Graded Exposure to Feared Stimuli: The Role of Movement Exploration

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Background – “Prague School to Athletic Development” course in Winnipeg

In 2008, I injured my hip during ballet. I spent 3 years trying to cope and “fix” the weakness, painful snapping, mobility restriction, and feeling of instability. While on various medications (for pain and sleep), I cycled through AT, PT, chiro, injections, and had multiple imaging studies and surgery consults.

Summer of 2011 brought my first hip scope; psoas release, labral tear repair, acetabular cartilage delamination repair, smoothed out the femoral head, and clean up of the frayed ligamentum teres.

I did relatively well with that rehab – my surgeon expected 6 weeks until “normal activity”, but I think it ended up taking me around 3-4 months to be comfortable with regular activities around work and the gym. I had some off and on pain, development of hip flexor tendinopathy after 6-8 weeks, and general nervousness about “ruining what my surgeon had fixed”.

About a year later I started having some similar symptoms again. After more therapy, inconclusive imaging, and more injections, we set up another scope in the summer of 2013.

Structurally, it went great. He cleaned up some synovitis, released the adhesion between the labrum and the capsule, and sent me on my way with some Tylenol and no restrictions.

As a brand new athletic therapist (waiting for exam results at the time of this video!), I was stressed about starting a new job, ignoring advice from colleagues that challenged my mindset and beliefs around my hip, and trying to find ways to compensate/avoid things that would make me feel like a hypocrite (because in my mind, who wanted to work with an AT that struggled to help herself?)

I had the opportunity to attend Dr. Liebenson’s course around 5 months after that second surgery, and was excited to build on some non-biomedical based education, while denying my own anxieties (which I thought I hid pretty well, but this video clearly shows otherwise ☺)

Video Commentary

Throughout the first day of the course I was doing pretty well with going through the motions, avoiding some exercises that I was scared of. Eventually we got to the point of me being an outlier, where calf tightness was persisting and the body-saws and other resets weren’t clearing it up.

Dr. Liebenson went looking for that key link, and along with it uncovered what was going on with my hip.

I wasn’t kidding when I said I thought I was doing ok and my issue was just my hip wasn’t totally “fixed yet”. But looking back, I see just how clear the nervousness was (restless legs, avoiding eye contact, constant fidgeting). Even just standing up from the bench, I avoided putting more weight on the left (surgical) side.

One of the reasons I trusted Dr. Liebenson to go through with using me as a case study, was that even through the activities prior to this (like my nervous sweating during birddogs), or listing off my mechanical sensitivities and activity intolerances, he never really reacted. He would say “okay”, or dig a little deeper into what exactly I was feeling, but it felt like nudging me in the right direction, not pushing me. I never felt like the intent was to criticize my beliefs, or prove something to me.

As Dr. Liebenson dug into the history a bit, it seems so casual how I replied that “I couldn’t do anything single leg” and “I can’t squat” – but in hindsight, those are some deep statements.

And clearly I was able to be on a single leg or squat, because I was walking and doing ankle mobilizations, and getting up and down off that box.

But he didn’t call me out on that or try to prove anything. Or put me on a plinth and rattle off a list of biomechanical concerns, or things I wasn’t good at or couldn’t do.

Instead, he showed me what I was actually capable of, by meeting me where I was at – physically, mentally, and emotionally.

As we started off doing some single squats and hinges on my right leg, an important piece was the constant positive reinforcement from Dr. Liebenson. The form on that SL squat wasn’t great, but he didn’t pick it apart. Just simply said “good job”, and changed the environment or context until the result he wanted appeared.

Using training as an assessment was new for me, so I kept waiting to get picked apart, or rushed onto my left leg. I almost thought he forgot which hip was my concern, but I wasn’t about to speak up since I was so anxious anyways.

Going through a few variations on the right side and seeing him respond to what I said or he saw, showed me that we were just exploring. That I wasn’t failing at an exercise, because there was never anything negative said before the change. So, I continued to (less anxiously) trust the process.

It didn’t surprise me that we went to the right side SLDL with a weight. I’m not quite sure if I was nervous because I didn’t want to let anyone down, because I knew I “should” be able to do it, or if it’s because I could sense what would be coming next.

But like always…more positive reinforcement without pointing out “dysfunction”.

I think that having various successes and challenges on the right side reps helped frame going to the left side in a reassuring way. I was able to try it out knowing there would be options besides this exercise and that my technique wouldn’t get criticized, so there was nothing to fail at.

I appreciated the simple no-pressure “let’s try the left side now” approach. But I can still see the nervousness in all the non-verbal cues.

Not surprisingly, I was met with positive feedback after the first apprehensive rep on my left side.

I might have tried to tough it out (and panic later) if he didn’t ask if I felt threatened, but I was comfortable being honest when he did ask, because I knew he wouldn’t get offended or defensive.

Like always, it was another casual, non-critical adjustment.

CL: “Less threatening? So at this height you feel like you can do that, and you felt target tissue?”

MP: “yes” – and side note – this proud smile while replying became my “why” for my athletic therapy practice. I want everyone else with pain, injury or exercise related anxiety, to experience that kind of positive experience with movement for themselves.

Moving on from that pivotal moment, another key aspect of this session was not quitting while we were ahead. It showed me this wasn’t a fluke, that I had options, and I could take on the challenge.

An important piece while switching things into that teeter-totter hinge pattern, was that similar to the others, he planted the expectation in my head that it was going to go well.

If he asked me “does that hurt”, I likely would have just said no.

But asking “how does that feel?” led me to say aloud what I was thinking… “it feels good”.

I needed to hear myself say it, not just feel it, for it to seem real.

It built so much more confidence hearing Dr. Liebenson say that I was training a deadlift while going through this exercise.

I typically thought of a deadlift as only when I was lifting a loaded bar off the ground. And since I wasn’t doing that, I wasn’t deadlifting, so there wasn’t really anything to be proud of. It was a horrible way to think!

It started to shift my perspective on the power of words, and it’s something I’ve taken to my practice with all my clients too. We aren’t “regressing”, or “making it easier”, or anything like that.

We’re exploring training.

Wrapping everything up with Dr. Liebenson asking me what my home program should be was another vital part of the success of this session. It allowed me to take in the positive progress I had made in the previous 20 minutes, and take some ownership for continuing to progress.

I left that weekend in a much better headspace.

I had a plan I felt good about for myself, and a lot of motivation for my athletic therapy practice.

Creating a positive experience with movement did way more for me than being shown a normal MRI scan, doing floor-based corrective exercises, or being told my surgeries were successful so I should be fine. I have had some challenging periods since, with other injuries, hip stiffness, or mental health stuff, but going back to the First Principles of Movement is a big piece of how I continue to get through them.

Dr. Liebenson and I continue to stay in touch personally and professionally, and have debriefed countless times since that weekend. It was a pivotal moment for my own journey, and I transitioned into clinical working knowing that if I can create a safe, reassuring training atmosphere for someone the way that he did for me, it can be life changing.


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