Functional Dysfunction
Posted by Gray Cook
How to Ask a Better Question
Written by Brandon Bennett FMS
My article following the Stanford event with Dr. Stuart McGill discussed “It depends” as a correct answer to unclear questions. Many times during the question and answer sessions, Stuart touched on the tendency to ask general questions with the expectation of specific answers. I want to discuss how to formulate and ask a better question. I’m passionate about asking better questions myself and helping you ask better questions.
I remember a lon
g time ago working as a young physical therapist. I would have a patient in my exam room and he would say, “You know, your treatment and your exercises really helped me with my low back pain. My wife has low back pain too. Do you think she should do these exercises as well?”
My answer was, “Absolutely not. I would prefer that she not do any exercise in regards to her low back pain because the potential of making things worse is equal to the potential of making things better. If I meet her, see her and evaluate her or if she goes somewhere else with a responsible individual, she may very well find out that she’s got the same type of problem you do or she may have a completely different problem.”
Either way, low back pain is a symptom—not a diagnosis. I can’t provide a treatment plan for a symptom. I can do things to cover up the symptom but I can’t cure the problem unless I first diagnose the problem.
I would much prefer to answer questions about people or groups of people than I would about exercises. If I make one statement about a certain exercise, I’m absolutely sure that what I say will get misapplied due to a lack of clarity.
First of all, asking a question about a training or rehabilitation program for an individual or group requires us to get specific. Begin by stating the primary goal—which in rehabilitation is often getting rid of pain. We add the goals of removing movement dysfunction and combating mobility and motor control problems to the goal of getting rid of pain.
Think about that. If we confront every functional issue, remove all mobility and motor control problems and they still have pain, then we, as musculoskeletal specialists, have done our job. The person’s pain is coming from some other part of this situation than their movement dysfunction.
We frequently see musculoskeletal pain presented and yet we find an underlying disease process. The fact that we go through a differential diagnosis every time somebody has musculoskeletal pain is a hallmark of a responsible therapist, chiropractor or physician.
The first thing we’ve got to do is make sure it’s not something else.
With any question about a specific individual, we need a health history.
- Have they had previous injuries?
- Do they have a disability of some sort?
- Is their goal realistic or are there multiple unrealistic layers to the goal?
- Are there any time constraints?
Believe it or not, that’s still not enough information, which is why I’m so passionate about something like the Functional Movement Screen, the Y Balance Test or vital signs. I want to know if all the systems are functioning at an average level, at minimum.
How’s their cardiovascular system? Well, we could find that out just by simply doing some vital signs and seeing their response to a cardiovascular load. We could also do a number of strength tests on you to find out where you rate within your group in your age, your sex or in your particular sport or category.
Here’s where I’ll give you a shameless plug for the program that Lee Burton, Alwyn Cosgrove and I did last year on how to take movement screening information and some other information and put it directly into a program.
How can we intelligently make decisions when more information is introduced? If I’ve got a 14-year-old cross-country athlete who wants to train with me in her off-season, I will typically have a complete and thorough past medical history. I will have had a conversation with her and her parents. I will have at least done some vital signs, body composition tests and a movement screen.
Her body composition shows me that she has far less lean body mass than other females her age. Obviously after meeting her, we see the ectomorphic physique and realize that part of this could be her nutritional plan. She might not be getting enough protein.
She could be growing a little more muscular than she currently is if her nutritional components matched her athletic goals and her growth spurt. I may impose a questionnaire and find out how much good source lean protein she gets every day and what her nutritional favorites, staples and dislikes are.
Her movement screen shows me that she’s got ‘2s’ on every test at least with no asymmetries and no discomfort or pain. A vertical leap test shows me that her power is extremely low. A few other tests of overall body strength show a strength measurement that is not average for her age. However on the treadmill, her endurance is impressive.
Obviously, I see some biomechanical errors in her running cadence but instead of trying to change those right away and become her running coach, I think—what would she be like with five extra pounds of muscle, stronger quads, glutes and abdominals, a more erect posture and reduced anterior head posture? Would she stand more erect if her self-esteem was higher and she didn’t feel so intimidated when she was in the weight room?
I’ve got a situation here where an athlete wants to perform better at an endurance sport but I have every reason in the world to challenge her assumptions about the benefits of a strength-and-conditioning program. The weight room is not simply for people who want to get stronger for the purposes of strength.
Strength is the single best way to hit ‘save’ on a good movement document. We often talk about motor control as a demonstration of stability and strength—a demonstration of how we manage force. But strength is simply an outgrowth or an extension of superior motor control—the ability to both control motion and create motion.
I share the belief with most strength coaches that a fundamental strength quotient is the cornerstone upon which other athleticism is built. Can we achieve athletic goals without a good, strong base? Absolutely. Young children often develop impeccable technique long before they have impressive strength.
But as bodies get bigger, biomechanical stresses increase, sports loads and competition becomes more intense and that great technique possessed by the growing body all of a sudden starts to erode. The body changes, the lever arms get bigger and the stress gets higher.
If that same 14-year-old female athlete had had three ‘1s’ on her movement screen, regardless of where they were, I would put a hold on her strength training. I don’t want to hit ‘save’ on that document.
My goal is still to get her stronger. Her strength measurements are extremely low but I don’t know if her strength measurements are low because she’s weak or because she can’t move through the positions where I’m testing her strength. We’ve long thought of strength moves as being the defining factor of individual strength. In reality, weakness in some positions and strength in others, averages for the overall strength quotient.
Some powerlifters don’t look very strong by Olympic lift standards. Likewise, some gymnasts don’t look strong by powerlifting standards. To be called strong without reservation, someone would have to show me a battery of strength moves with both load and bodyweight and cover most of their functional positions and patterns.
How many of us does that apply to? The more functionally you work out, the more it probably applies to you. The more specialized you work out, the stronger you may appear in your comfort zone but the weaker you may appear outside of that comfort zone.
Part of coaching is taking the athlete outside of their comfort zone, making them more adaptable and ultimately changing their environment. We may be training them in the same weight room but the exercises and the loads—everything is getting ready to change.
The best way to survive environmental change is adaptability and the best way to be more adaptable is to keep learning pathways open. Maintain a good range of motion. Keep adequate mobility. Motor control should be at least ‘good enough’ with body weight.
An intuitive, well-educated coach can systematically load that athlete until they’ve developed the strength reserve that can take them where they want to go.
In rehabilitation, we’ve got to ask a lot of questions before we discuss the injury or the treatment plan for that injury. In strength-and-conditioning, in personal fitness and in wellness, we’ve got a lot of information we need to consider before we take that focused isolated approach.
One of my favorite terms is ‘manage your minimums.’ If we could set minimum standards for movement, flexibility, motor control, mobility and strength within your particular group, then we could find out if you have any minimums. It is my philosophy to manage those first. From that foundation, try to grow and train in the direction that best suits your environment and your goals.
We’ve got to ask ourselves better questions and we’ve got to ask our mentors better questions. If we do both of those things, we’ll get better answers.
We’ll have better outcomes.
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