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Patient adherence to home/gym programs following regimen of physical therapy – A first hand clinical perspective

I asked my coworker to write a guest blog post on anything he wanted to write about.  Naturally, he chose to write about home exercise programs for the patient.  This is a great read for anyone from therapist to the rehabilitated.  Check it out, and be sure to look up Ben Sherr as he is a tremendously smart therapist and definitely helps me on a daily basis.

During a course of physical therapy treatment, a patient may be seen up to 2-3 times a week for an extended period of time.  In my short history as a PT, many outpatient orthopedic PT programs will not come to an end with the clearance and official discharge by a PT.  Many people will self discharge, or not return to PT. Those are the cases that I will not be visiting in this blog. However, those who are officially discharged from physical therapy, where do they end up?  Are they compliant with their programs that are set up for them? Are we as PTs working hard enough to ensure that the programs are sufficient for them after they finish their formal PT? The answers to these questions do not seem too clear.  This is just one PT’s self reflection regarding patient’s adherence to their gym/home program following outpatient physical therapy care.

Recently, I have had several patients for whom I have set up gym or home programs to work on their PT exercises following successful completion of PT care.  Whether they will complete their program at home, at the gym, with a trainer, or with a CSCS, they are all discharged with a plan going forward. I work in a clinic where there is a gym next door and there are plenty of terrific, certified personal trainers who are willing to help at a reasonable price.  A goal may be to have them work with the trainer and then become independent and join the gym, once again at a reasonable price. I have found that many patients have a hard time following through with this or start this program and then fall off the wagon. The same speaks to the patients that will “complete their program at home”. Unfortunately, compliance to these home programs is usually slim to none. Some patients may leave physical therapy “pain free” but predictably down the road, they return with the same issues they started with. I put much thought into each individual home program to help my patients be successful. With a lack of adherence to these programs what do I get to show for it?

Most of these patients do very well while in PT, so when they return, are they using PT as a crutch?  That is something that we as PT’s cannot enable, but that is a whole other topic, for another day. Back at the topic at hand.  

Why do patients have such a hard time following through with their plan of care.  Is it because they feel great and no longer need to do it? Is it because of differing mentalities?  Is life just too busy? There could be many reasons. Well, research does back it up that most patients are not completing their PT home programs after PT, as documented by Rizzo, et al in 2014, stating “patient adherence to physical therapy home exercise programs (HEP) is estimated between 35 and 72%”.  In addition to this statistic, the article also discusses mental models, which is basically how individuals view the world and how they think. Bottom line was that most patients and PT providers have differing mental models, so PT’s have to work extra hard to change their thought process to connect with the patient. Should we be the ones adjusting to them, or should they be adjusting their mentality to match ours? Again, difficult to answer.

I went into PT to help people.  It is as simple as that. I unfortunately have to ask myself am I doing so?  I believe that I am. I can only take a patient so far. If the patient is committed to PT as well, then they will do a great job.  Not only during their official treatment time, but also when they’re on their own. I have come across some tips that may help a patient stay with their routine following PT. First off, finding a purpose.  Why should this patient continue their exercises? Mostly, it will help them avoid re-injury and maintain their improvements. Maybe they are training for something, or maybe they want to better themselves in general.  Any of these are reasonable. Another tip would be connecting to the patient in a more effective manner. The patient may feel more accountable to complete their exercises following completion of PT. From Campbell et al, “initial compliance with PT is high because of loyalty to the therapist.”  It did not state that it drops off as time goes on, but I am sure that it does.  Lastly, education. Educate the patient to the best of your ability as to why they must continue their rehab to avoid decline in their status.  Or put a positive spin on it and educate them on how much improvements they will make by continuing the exercises. Use a goal as an example.  Just a thought. In all honesty, and according to research, somewhere around half of the time it will not work.

Back to the personal cases that I have come in contact with in the outpatient orthopedic setting.  I have had plenty of situations where past patients have followed through on their programs and eventually do not have to continue them.  Mostly this is a post-operative patient who has done great. Those who continue their programs in the long term are most likely athletes who play a sport or in training for an event.  These patients do great with continuation of care. The general public on the other hand, are very challenging. You try your hardest to adjust your mindset to think like the patient. Set them with plan for success.  I have had three gentlemen in the past month who have been set with gym programs, and have not returned once. Is this my fault? I do not believe so. I set them up for great success and put in a lot of effort. The patient themself needs to be accountable at some point, and that starts right after discharge.  

Maybe it is a possibly jaded view on the subject, but it seems that some patients just do not want to help themselves.  In the healthcare system we have today, these people want a quick fix, and some get it, albeit sometimes temporary. Unfortunately, these patients are the ones who are the returning patients.  And what do I do? Treat them with the best care possible. And will they follow their home program when finished? Maybe. Maybe not.

 

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Random Thought: HRV

I just finished up working with a group of peeps that I’ve been working with for the last 10 years–take a moment just to think about that one–and as I was driving home it hit me, “why do I measure HRV?”

Great question, self!

What the heck is HRV anyway?  HRV=heart rate variability, and it is something that I learned back in undergrad when dealing with the heart.  Somewhere around Exercise Physiology 1 if I recall correctly.  This was information so prudent, much like the Kreb’s cycle, electron transport chain, lactate threshold, etc that I immediately deleted the information from memory as soon as I wasn’t responsible for it (lost? don’t worry, these other terms aren’t the topic here).

If you really boil down what HRV is, it is the measurement of one QRS complex to the next on an ECG, or more specifically the R piece of that gathering of letters.  In a normal individual you would expect to find that from heart beat to heart beat they would be roughly the same.  This in turn means that your nervous system is regulating pretty darn well as that silly system drives each heart beat.  However, in fatigued individuals such as athletes, corporate execs, and just anyone who has kids or multiple jobs you’ll find that from beat to beat there are slight differences.  Simply put, your nervous system is struggling to keep everything regulated…just a bit though.

Why does this even matter?

If your nervous system is a little whacky trying to control the autonomic (automatic) systems in the body, then how do you think it will do with the controllable parts like the ever important biceps?  Knowing that you’re HRV isn’t so great could give you or your coach the ability to maybe take out a set or two, maybe even give you the day for active recovery.  You’re definitely not going to hit any PRs.  You’re most likely going to crash and get some sort of illness or hurt if you keep pushing it.  Think Seyle’s diagram where you’re overstimulated.  Or to the layperson, think pneumonia or mono.

 

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Not too shabby this week
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Notice the red and yellow??

 

 

 

 

 

 

 

 

You can get this stuff pretty easy too.  Shoot, the programs basically tell you if you’re good to go, mildly stressed, or in need of a staycation.  You definitely don’t need an ECG/EKG everyday.  I’m not personally affiliated with any group out there, however, I do use Bioforce HRV.  I think that the owner is an incredibly smart guy and does his homework when it comes to the state of the nervous system and cardiac system which is what sold me ultimately.  There are holes here and there for sure, but ultimately it is pretty high quality.

Take your training to the next step and work smarter not harder!

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Squatting: Good or Bad?

I was speaking a someone in a gym recently about squatting.  The conversation was more a list of excuses of why they couldn’t do a good squat.  So at the end of the day I was reflecting back on the conversation considering some of the points they were making regarding why squats weren’t good for them.

Before I get into the nitty gritty here, let me disclose some of my biases.

I like to lift things, so when the discussion comes to lifting or not my attitude usually sways in favor of lifting.

In discussing points of performance or health, I prefer to program single leg squatting/knee dominant activity versus the more traditional back squat or front squat.  Don’t get me wrong, I’ll still plug in the front squat and the trap bar (virtually a squat) where appropriate.  The back squat I’ll reserve for individuals who are competing in events that require it, for peeps who have a higher training age and are working in a more 1:1 setting, or for those that will go back to their college or pro strength coach who makes them squat.

Triple extension activity and hinge activity has more carryover to jumping as opposed to squatting in my eyes, but both are prudent.

Finally, Im generalizing here.  Squats are an awesome exercise, do them in some form within your training programs.

Good

When dealing with sport performance, squatting is absolutely necessary for a number or reasons.  But, beyond the performance world, squatting is important for general population and rehab as well.

Doing all hip dominant activity would eventually lead to overdevelopment of the posterior chain, and more than likely a poor quad:hammy ratio.  This would eventually lead to knee joint dysfunction, hip joint dysfunction, poor athletic quality, poor general purpose carryover, and more than likely injury.  Including knee dominant activity (squats in their variable forms) helps to keep the ratios balanced, injury down, and improves control of the knee in space.  The reality is that most high school athletes coming into the clinic have either overdeveloped quads or extremely underdeveloped everything.  For those individuals who are extremely underdeveloped, the best corrective exercise is going to be lift some weight.  Parents, even though you’re trying to do a good thing by protecting your kids, get out of the way.  You wouldn’t hire a mechanic to do your taxes, don’t hire an artist to train your kid.  Find a professional with a good reputation and the appropriate credentials.

Training a squat pattern is essential for basic activities of daily life….like sitting and standing, or going to the bathroom.  I would like to preserve these abilities personally.

Squat patterns are a great way to add variety to your general training programs as well.  It doesn’t even have to be the traditional back squat.  You can do so many different types of squats like goblet varieties, front squat, double kettlebell versions, single leg, split, etc. Not only do they add variety, but they also tend to be so much more of a usurper of energy, requiring the entire body to work.

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Bad

Just like with any exercise you potentially perform, squatting has the tendency to get ugly quick leading to injury.  If you have the ability to watch high schoolers squat either with their football team/coach or with their buddies it almost seems straight out of a cartoon.  Not being able to perform the action without weight they immediately put on 135 because they want to get faster and stronger.  It’s difficult to articulate the silly events that occur.  For that reason, putting a back squat in for groups of people is a challenge.  Front squats are also a challenge because you still have to be able to squat correctly and you need to be semi humble.

Not everyones levers are the same.  Simple.  Someone with extremely long femurs relative to their trunk will squat significantly different than someone with shorter femur length relative to their trunk.  Butt-wink is not a good place to be.  Not everyone is going to squat ass to grass, so please stop enforcing that.

People tend to get too crazy with things too soon.  Simplicity is such an amazing and under appreciated variable.  Monitoring your numbers becomes important so that you’re not exhausting your options too soon.  Adding bands, chains, weight releasers, etc are all cool things to post on the gram, but not always necessary unless you need to change the stimulus based on stagnation.  Keep it Simple.

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Fitting the Puzzle Piece Together

I was recently golfing with a fellow strength and conditioning coach and had a fun little statement about what is going on with my swing.  Normally, I am long with my irons.  This isn’t to toot my own horn, it’s simply because I swing out of my shoes and throw a little extra bicep curl into the swing.  Here’s the problem:  I was falling way too short.  I was making great contact with the ball and everything looked the way it was supposed to (to my own standards), but I was way short.

I know that my infrequent visits to the golf course are part of the issue.  However, I have also not worked on any piece of the spectrum of lifting except strength for the last few months.  A little bit of bench, some accessory work, maybe sit on a bike and think about cardio for a few minutes, call it a day.

In the world of strength and conditioning, personal training, physical therapy, etc. there are some potential short-comings.  With PT, the general consensus is to get them long, get them strong, then get them fast.  That’s great, but you can’t really do that with your athletes efficiently.  Especially if you’re only going to see that athlete for 12-36 weeks.

If you want to be the biggest dude to walk the planet and still not be able to pick up a spare tire for your car, go get your pump on.  If you want to move a house, go lift the heaviest things you can.  But, if you want to be fast and explosive, you better train that too.

Traditionally with strength and conditioning and personal training, you would train absolute strength to develop a base to build off.  True.  But most people coming in off the street have some strength.  Quite the assumption I know.  Most athletes, believe it or not, can already jump or run.  The idea is to make them jump higher or run faster.  Program plyometrics, speed-strength, strength-speed, and power (not all in the same day perhaps) as well as your strength.  This way you’re a little more efficient with your programming.

You can allegedly hold 98 per cent of your strength for a month of not training it.  But, those numbers drop much more significantly with power where you can hold roughly 98% for about a week before you see large drops.

Don’t throw the kitchen sink at your athletes.  Still program intelligently.  But make sure to train some expression of power even if that isn’t your emphasis.  This will allow you to not swing a golf club like a nana.

Some of the speed-strength/power exercises that I like to use with my programming include:  olympic lifts, kettlebell swings, kettlebell snatches, loaded jumps, loaded bounds

You can also place an emphasis on speed with the tempo of the lifts that you are comfortable teaching or that you’re already using.  This would simply require that athlete to explode through the concentric portion of the lift.  I like to remember the “do no harm” phrase here.

I would love to hear what other coaches are using out there.  Please share if you have a different philosophy.

 

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How To Program Med Balls into Your Workouts

Today I have a guest post from a good friend of mine, Nick Esposito.  Nick is a strength and conditioning coach in Waltham, MA at Champion PT and Performance.  He also happens to be a pretty smart kid.  Here is a link to the original article if you have a chance to check out some of his videos too!

How To Program Med Balls into Your Workouts

 

Med Ball Exercises are a great way for a rotational athlete, such as a baseball player, to develop power and strength from their lower body to their upper body.

You often hear about rotational power or kinetic linking…but how do we maximize that?

How does that relate to athletes, especially baseball and softball?

Movements often found in sports are considered ballistic.

What is Ballistic Movement?

“Movements that are performed with maximal velocity and acceleration can be considered ballistic actions. Ballistic actions are characterized by high firing rates, brief contraction times, and high rates of force development.” -Department of Kinesiology, McMaster University, Hamilton, Ontario.

SO, WHAT ARE SOME OF THE BENEFITS OF MED BALLS?

  • Improved coordination in movements demanding high rate of force development in all planes of motion (rotational power)
  • Improved ability to control and decelerate rotational forces
  • Improved kinetic linking through which helps the ability to generate and transfer force through the body.
  • There is also injury prevention qualities as well. Controlling rotation and deceleration.

After seeing some of those benefits, you can see why Med Balls are commonly seen in sports performance programs.

SETS & REPS

When done right, med balls can be a very demanding on the body, and the central nervous system. We program all med ball work to be done BEFORE any lifting for that day.

We will pick 2-3 med ball drills per workout day that will benefit the athlete the most.

Taking that into consideration, here is a how we commonly program for our athletes:

2 Days a Week Strength Program:

  • 3-4 sets of 5-8 reps

3 Days a Week Strength Program

  • 3 sets of 5-8 reps

4 Days a Week Strength Program

  • 2-3 sets of 5-8 reps

TOP 5 CONSIDERATIONS FOR MED BALLS

STANCE

There are several positions you can begin your med ball exercises in. Typically, I work from the ground up with new athletes. This gives less room for error with form, and a progression to reach in the short and long term goals.

Tall Kneeling (TK)
1/2 Kneeling
Iso-Hold Stance
Split Stance
Athletic Stance
Single Leg

DIRECTION & BALL PATH

Where is the athlete and med balls intended path. Taking the stances from above, now add in the follow 3 items:

What direction the athlete is facing…are the facing the wall, or facing sideways, etc.
Where the ball is starting from. Is the ball starting above their head, at their side, at their hips, etc
Where the Ball is Going. What is the intended target or direction you want to slam/throw the ball?

INITIATION

 

There are typically 3 initiation methods for med ball exercises:

1. Non- Counter Movement

This will be your traditional slam method. Accelerate at the wall, floor or target from a specific starting point.
2. Counter Movement

This will be a movement initiated by a partner or a coil motion. The ball is moving in a against you so that you must stop, load, and then unload in your intended direction.
3. Continuous

This will be a rapid movement…quick and precise. You will commonly see a plyo based or rubber bouncy ball for continuous med ball exercises.

MED BALL TYPES

There are several types of med balls out there. Some have handles, some are large, and some are small. Here are the common types we use with our athletes:

Jam Balls – These balls won’t have much bounce. They are very dense, and can be on the heavier side.
Plyo Balls – These are commonly smaller, and offer a bouncing recoil when you slam it. These are great for continuous and rapid med ball type exercises, and even single leg stance exercises.
Soft Toss Med Ball – Commonly seen in gyms as Dynamax or PB Extreme Balls, these are great for slamming, tossing, and offer many uses.

INTENT

This may be the most important one. For athletes, one of the common goals is becoming faster, and quicker, something med balls are great for. However, many can check their ego at the door and grab the heaviest possible ball to throw or slam…VERY SLOWLY!

If the med ball is going slow, are you truly gaining the benefits of ballistics and what med balls have been proven to help develop…probably not.

You have to put full effort and intent into each throw. Med Ball exercises are truly a “You get what you put into it” exercise.

FIND MORE ABOUT NICK

For more articles like this refer to the link above.  There you can check out some pretty cool videos, articles, maybe even grab some swag.

 

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Why Do You Lift That Much?

So, this past weekend we made a trip to the wonderful vacation destination of Syracuse, NY for my sister’s graduation party extravaganza.  My sister, much like my father is a runner.  If any of you follow me on social media, you’ll know how I feel about the whole running cult.

Running Sucks
One of the coolest t-shirts

With that said, I should say that I do actually like to do sprints following a workout as nothing will make you feel like you’ve accomplished something more.  Not run for 9 miles because gross.  So if you do see me outside running then you should probably run in the same direction really quickly as I’m probably being chased by Sharknado, a lion, or Dunkin’ Donuts advocates.

I was lifting a large cooler out of the car by myself when my father told me to stop because I may hurt myself.  Checking my ego I said, “nah it’s not that heavy, I pull over 400 pounds off the floor”.  When in my habitat, that statement is usually met with some grunts followed by how much others pull.  To people who don’t lift heavy weights often that is a meaningless piece of information.  So he asked, why?

I’m generally pretty quick to fire back at my dad, the only person on the planet who has mastered the ability to find every single one of my buttons of irritation–and press them over and over again for the pure amusement.  This time I still fired back because I like a challenge.  But I stewed over this for a couple of days.

Part of me wanted to say, why do you run?  That’s a silly thing to do.  You can certainly develop your cardiovascular system in many other ways.  Nothing in your life requires you to be good at running.  But, this is more a look at why I like to lift things (don’t make that cliche statement from that stupid commercial about lifting things please!).

A couple of years ago I set a goal to bench over 315, squat and deadlift over 405, clean 275.  None of this is necessary in my day-to-day requirements, however, when demonstrating to my athletes it was important that I could lift a semi respectable amount of weight.  Otherwise they would think that I’m a phony (their words not mine).  Plus, doing the same thing over and over again expecting different results was some smart guy’s (Einstein) definition of insanity.  And I know with my education in physiology that I need to continue to push the status quo in order to achieve adaptation.

Loaded Bar
415 for a couple singles…

School threw my aggressive training routine into the toilet.  Basically, life happens.  Now I’m finally hitting those goals and striving for different ones.

So now I understand why my parents always told me to think before I spoke.  Not only does lifting my goal coddle the ego a little, make sure that the high schoolers don’t chirp, but mostly I lift it because I like to.  The feeling of accomplishing your goals is awesome albeit short lived.  Runner’s want to run for 4 days straight–go ahead.  If you’re goal was to do that and live, then awesome.  If I want to lift a 20 pound cooler out of the trunk of the car without hurting myself, then don’t bend and twist.

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Coaching Cue on the Deadbug

The dead bug is a great tool to use for both rehab and for improving performance in the athletic and general population.  Creating stability with the floor will help the trunk musculature brace appropriately with virtually anyone on the planet being able to figure it out.  There are a couple different ways that you can attack this exercise and I’ll cover that in this article.

The deadbug exercise is used for a variety of reason in strength and conditioning and PT.  In PT, we can use it to help develop the trunk musculature which will potentially give us a better brace for protecting our low back.  Or a better anchor for our hip extensors to fire from (by protecting the integrity of the pelvis).  In strength and conditioning we can use it in a beginner program to help someone find their anterior core.  We can also use it as an offseason type exercise to help the athletes reset.

Generally speaking, when thinking about strengthening the trunk musculature–or core–people immediately think about the 6-pack.  Sure that is an important piece of the puzzle, however, consider all the other parts too.  If you  don’t have the ability to engage that internal Transverse Abdominus you’re going to have issues.  The idea isn’t that you want to live in the 1980’s and make each muscle fire independent of the others (impossible by the way).  Instead, find a way to coordinate all these groups together.

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A common cue that is used to train the deadbug exercise is “push your low back to the floor”.  This will certainly get you to engage your anterior core.  But is it the best way to keep you in a neutral position and bracing?

 

 

 

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Instead, try using a different line of cues.  Let the patient/client use their fingertips to feel the brace.  Simply have them find their ASIS and move in roughly an inch.  As they brace appropriately they should feel their “core” push out into their fingertips.  This is different from trying to suck your belly button to your spine though.  It is more of a hollowing effect similar to that used in gymnastics.

 

This also has an impact on the rest of your body.  If you’re cued to push your low back into the floor you will invariably drive all force into the floor.  But what happens to your upper trunk, neck, head?  If you’re bracing hard enough they’ll come off the floor similar to a crunch.  Fine, if you’re trying to get the anterior core work.  If you’re trying to get those deeper muscles to fire more effectively though, keeping neutral is a little better.  It will allow the patient to keep their head and upper trunk on the floor with the neck finding the natural, neutral position.

Give it a try in your programming and find what works best for you.  Feel free to give some feedback.

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Quick Comment About Sleep

Today is a short post serving more as an addendum to the pool of recovery that we have already dipped our toe into.

Previously, I wrote about how sleep is such a vital component to the recovery process.  I was writing it from a perspective of athlete or performance without really thinking too much about how it also impacts aesthetics.

Sure, if you’re not getting enough sleep following a training session or day, it will take you longer before you’re able to go at 100% efficiency again.  Sure, if you’re not getting enough sleep you’re going to be crabby and probably make a lot of your coworkers/friends a little bothered.  You’re physiology will be a little off because you weren’t able to clear out all the gunk from your CSF.  Common knowledge now that we revisited the idea, right?

Now consider this scenario.  An individual works out 3-4 times per week expending a stupid amount of energy.  They eat mostly whole foods because they’re allegedly allergic to refined sugars and any gluten containing product.  They supplement with BCAAs, hydrolyzed cross-flowed microfiltrated isolate whey protein, organic greens, wild salmon oil, etc.  But they still have a beer gut? How?

They neglected to say that they sleep 3-5 hours a night on average.  That doesn’t really create a great internal situation for your hormone profile.  Cortisol (stress hormone) has received such a negative rep in the physiology world mostly for good reason.  It is necessary, however, in excess can be your own worst enemy.  High cortisol levels can be the result of high stress because you work 5 jobs totaling over 100 hours of work per week–stupid student loans.  You need to make yourself dinner and attempt to go grocery shopping.  Make appearances at family/friends/athletic events.  Even if you did get a perfect 8 hours of sleep per night (56 hours a week) with the 100 hour work week, that leaves you 14 hours to accomplish the other things.  Something has to give and it’s usually sleep.

Boom! Increased cortisol levels.  Not to mention the accompanying stress that tags with all this madness.  Feedback loop says: more cortisol.  Unmanageable levels and you’re left with a petit beer gut even though you haven’t consumed a carbohydrate in about 5 years.  What the what??

Get rid of one of the jobs (as long as you can pay your bills) and start getting some sleep.  Eight hours is recommended but some people need more, some less.  You’re body will thank you, and you’re results in the gym/practice facility will get exponentially better.

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Getting to Overhead Pressing

 

Today I wanted to share a quick breakdown of how we progress to pressing overhead.

A lot of our overhead athletes have difficulty owning the overhead position so we use a variety of methods to help get them there.  We start by reducing the amount of motor control that they need to use by putting them in a tall kneeling position.  This allows them to focus on what the torso is doing.  We also will use the landmine apparatus before they go straight overhead.  This allows them to continue to get strong before they’re truly able to own the overhead position.

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Hang Clean Progressions

Here is a quick video on how we coach athletes to get to a proper hang clean.

If we have a novice athlete in our facility, we generally try and teach them the hang clean first, however, if they aren’t able we will regress.  We will focus on using triple extension, then move to triple extension with the arms, then put it all together over the course of a training block.  These exercises are also great for athletes who do not want to use the hang clean because they’re under the impression that they aren’t good for them.