Finding comfort in challenging positions (or how to teach clients how to get up and down from the floor)

A couple of months ago, I was chatting with a massage therapist. He asked me how I teach people of varying ages to get up and down off of the floor. I began explaining all of the different techniques I use to expose people who have fear or are uncomfortable with the floor how to begin interacting in a non-threatening way. “Could you write a blog on this?” he asked.

“Sure,” I responded. 

So here we are, taking a break from the normal exploration of anatomy and its relationship to training to explore the art of regressions.

Before I begin, I am going to share a brief overview of the fear response. I have discussed this before, but it is important when introducing foreign or potentially scary position to people to have a basic understanding how this works.

When you expose a client to a new stimulus, many people will do what you say, without giving it much thought. There won’t be any fear around the position, and the client won’t question whether or not he can actually do this thing you are asking. For a handful of clients (particularly those for whom pain is an issue), there will be a moment’s pause. The individual will think about what you just said. Doubt will flicker across his face, and you might even catch a glimpse of fear.

The problem with fear is it affects how a person moves. During the startle response, the sternocleidomastoid activates (1). Posture because rigid, and muscles activate rapidly and in an exaggerated fashion. Research on the topic suggests subjects expecting pain to occur with movement (so fearing there will be pain) move in a more rigid way with excessive muscular activity in the superficial muscles of the spine (2). Basically, fear and anxiety leads to stiff movement.

When you watch a martial artist perform a roll or a dancer falling towards the floor, there is a fluidity, an ease and quality to the movements they perform. If they were to brace, things wouldn’t look very pretty and the outcome might not be very favorable. They learn to relax instead of stiffen.

What does this have to do with getting clients into new positions? As trainers and teachers, we can use this information to understand there might be fear, which might lead to bracing. Developing a sense of empathy for what the client might be going through is important.

It is also worthwhile to note muscle activity will be greater during any sort of new movement or position, even if conscious fear isn’t present (3, 4). This makes sense. The neuromuscular system is trying to figure out how to keep the organism safe while still performing the task at hand. This leads to higher muscular contractions until the sense of threat is reduced or the movement becomes familiar.

We can take two major things away from this. First, we need to introduce the position in a way that is non-threatening or catastrophizing. (Good physical therapists excel at this. There is no question whether or not the patient can actually do the thing. The assumption is of course the patient can do it). It’s a little trickier for trainers because of the whole pain thing, but if we treat the client as robust and capable, they will begin to believe they are robust and capable, regardless of age or ability.

Unfearful puppy:

The second thing we can take away is gradual exposure to the position over multiple sessions should reduce tension and effort. Clinically, this is known as graded exposure therapy, and is often used to reduce fear avoidance in clients with chronic pain issues (5). Instead of placing a person in a position that is clearly uncomfortable or fear inducing, you can ask the person to move towards the position and back out. For example, if a person is afraid of being on the floor, you can place the person in a tall kneeling position with his hands on a massage table or bench in front of him. Ask the client to sit back the smallest amount, and the come back up. The client will feel safe because his hands are on something, providing a sense of security he can get back up. By making tiny little movements closer to the floor, the sense of threat will be reduced, and the sense of muscular tightness should lessen. 

You can also ask the client to perform the position with the body in a different orientation. We do this all of the time with the squat. Supine 90/90 position, quadruped position, and even a seated position with the legs and feet in the squat position are all ways we have our clients mimic squatting. Usually positions where the client feel supported, such as on his back, are ways to safely introduce new positions. 

So what about the 72 year old client that wants to learn how to get off of the floor because he’s scared he’s going to fall and not be able to get back up? How do we effectively improve his confidence and teach him the components to accomplish this task successfully?

First, break down the skill to its smallest parts. The positions (without the transitions) needed to do this are:

• Supine position
• Quadruped position
• Tall kneeling
• 1/2 kneeling
• Standing

There are other options, but I find I am most successful when I teach the most “normal” way of getting up and allowing the client to master the normal or basic skill before moving on to more diverse ways of getting off the floor.

I often use the massage table to introduce supine and quadruped positions. Supine is the most basic; however, it does require a rolling transition to move either into quadruped or to get off the bed. This might be challenging for some (I will discuss this more when I talk about transitions). Many different limb movements can be explored in supine. It is also a great place to introduce the concept of proprioception (“can you feel your back/feet/shoulderbladed/head on the table?”). 

Unlike the supine position, the quadruped position can feel foreign to clients with a limited movement vocabulary. In addition, arthritic clients might have trouble placing weight on their hands. I frequently begin clients in quadruped on their forearms and knees, rather than hands and knees. It tends to be a little less threatening, which enables me to teach shoulder blade movement, cat/cow, reaching, and rock backs in an accessible way. Begin with exposing the client to the position for a short amount of time (I like to have the client count 3-5 breaths), before introducing dynamic movement.

The client can work towards tall kneeling and 1/2 kneeling the same way, for short amounts of time, gradually working into incorporating arm movements or neck mobility. Make sure you have a very soft pad to place under the client’s knees. Often, there will be heightened sensitivity ala princess and the pea, which may or may not decrease over time.

In standing, help the client understand the relationship between his feet and how stable he feels. A recent paper suggests elderly individuals rely more on plantar sensitivity for postural control than younger individuals, possibly because other sensory systems (such as vision and vesitubular) may deteriorate with age (6). Helping the client tap into how the foot interacts with the ground increases a sense of stability, reducing threat.

There are 5 transitions that take place: supine to quadruped, quadruped to kneeling, kneeling to 1/2 kneeling, and 1/2 kneeling to standing. The two videos below are examples of how I generally teach the transitions:

• Supine to side lying and side lying to quadruped: https://youtu.be/hRfMDU3Lp9U
• Quadruped to tall kneeling and tall kneeling to standing: https://youtu.be/xeEF-NutYtI

As you can see, there are several components to the seemingly simple act of getting off of the floor. Any portion of this skill can be turned into an exercise or mobility opportunity. In order for the client to be successful keep in mind the following guidelines:

• Break the movement into its smallest parts. 
• Create an environment where the client is introduced briefly and safely to positions before adding too much complexity
• Encourage relationships between the ground and the limbs for proprioceptive feedback
• Keep the mood light and playful. Don’t push the client before he’s mentally ready, but don’t be afraid to offer encouragement and challenge him appropriately
• Remember, the transitions are work. Program accordingly

It is easy to forget the simple act of getting off of the floor can actually be quite challenging. To successfully build confidence requires finding appropriate regressions, being empathetic to struggles and fears, and slowly helping the client acquire a sense of efficiency and ease throughout the transitions. Sometimes, functional training is less about how much work a client does and more about how smooth the movement feels.

Your in health and wellness,
Jenn

References:

1. Sanders, O.P., Douglas, N.S., Creath. R.A., & Rogers, M.W., (2015). Protecting balance and startle responses to sudden freefall in standing humans. Neuroscience Letter, 586, 8-12.
2. Moselet, G.L., Nicholas, M.K., & Hodges, P.W., (2004). Does anticipation of back pain predispose to back trouble? Pain, 127(Pt 10), 2399-2347.
3. Sigward, S., & Powers, C.M., (2006). The influence of experience on knee mechanics during side-step cutting in females. Clinical Biomechanics, 21(7), 740-747.
4. Hewson, D.J., McNair, P.J., & Marhshall, R.N., (1999). Aircraft control forces and EMG activity: comparison of novice and experienced pilots during simulated take-off and landing. Aviation Space Environment Medicine 70(8), 745-751.
5. Riecke, J., Holzapfel, Rief, W., & Glombiewski, J.A., (2013). Evaluation and implementation of graded in vivo exposure for chronic low back pain in a German outpatient setting: a study protocol of a randomized controlled trial. Trials, 9, 203.
6. Machado, A.S., da Silva, C.B., da Rocha, E.S., & Carpes, F.P., (2016). Effects of plantar foot sensitivity manipulation on postural control of young adult and elderly. Revista Brasileira de Reumatologia.