It’s All About Motor Control

A key component of motor control is muscle tone, and I want to specifically discuss inappropriate muscle tone

Very often, from the perspectives of physical therapy and rehabilitation, we don’t necessarily see just tightness or weakness.

Tightness is often a way that the body uses parking brakes in the absence of real, authentic braking systems. The braking system that the body has is called motor control and it is finely tuned to input, processing and appropriate output. When a fault is present somewhere in that system—somewhere in movement, somewhere in that coordination, timing and symmetry—a dysfunction is observable.

The body is set up to survive and in a situation where the original operation is compromised, it simply creates a parking brake system—one that tends to stay engaged, slow you down and keep you out of trouble. This parking brake is a fail-safe in fatigue, injury, protection of other structures and avoidance of pain. You may have improved control, but you also waste energy and lose efficiency. The weakness issue remains evident. It is often deconditioning; it’s body-wide and not isolated and it’s easily fixed by getting up and moving today  . . . and then moving a little more tomorrow. However, isolated weakness is rarely just weakness.

Isolated inhibition of a single muscle or group of muscles is best diagnosed in rehabilitation as a neurological problem or impairment resulting from injury, disease or dysfunction. The subtle and background inhibition I’m speaking of is the inability for a muscle to take a command to an appropriate level of tone to execute a posture or a pattern. Our real problem here is when we simply discuss tightness or weakness of a muscle, we can go down the rabbit hole thinking it’s a muscle problem. Very often, it’s a command problem.

If there is tissue tightening, everything from deep fascia to superficial scarring or scar tissue from a previous injury, the muscles will be told to tighten prematurely or even maintain a significant amount of resting tone simply to protect the kink in the system. This tightness can also be preserved not from a signal from other tissues but it can be left over from a previous injury that has already been resolved. The muscles never got the memo.

Imagine the child who, having broken a leg bone, graduates physical therapy with full range of motion, full strength, and even a fairly good movement screen, yet continues to limp when walking fast or running. Why? Because it’s a habit. The input is correct, but now the habitual lifestyle burdened with pain and rehabilitation has created a limp that is actually the problem in itself. A new dysfunctional pattern is in place. A limp is functional following an injury because it offloads stress and maintains some degree of mobility. It becomes dysfunctional when there is no longer a reason to offload stress—when the problem causing the limp has been resolved.

The injury that caused the limp is gone and yet the limp remains—that’s a processing problem. Inappropriate input from unnecessary tightness, poor joint mobility or poor tissue extensibility can actually cause protective tone, which we see as tightness. Even when those compensations are gone, the habit of protecting can still remain.

The best way to deal with increased tone when flexibility and mobility are in question is to look at the pattern. Within the pattern is the answer. It shows us all of the other issues that we’re not thinking of that could be driving the mobility or flexibility problem.

Likewise, the weakness that we challenge with strength and exercise routines, loads and movement pattern development may often be inhibition. Inhibition doesn’t reset itself very well. When we have a choice to reset our own system or simply compensate, we often compensate.

Corrective exercise is a methodology that understands the biological need to compensate and removes the opportunities to compensate, usually by exploiting regressive developmental patterns. Rather than doing everything on a functional foot position, we go back through those patterns and postures that got us standing in the first place—rolling, crawling, kneeling, tall kneeling, quadruped. We add action to demonstrate that the posture and patterns at every level support the progression to the next level.

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These patterns can actually magnify the problem before we get to our feet, where compensation is our only opportunity. We can often measure flexibility problems locally and even measure strength problems locally, but ultimately, we must understand that there’s a motor control system driving this.

That motor control system is dealing with input, processing and output. Believe it or not, the easiest way to check is to simply look at output. If a movement pattern is at an acceptable level of quality, start loading and stressing that pattern to uncover the physical resources available in that particular movement pattern, shape and posture.

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If a movement pattern is broken, we must go down the rabbit hole and dissect out that movement pattern understanding. Is there a mobility problem driving poor input? Or a processing problem allocating poor stability and motor control?

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We can find, treat and correct these problems.  We can manage these problems, not by looking at muscle, but by looking at the patterns (or the lack thereof) driving inappropriate muscle tone. Remember, tightness and weakness represent the same problem, just at both ends of the spectrum.

Too much unnecessary muscle tone looks, on the surface, like poor mobility and must be managed. Is something driving it or is it simply a habit that is stuck on a hard drive that could use cleaning?

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Is the weakness actually something that just needs sets and reps or is the weakness driven by inappropriate mobility, motor control or inefficient patterning causing compensation?

Is that compensation due to a lack of mobility or motor control somewhere else in the body that has gone undetected for years or is it simply something on the hard drive that just needs to be scrubbed off?

To easily find these issues, we need systems. But as long as we insist on talking about local muscle tightness or weakness, we will miss it. It has often been said that the finger pointing at the moon is designed to show you the moon . . . most people just see the finger.

Inappropriate muscle tone is a symbol representing disharmony in the system. The disharmony can either be due to an input problem being appropriately processed or appropriate input being inappropriately processed.

We need to approach it in this clean and systematic way so we can find out which is driving, because it is not always clear otherwise. The clichéd answer is that inappropriate input and inappropriate processing is likely what’s going on in every situation.

That may be true to some degree, but now your action points are spread out and you do not have a feedback loop for your intervention. If, on the other hand, you think that somebody’s poor anklemobmotor control in their hip is due to a lack of ankle mobility, you can simply answer that question without even going onto social media. Create a little more mobility in the ankle and then recheck hip motor control.  If the ankle mobility problem was creating poor input and driving the bad motor control and general weakness in the hip, then you’ll have your answer. If it wasn’t, you’ll also have your answer.

This deductive reasoning is the ‘source code’ behind Functional Movement Systems. If you want to know whether it’s a mobility or motor control problem, do the test. That’s why we built it—for us. We had the same questions and could not find a tight system with logical answers. We didn’t set out to develop a screen or a system . . . we just wanted a competitive advantage. If you want to find out what’s driving the inappropriate tone, we have some assessments that will do that very well. If you want to measure motor control with an unbelievably efficient and functional test, we have that too.

We try to embrace movement metrics in a way that helps you have tighter feedback loops—to know whether you need to focus on individual correctives or programming modifications.

At any given time, one of those moves will make the biggest difference. Understanding in a biological system which is broken—the organism or the environment—is the hallmark of good science, and tracking movement behavior is where this starts in exercise and rehabilitation.

We’re Functional Movement Systems. We’re not an exercise company.

We offer better tools to look at movement and to create feedback for the individuals who depend on you for programming, rehabilitation and specialized performance training. It is true that movement screening, testing and assessment take time. No apologies there, as we should all take more time developing an action plan. That time spent in evaluation saves experimental time in rehabilitation, movement correction and physical development.

It’s the old Carpenter’s Rule: Measure twice and cut once.

When a new measuring stick is introduced and appropriately vetted, there are only two reasons why one would not adopt a tighter feedback loop into their professional practice:

  1. They don’t have faith in the new tool. More articles and posts won’t give them that faith. . .they need to put it in action.
  2. They don’t have faith that their methods can positively influence the baseline. Isn’t that the challenge we all face.

 

 

 

I look at the same issues from a mobility point of view in my talk, What’s Behind a Mobility Problem at OTPbooks.com

 

Movement Club

 

The first rule of Fight Club: You do not talk about Fight Club.

It would be easy for me to apply the same rule to the passionate group of people who look at movement in a systematic way.

The first rule of Movement Club: You do not talk about Movement Club.

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Let me go back and qualify the reference here. Fight Club is a movie about a counter-cultural movement to release, in a very primal way, the pent-up tension of an over-civilized society encumbered by political correctness, technology and a devaluation of all things manly. (There’s a lot more to the movie than that and you’ve probably got to read the book or watch the movie to understand what I’m talking about.)

The character Tyler Durden (Brad Pitt) states the first rule, but I’ll paraphrase. If you do get invited to Fight Club, show up and witness something unbelievably amazing. Don’t go talk about it. If you do have a few fights, understand the benefit of the primal release and actually feel somewhat empowered, then stick around and get better. Benefit from the experience but please, still, don’t talk about it.

That’s the reason for the repetition in rule #2: You do not talk about Fight Club. If it actually becomes a ritual, something that you rely on to sustain a superior level of integrity and resourcefulness, don’t talk about it.

It’s something you simply must experience and that’s the point. Let me borrow the same sentiment for people doing the Functional Movement Screen.

Yes, I’m sitting here writing about the movement screen. I often talk about the FMS but in a way to encourage you to at least sample or experience screening—an invitation. Can it add something to what you currently do?

Now, think about this. Steve Jobs realized that the personal computer could change the world because it put technology in the hands of the single user, for creativity, but also for entertainment. That is why Apple is where they are today.

From the Apple I to the iPod/iPad/iPhone and iTunes, Steve Jobs realized that empowering the technical consumer for both processing power and entertainment largely in the same device would probably change the world. He was right.

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Thinking in that vein, the Functional Movement Screen adds processing power to the current trends in fitness. For the last 30 years, fitness and the fitness industry have been more about entertainment than about strengthening our nation.

You want proof? In the last 30 years, we’ve gotten fatter and less fit. There are currently more obese Americans than there are overweight Americans. The generation of kids currently born won’t outlive the generation that’s raising them. Therefore, the current consumption of fitness media and fitness information is largely done for entertainment value and not so much for scientific, tangible, objective outcomes. The outcomes are horrendous.

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Another example? Do you know how many personal trainers peruse the Internet on a weekly basis looking for something new because their clients are bored? There you go: fitness is about entertainment.

Sure, some of us get results. But are they sustainable? That’s the big question. We just saw that the big picture is not looking good.

With the metrics in the Functional Movement System, we say “Let fitness entertain you. Let sports entertain you. Let these things engage you and allow you to play and experience new ways to move your body.”

But, if you expect some physical development benefit in any way, whether it’s skill acquisition or weight loss, you must set a baseline. You must check the baseline and make sure you’ve got a reliable tool and you’re at the right level of development with the right test that tells you to move to the next level. The journey to fitness needs tangible metrics—a GPS that tells us where we are and maps the best route to success.

Otherwise, keep looking for new routines and be satisfied with the entertainment value. You’re not going to look any better two years from now but you will have burned a lot of calories. Yes, it’s better than watching TV and it’s better than sitting—but physical development was not the result. Physical entertainment was.

I reference the first rule of Fight Club for people experiencing the Functional Movement Screen for the first time because so much of the Internet discussion about the efficacy or value of movement screening is done by people who aren’t even in the Movement Club.

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The people who ‘get it’ have enough of a feedback loop and enough expertise that if they do movement screening and do it correctly, they either find value in it or they don’t. Either way, the minute they find value, they might not necessarily be interested in sharing that value with their competition down the street. They have created a mentorship literally with a systematic mentor instead of a human mentor. They have a tighter feedback loop. They get results from smaller amounts of information than their competition does.

If you’re making comments about movement screening or movement assessment you need to have some background in the system. You don’t have to like the system, you’ve just got to be good enough at it to know that your dissatisfaction in the system isn’t because of your inability to technically replicate the system.

“I did the system good enough to be reliable and it’s not benefiting me in any way.” I can handle that critique all day. I can’t handle scrutinizing a system without at least sampling it. For those of you who have already performed movement screens (whether you value movement screens or not), I would prefer you honing your skills and tightening your feedback loop instead of saying positive or negative things in a public forum.

I want the technology that we created to empower the individual user—to press them to be creative, to press them to utilize that processing power—so that they can create a more entertaining product for fitness or athletic development that keeps people engaged but also delivers significantly better results than the past 30 years of fitness.

I take shots at physical education and fitness because we have all watched the physical landscape of a nation erode before our eyes. I want to leave you with a rule of thumb that might help you in your own journey in understanding and developing movement and movement screening and assessment tools.

First, don’t talk so much. Just do. Participating in Fight Club is fine. Talking about Fight Club is not fine. It distracts you from what the experience will give you—a break from the sedentary and soft dogma that is our modern society.

Secondly, if you’re in the Movement Club, don’t talk about the Movement Club. Do movement. Do movement screening. Do movement corrections. Do physical development. Do skill development. Don’t talk about it.

The more ‘movement’ you do, the more you will be able to say in less words. You will simply refine your ability to think and discuss movement screening, and when you’ve reduced it to something that you could effectively communicate in a matter of well-placed sentences, then talk about it a little.

Here’s a simple rule that will help you in your own physical development but will also help you in the development of your teaching, coaching, training and rehabilitation skills and it will also help you educate another person:

When you are provided with an opportunity to embrace a new experience, whether a new exercise, a new adventure race or a new skill set, start with observation. Look at it from every angle you can. Read and study. Consume information and see how much you can learn without participation. Stay in the bleachers. Develop an appreciation of what you’re seeing.

First, look directly at the activity or the skill set. Then, look at the subtle intangibles that may go unnoticed by others focusing directly on the activity. For example: watch a juggler. Everybody’s looking at the juggling. Nobody is watching the breathing, the foot position or the posture. They’re all important.

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Observe, then sample. Attempt bits and pieces of the activity without the obligation of starting or finishing anything.

Once you’ve adequately sampled, consider participation. Participation means that you actually consumed the thing from start to finish. You actually did the entire task. You didn’t work on the beginning or end or the middle of a deadlift. You simply did a deadlift. Only integrity and completion matter . . .  and they are non-negotiable.

After participation, there’s competition.

Competition means that not only did I participate, not only did I go through the entire activity but I actually accomplished something. Now if it’s a race, finish in the top half. If you’re finishing in the bottom half, that’s probably more participation. Participate as long as you want but when you get your window, try to compete.

Last comes winning: beat everybody else in the group. You learned faster than everyone else. Your speed or pound-for-pound strength might be better than everybody else in the group—whatever it is, you’re winning.

How many people go straight to competition and winning with a new activity? Might that not be the current problem in fitness today?

I’ll leave you with this thought. Dr. Ed Thomas said, “We used to go to the gym to acquire a new physical skill and the workout and physical development were the secondary benefit.”

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Now, we’re so busy sampling every little thing in fitness for the entertainment value and variety that we never, ever truly compete. If you don’t compete, you can’t win. We’re simply sampling everything and accomplishing nothing.

Sometimes, we quit sampling and participate but never with the quality or skill level that will get us anywhere in physical development, on the athletic field or in our sport.

The same could be said for movement screening. Learn about it. Sample it. Participate. Compete. What do I mean by compete? Do movement screenings and see if you can change the way people move. Enhance movement quality, then quantity. Install it as a successful cornerstone to your movement practices.

The art of technological development is in creating something that you don’t know you need until you consume it. That’s what Steve Jobs did for us with Apple products.

When we originally looked into movement screening, nobody was asking for movement screening. But everybody was asking for better fitness methodology because the results were so poor at the time.

We’ve built a fitness empire without considering movement . . . maybe the better fitness methodology starts with realizing what was overlooked in the first place.


Alwyn Cosgrove, Lee Burton and I discuss using the FMS as part of a fitness standard operating procedure in The Future of Exercise Program Design . . . Here’s a clip of Alwyn talking about using the screen vs. ‘talking’ the screen, just how much the system considers and how easy it can make your choices.

 

 

The Art of Screening, Part 2: Failure, Feedback and Success

There is an art to screening.

Screening must be performed with no agenda whatsoever. We are not trying to change the way people value exercise or activity. We are not trying to change the way people value medical intervention.

We are simply trying to ask, “How do you move? Can you do better on your own with more opportunities? Do you need help interpreting the opportunities? Where are your problems?”

By creating screens, we’re actually protecting you from the next experience that could create harsh consequences to what could be an opportunistic failure. If you fail a screen, it’s still a failure, but you’ve lost nothing. You’ve gained the opportunity to learn why you failed, what it means, and how you can change that.

A screen must ask you to do a very simple movement. Even though you could lie and do worse, you cannot lie and do better.

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The movements chosen for the Functional Movement Screen seem overly simplistic and almost elementary to the exercise professional. They seem like something any child should be able to do.

Those assumptions are very close to the truth.

On the flipside, the movements might seem excessive or ambitious for the healthcare professional working with aging adults. Why? Because we know that they will not do as well when compared to a younger version of themselves. However, we still make aging eyes read eye charts. We know they will often do worse, but we do not know the severity of decline or rate of change against a lifetime.

A poor score on an eye chart doesn’t hurt anyone and may actually prevent problems. Likewise, a poor FMS score doesn’t hurt anyone and may actually create clarity, direction and a logical decision for the next movement-based assessment.

The movement learning platform that gets us to adulthood is represented in the simple movements that all children possess in common. If you look at the developmental sequence of growth, children go through predictable phases: crawling, planking, kneeling, bridging, walking and running. On top of that, they build movements like jumping, carrying and climbing. They do this without a manual or an instructional video. They do it without a teacher or a coach. They do it in a very consistent and predictable way. The unpredictable factor is the decline of these abilities across the life span.

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Life happens and preferences are installed. Environments vary and we all travel a slightly different moving path based on the people around us, environmental fluctuations and our own internal drive to challenge ourselves (or our own internal drive not to challenge ourselves due to fear of risk or failure).

If we were to ask the honest question, in the simplest way, we’d say “Do you currently have the learning pathways of movement that you had when you started this journey?”

If you answer “No,” I’d like to know which ones are lacking. They would demonstrate the areas to revisit and help you regain the learning platform before I can expect teaching to occur. Think about that big, big mistake in exercise—we assume everybody must be taught exercise. There is no reason to teach it if they can already do it. If they cannot do it, we must ask ourselves, is it because they haven’t been taught or because they can’t learn? Have they not had a learning environment or are they not capable of learning without some assistance and feedback.

The movement screen is designed to separate those who can simply use better teaching—those who have embraced faulty habits and poor exercise programming—from others, who even if the program is good, cannot learn at the rate of those around them. Their current state of learning does not provide clean, clear and actionable feedback.

Let’s keep it simple and create an honest feedback loop. Before we ask questions about human performance and human work capacity—human skills in particular environments—we should have a measurement tool for the bottlenecks in the learning process. When you cannot complete a fundamental movement pattern, I’m not so sure you need a particular exercise, piece of equipment or even a new program, because you may have a learning dysfunction. We need to find out if that learning dysfunction is going to be long-term or short-term.

Movement screening separates those people having enough movement faculties to learn—even independently, from those who have plateaued and probably won’t make it much further without outside intervention. We see people who hit plateaus in their medical progress, in their ability to lose weight and in their ability to function in other environments. They just hit the wall and can’t change any further. Sometimes, even outside intervention doesn’t help much.

In the field of movement—our field, I think we can do better.

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The human brain is the ultimate learning system. Much of what we do with computer engineering is based on the brilliance of the neural network in the human brain. The only thing that can screw it up is poor input—the brain has nothing to work with. In computer terms, its “garbage in, garbage out.” But as long as that input can create consistent and beneficial patterns, the brain can learn from those patterns and successfully adapt to new environments.

The first demonstration of human learning is movement. We should screen it better.

. . . And by better, I mean, simply and honestly.

Move well enough to respond appropriately.

Move often enough to adapt accordingly.


Did you miss Part 1 of Art of Screening? Take a look for recommended reading and more thought on the philosophy behind screens.

The Art of Screening: Simple Questions

Screens are a good idea.

A screen creates a situation requiring a low investment of time and expertise that provides a high return of information regarding potential next decisions and beneficial priorities. The best screens work even when time is short and resources are scarce.

In times of convenience and in the presence of technology, screens are even more important because they keep us grounded in a standard operating procedure based on history and science. It forces the next new ‘shiny thing’ to prove itself against a set baseline. I like the way the book Sway by Ori and Rom Brafman elaborates on this concept and I highly recommend it.

YSway-the-Irresistible-pull-of-irrational-behavior-195x300ou see, a screen creates direction. It’s not an assessment. It lets us know if we need further assessment in a particular direction. The biggest misconception in the health and fitness world about the FMS is that it is an assessment.

When we think about movement screening, it’s better to think about good screening before considering the specific movements we would prefer to cram into our movement screen. We must protect ourselves from our own movement biases, our own movement methods, our own movement preferences and our own movement abilities.

Simply stated, the only agenda in movement screening should be the question, “does the individual being screened move well enough to enter at the next level?”

“Did they meet movement vital signs?” Yes. Then get on with whatever is next.

If we’re screening human beings, then the prediction of behavior is a very important thing. General behaviors will tell us a lot. Until we know general behaviors, asking questions about specific behaviors may not be the best use of our time. Psychologists know this all too well.

When the movement screen was first introduced, I was hit with a barrage of questions about a screen for soccer or a screen for baseball . . . or middle school or the military? My response: a movement screen should be species-specific, not sport, activity or even age-specific. That is what I have always said. Obviously, we can have different distributions, grades, and assigned values, but movement is movement. We need to do it from the time we’re born until the time we leave.

Young and old

At some level there should be a baseline for movement that holds our hand across the entire lifespan of movement existence. The FMS may or may not do this job, but the category is needed and proven. Screens across the life span create clarity and direction.

From the time you can recognize letters, you are exposed to an eye chart. As long as you have some degree of vision and letter-literacy, the eye chart can tell us if your vision is acceptable for movement to the next level or if you need a more thorough assessment. If the next level is reading and writing, you may be ready. If you would like to drive a motor vehicle, knowing about peripheral vision and color blindness are helpful and sometimes vital. Want to be a pro golfer? The ability to read distances is also key.eye chart2

It all starts with the eye chart, every time . . . all the time. Things change and baselines are the best way to apply science and objectivity to get to the truth when it seems unclear or hidden.

If I were developing a psychological screening questionnaire that would predict your basic and general behaviors, I would have to ask simple questions, while creating a situation in which you were forced to answer them honestly. That’s a hard task.

Let’s look at the first dilemma: asking a simple question. A simple question is one that cannot be misconstrued or misinterpreted, regardless of who is doing the asking. That’s the first and most important part of a screen: a question that can be reproduced by people of different skill levels in different situations. A simple question, hopefully, with the intent of improving both communication and accountability regarding the answer to that question, which then creates the second dilemma: the answer to the question is only beneficial if it is honest.

The simplest question I can ask you about movement is, “can you or can’t you?” Regardless of your answer, I should pick a movement and ask you to do it. If you choose, you could always do worse. But if I asked the question correctly, you can never do better than your ability.

When we’re trying to predict future behavior by asking a series of questions, we must decide whether we want to try to predict success or failure. If we follow the laws of nature, nature does not necessarily create success opportunities. Nature offers us non-failure opportunities. With our failures and non-failures, we learn about ourselves and our environments. If we learn correctly, we succeed. If not, we don’t succeed.

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We actually learn more through our failures than our non-failures, and that’s why following nature is so important. Some of our failures can have pretty harsh consequences—consequences that may not be deserved. Sometimes they’re not survivable. A little bit of prudence and learning needs to be pre-installed allowing us to gauge our own abilities in different environments.

We might not always succeed, but we can create opportunities where we quickly and clearly learn from failure. It is not necessary to fail the same way (action) at the same task (environment) a second time. Always modify the action or the environment if the desired result is not observed. Remember, modifying both at the same time destroys the feedback loop. Some of the most successful people in the world have a history of numerous failures, but it’s what they did with that information that took them to the next level.TOITW

They used a failure opportunity as a feedback loop. The Obstacle is the Way by Ryan Holiday is a study of this learning process—highly recommended.

Next time, we’ll delve deeper into improving the art of screening, the patterns of the FMS and keeping it all simple.

 

 

 


“What’s Behind a Mobility Problem” is my new talk at MovementLectures.com. It’s a good look into how my mind and our systems think about the causes and remedies of mobility problems.

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Networking

Lately, I’ve been pondering professional networks. With the advent of Facebook, Twitter and the like, I believe we actively manage our social networks better than our professional networks.

As a young physical therapist, I decided to move back to my hometown. I was very passionate about what I had to offer—both as a rehabilitation specialist and a strength and conditioning specialist. I wanted to be a community resource.

If you’d prefer to listen instead of read,
here’s an audio version of this article,
Episode 54 of Gray Cook Radio

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I could have easily joined a network-marketing group that met every Thursday morning at a local restaurant. I could have taken that opportunity to encourage people to refer their clients and patients to me for either conditioning or rehabilitation. I just didn’t like the confines of those networks. The busiest people in my town didn’t have time on Thursday mornings to go to a network-marketing group—they were too busy servicing the needs of the people who were already coming to them.

That left me asking myself the uneasy questions: ‘who was actually at those meetings and did I want to be their equivalent for my profession?’

I decided on a different approach. My staff and I began covering local football games. In the rural area where we resided, we did not have certified athletic trainers on the sidelines. We had EMT’s and paramedics in the end zone to deal with the high-end trauma and transport, but we wanted to be there to manage the orthopedic and sports medicine issues. We wanted to keep the emergency response team ready for when they were truly needed.

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We also tried to encourage our local sports coaches: “Don’t just call us in-season to deal with injuries. Let us interact with you pre-season to try to manage some of those. Let’s live the ‘ounce-of-prevention’ strategy and not just quote it.” We would speak to local runners’ groups or at tennis camps. We would accept any opportunity to be an educational resource.

We gave away a lot of time and service to try to distinguish ourselves as a professional group that could help the community.

We started talking to the podiatrists in town: “Can we help you manage your foot and ankle patients? We’ll look above the foot and ankle and deal with the issues that your specialty doesn’t have time to deal with. You’ve got plenty of patients with foot and ankle problems. What can we do to help?”

Here comes the important part. If you’ve only read that I was trying to educate the professionals in my community about how I could help them with their clients and patients, that’s not the whole story. From every person who I tried to be a referral for, I also asked for help.

I always sought out good nutritional counseling in my community. That may require two different people because the needs of a competitive body builder are different than those of someone with diabetes.

It is imperative that physical therapists know when to refer out to a surgeon. If we’ve mapped out some problems that obviously need a surgical consult, we need to act on that quickly—not after four weeks of rehabilitation doesn’t work. We should know the signs, symptoms and structural issues that probably need to be vetted by greater investigation through surgical consult or MRI.

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I received cases from my professional network and I referred cases to my professional network. When I sent people, I didn’t just blindly refer them. I informed the provider, “This is what we’ve done and this is why I think you are the right person.”

There’s some vulnerability when we send a client or a patient to someone else. We have to know that there will be consistency in treatment and management. I think a lot of people are scared to make a referral—they’re scared that they will get blindsided.

Personal trainers have been scared to make a referral to me because they believe that they’ll lose the client or that I’ll tell the client not to train at all. That’s far from reality. These clients value fitness so much that they’re probably trying to cover a medical problem by staying fit. I wanted to help them with that problem, so we let the personal trainers and performance coaches in our community go through a movement screen and see the benefits. We let them attend the evaluations of the clients they referred to us.

We helped them deal with some of their physical issues and they in turn had a story that they could tell another client. “This is not just a mundane physical therapy referral. These guys know what they’re talking about. These guys know what they’re doing.”

For every person that you try to get to refer to you, also find a specialist or an expert to whom you can refer out. Got a cyclist? You should know somebody who can fit a bicycle. Like kettlebells, but you’re not certified? Find somebody who is. Think yoga is the right thing for this person as they become independent and free of low back pain? Find an instructor.

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If you want to increase your professional network, by outsourcing problems so they can get managed by a specialist and by pulling stuff back in when it is your turn to be that specialist, it’s extremely important that you don’t just follow a recipe of network-marketing.

Know how to treat people when they come to you. Make their experience with you good and they will talk about it. When you’re not the expert, just make sure that the expert is in your contacts and you will still get the credit.

That’s right, when you make a referral, you share the credit of that good decision. Most of my professional network are people who I would trust with my family. Do I get a secondary gain for making that referral? In most cases, I don’t.

The ‘good’ people don’t need a kickback system. They’re busy enough. If many of your referrals are generated on the basis of a financial decision, you may want to reconsider how you work. It happens frequently in medicine—a referral is made and it’s somehow profitable or it locks somebody into the system. This is evident when medical professionals send friends and family to one place and everyone else to another.

Some of these same people are angered when you mention a second opinion of their assessment. I’m not scared, intimidated or insulted when somebody tells me, “Gray, I appreciate what you said. I’m going to get a second opinion.”

Here’s how I view that statement: either they’re getting ready to learn something or I’m getting ready to learn something. Learning is good. I missed something or I didn’t miss anything and they’re going to see that the integrity and authenticity of my examination was superior to the convenient diagnosis that someone else gave them.

If they go to someone else and they find something I missed, I don’t need to defend that miss. I need to own it and say, “I am so glad you got a second opinion because we haven’t been looking in that direction for your problem.”

That level of honesty makes you better. If we all managed our professional networks like people manage their social networks, we would all be so busy that we’d never have time for that Thursday morning network-marketing group.


“What’s Behind a Mobility Problem” is my new talk at MovementLectures.com. It’s a good look into how my mind and our systems think about the causes and remedies of mobility problems.

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