joint by joint mobility control. My recommendation is to start with the first level of Z-health that starts in neutral stance - no moving around really - and as soon as comfy there, get into I-phase. Here's a longer discussion on why the progression from R (vocabulary of movement) to I (control of movement templates) is important for performance

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