*UPDATE* Psychological Effects of Heart Rate Monitor Use Study

12/21/2010: Preliminary results were reported at Indoor Cycle Instructor in October 2010. Manuscript in preparation. Once published, results will be made available on this site and at ICI.

Saturday, September 19, 2009

"Own Your Discomfort" - a 75 minute profile

We all have uncomfortable moments in our worlds -- as athletes, as coaches, and human beings. As a second-year medical student who, despite knowing a ridiculous amount of useful, important medical things, knows really quite little about how to actually help really sick people in the clinic or the hospital where she spends time, I have a lot of them. I debuted a ride last night based on the past few months of my world, very specific efforts to ponder the concept of "discomfort" and what to do (or NOT do) about it. It turned out to be the most rewarding and successful ride I've ever presented. So clearly, I have to write about it.

Pardon the long background -- but I thought it was important to frame where this ride came from, so that you can inhabit it enough to devise your own personally meaningful cues if you use this training session for yourselves or your classes. Otherwise, it's not going to be any different from any other profile. This is a ride that comes from pain, self-doubt, and inadequacy. That's hard to describe in a paragraph.


As a med student, I spend 70% of my clinical training feeling anxious, useless, and awkward. When I experience these emotions, my sympathetic nervous system fires off a crazy storm of catecholemines. I'm tachycardic, sweaty, stuttery, and a big ol' mess. When I try to "squash" these uncomfortable sensations by reasoning myself out of them, however, I find that I get all the more awkward. I'm consumed by "my awkward." My brain shuts down, and I am distracted from soaking up the important subtleties of the world around me -- not to mention unable to remember any useful content once encoded into the archives of my memory, which is what typically triggers these episodes in the first place. While I acknowledge that this discomfort is normal/common/expected, that doesn't make it less uncomfortable.

As an athlete preparing for my first Century ride this summer, I knew that "discomfort" was my #1 challenge. I knew how to keep my heart rate low under exertion. I knew how to eat and hydrate effectively. I knew that my rate-limiting factor was going to be how COMFORTABLE I could train myself to be with being INSANELY UNCOMFORTABLE. So I trained for it. In addition to long rides outdoors, I included regular 3 hour, 4 hour, 5 hour training sessions on a Spinner (more tedious than spending the same length of time outdoors). I did not attempt to convince myself that I wasn't uncomfortable. I was completely miserable. Could I have reasoned my way through it -- that I wasn't ACTUALLY miserable, that I was doing so much of what I loved? Could I have done a pros/cons analysis to conclude that there was more evidence to suggest that I was actually happy? Maybe. But I didn't. I talked myself through every minute of those AWFUL trainings while explicitly acknowledging how miserable I was, and why I was doing it. What purpose would serve? What did I want to learn? What did I want to master? What would I be uniquely qualified to do for having completed this? What would the difference be between 4:59 and 5:00? I knew that if I could get through those 5 hours, there would be NOTHING that could ever possibly arise on my Century that I couldn't handle. On The Big Day, I reminded myself of that over and over and over again. "Remember your discomfort. Re-experience it. Re-inhabit it. You lived through THAT. Are you as uncomfortable as that moment? No. There is no evidence to suggest that you cannot conquer this moment."

One of the ways we treat patients suffering from panic disorder and others on the anxiety spectrum is to gradually expose them to known triggers, under safe conditions where they can experience their uncomfortable, undesirable symptoms in such a way that they learn that these experiences aren't the "worst thing that could ever possibly happen" to them. I've extended this theme to my medical school life now. I'm training myself to be comfortable with discomfort. I've started using the phrase "OWN YOUR AWKWARD," which I apply not only to awkwardness but perceived incompetency, inadequacy, and all sorts of horribly uncomfortable, negative emotions. I specifically seek out experiences that will trigger discomfort: interpreting an EKG in front of 114 people (despite knowing that I was terrible at this), giving a patient medical advice about chest pain in front of the specific attending physician (whose opinion of me matters to me more than most people in the world), asking the same character if I could accompany him to the hospital in the middle of the night JUST because it made me anxious to be there (he found this endearing). Through all of these experiences, I was awkward, anxious and inadequate. I didn't attempt to convince myself otherwise. "You are awkward. Yes, you are awkward. Roll with it. Own your awkward."

Over time, I'm actually a little bit more comfortable with being uncomfortable. So when I have these moments, my brain doesn't shut down. I acknowledge that I am uncomfortable, give myself permission to be uncomfortable, and keep on with my life. When I say something stupid/wrong/embarassing in front of 115 people, I feel the same catecholemine storm -- and I don't try to breathe it away. It's not "Shit! Panic attack starting. Breathe. Don't be anxious. STOP being anxious." Instead it's more like: "Look, catecholemines! There they are. Own them." And then they pass, pseudo-instantly. Fascinating.

Last Sunday, I rode my 2nd Century. I dedicated it to the concept that it was the ULTIMATE discomfort immersion. That somehow it would represent every aspect of discomfort that could exist -- and that, looking back on it over the next weeks and months, it would remind me that I could indeed accept discomfort and endure whatever came my way.

I wanted discomfort, and I got it. 1 mile in, my chain started squeaking and I was riding on false flats in my lowest gear (I didn't see anything visibly wrong with it, so I kept going -- miserably). At the 5 mile mark, it started pouring. By mile 10, I was soaked and freezing. At the 20 mile mark, my injured tibialis anterior tendon started spasming. I'd forgotten my sunglasses, which didn't occur to me until mud-slicked gravel started flying up into my face. I intentionally started out at 7:30AM in the middle of nowhere (50 miles from home -- I'd ridden out the day before and stayed overnight at the cottage where I lived for the summer near the clinic) so that I would be less tempted to give up and call for "rescue." At the 60 mile mark (see also: civilization), I went to a bike shop and got Triumph fixed (a spring had popped -- I didn't even think to LOOK there!) and had a hot meal (life-altering). I bought a dry shirt, new sunglasses, and a big ol' tube of chamois cream. Life was good -- for another 10 miles at least. Miles 71-85 were some of the most MISERABLE moments of my life. They never ended. It occurred to me that I was in some parallel universe where time and distance simply did not coincide. I couldn't get my HR up past 70% MHR. The friction rub on my left thigh (from my rain-soaked shorts) was getting unbearable. I hated my bike. I hated my mission. I hated EVERYTHING about this moment.

"You wanted this. You wanted to be so uncomfortable that you couldn't bear it, so that it can apply to situations that are far less uncomfortable than this one. You wanted to demonstrate your strength and patience. You wanted to learn that this "concept" you've taken on as a life theme really will carry you through every challenge of your day. This is precisely the unique condition that will best allow you to train for what you need."

Then suddenly, I saw it. A sign that, for all intents and purposes, said "HOME: 12 miles."
It was a moment I will never forget for the rest of my life. I have the chills as I write this, in fact.
A rush of warmth and gushing energy surged throughout my entire body, and I started BAWLING. I mean literally, bawling. For the first time in the ride, it was 100% undeniable that I would actually complete my second 100-mile conquest. For the first time in the ride, I justified EVERYTHING I'd been through: my emotional outpour demonstrated that this hasn't been "all talk." I'd wondered how "real" my belief that a bike ride symbolized some sort of great life truth, or whether that was just a gimmick I'd brainwashed myself to perpetuate to get myself and others to ride their bikes. No. Every tear came directly from my reality.

I was so close to realizing my goal that, suddenly, the discomfort was transformed. It became my "new comfort zone." From there on, it wasn't self-talk about how present discomfort would translate into comfort in the rest of my life. I didn't notice the discomfort. I was so comfortable with my discomfort, that it no longer inhibited my ability to achieve my goals. I owned it.

The Ride
When one of my regulars as a birthday, I invite them to select a "life theme" they want to process mindfully on a Spin bike. (This sounds nuts, I know -- but in the parallel universe in which I am fortunate to coach, I've trained people to actually enjoy this "life training through Spinning" construct I employ). So with a 75 minute session scheduled on the day of one woman's birthday, it was her turn. "How about self-acceptance?" she asked me.

A ride about the specific concept over which I've been obsessing for the past 3 months? Uhh, YES.

So here goes:

We all have situations and moments where we are uncomfortable. We all have various strategies to minimize discomfort, with various levels of success. Sometimes we invest so much time trying to deny our discomfort -- to talk ourselves out of it -- that we allow our discomfort to distract us from accomplishing the things we want in life. So today, we're going to practice another approach. Instead of talking ourselves out of discomfort, we're going to acknowledge that discomfort.

(Before class, I'd had each participant write on an index card "something that makes them uncomfortable that they're willing to invest time exploring during this ride." They taped the cards to their water bottles, for them alone to see. I do this index card auto-cueing move for every training session I coach that is longer than an hour. People LOVE it. For riders new to my long training sessions, I acknowledge its cheesiness up-front before they have a chance to write me off as "un-relatable" and tell them that this "surprisingly" REALLY helps people by the end of the ride when they're exhausted. "Surprisingly," my ass. It's enforcing that they set goals! Of COURSE this helps.)

This ride has 3 blocks:
1) Dabbling in Discomfort
2) Commiting to Discomfort
3) Owning Your Discomfort

WARMUP (5 minutes)
* Progressive loading to "4 out of 10" on RPE scale. Shoulder rolls/stretches. Cue mindful orientation to breathing, upper/lower body form, and pedal stroke.
Think about what you wrote on your index card. Why did you choose it? What is it keeping you from doing? What does it mean to you?

(18 minutes)
* Progressive loading to 80% LT ("5 out of 10"). When you reach it, maintain it -- subtle bits of resistance, lengthened exhalations, keeping the heart rate exactly where it is. When you reach the point that this place feels completely and utterly comfortable despite adding more resistance at the same level of intensity, that you are willing to entertain the concept that you can hold this all day and be perfectly happy to do it, then keep going.
* Progressive loading to 20 beats below LT ("6 out of 10")-- same.
By loading the intensity so gradually, you are training your body to allow you to get more work done without working harder. You are accepting each new challenge, adapting to it, establishing it as your "new comfort zone," and readying yourself for your next choice.

Focus on your deliberate, fluid breathing. In through the nose, long and concentrated out the mouth. Synchronize your breathing with your pedal strokes -- maybe breathing in for 2 strokes, breathing out for 3 or 4 strokes.

* Surges to 10 beats below LT ("7 out of 10"): 4x (30 seconds), 1x (60 seconds).
From the baseline of 20 beats below LT, 5 "surges" -- your choice of challenge: change in speed, resistance, or position. Recover "20 below" in between.

Focus on breathing more deliberately when you surge. FORCEFUL breaths out the mouth to keep the heart rate from exceeding 10 beats below LT. It's uncomfortable but it's a challenge that you choose to accept, and can conquer confidently.

* Recover to 80% LT. Progressive loading - subtle bits of resistance added but heart rate stays the same. When you're confident that this is your new comfort zone, progressive loading to 20 beats below LT. When you're confident that THIS is your new comfort zone, keep going.
* Find 10 beats below LT and commit to it, no matter what. If you're dropping, progressively load the resistance. If you exceed, back it off. If you need to stand up out of the saddle to accomodate a new load or new pace, do it. Drop back in when you can.
Demonstrate your patience, your willingness to make decisions to honor your commitments to yourself.

Surge: 1 minute (LT - "8 out of 10")
Your choice of the challenge that means something to you: speed, resistance, position, or no change at all. When you surge, surge with confidence. With pride. With the genuine belief that you will conquer what you decide to conquer.

BLOCK 3: OWN YOUR DISCOMFORT -- combining the two (30 minutes)
You have learned that your previous discomfort -- 10 beats below LT -- isn't actually all that bad if you a) accept it gradually (i.e., hitting all the heart beats in between); b) monitor your breathing to fuel your efforts. You've also learned that you are in complete control over defining your comfort zone. 10 beats below LT didn't feel so bad by the end of Block 2 as it did when you surged there in Block 1. (People nodded across the board, thank goodness!) So now we will build upon the skills you've developed, and apply your commitment and focus to re-define your comfort.

Same progressive loading from 80% LT ("5 out of 10") through 10 beats below LT ("7 out of 10")
Take your time over the next 5 minutes to gradually accept the challenge at hand. Spend time at each stop along the way, mindfully acknowledging your physiological sensations at each level of intensity. Does your breathing change? Does your pedal stroke change? How is your upper body? Is every aspect of your experience contributing to your ability to commit to this challenge?

* 5 surges to LT ("8 out of 10") -- recovering to 10 beats below LT ("7 out of 10") in between
Efforts: 90 seconds, 2 minutes, 90 seconds, 2 minutes, 3 minutes
Recoveries: 5 minutes, 4 minutes, 3 minutes, 2 minutes
Technical purpose: lactate clearance intervals. By spending time in incomplete recovery just below LT, your body is learning to clear lactic acid more efficiently -- because it has to!
Larger purpose: You are uncomfortable. You are SO uncomfortable. But your active "recovery" is a comfort zone you defined yourself. You believe in your ability to be successful there. When you choose to accept a new challenge, breathing your way through it, you know that you can and WILL achieve it.
You're uncomfortable, but you lack not in confidence and determination

We alternated 90 seconds/ 2 minutes/ 90 seconds/ 2 minutes for the LT intervals because I knew that half my class didn't have HRMs, and I wanted quality control over how hard they were pushing. I described that at 90 seconds of "8 out of 10," they should NOT feel spent. Burning in the legs might have started but they should feel like they can still get a few words out, no chest discomfort, NO inability to control their breathing, and a clear appreciation that they could have kept going. At 2 minutes, they should experience close to the same -- still NOT spent.

I talked about the scientific process of modifying lactate threshold, to increase the point at which they are still using mostly fat for fuel. Reminding them of the technical purpose for their discomfort, I felt, was important. But then I also cued them to look at the index cards on their water bottles and re-affirm their commitment to spend time making peace with where they are.

Own your discomfort. Own your self-doubts, your perceived inadequacy. Own your potential.
3 minutes - LT - OWN it.

And, daaaaaaaaaaaaamn, did they ever.

Sunday, September 6, 2009

"To Intervene or Not Intervene: That is the Question. See also: The Perils & Pleasures of Correcting Form

Could my title have been more obnoxiously complicated? Maybe. But it's fitting for the topic at hand: thoughts on when/how to correct form in Spinning classes.

In the interim since I've last written, I've been spending less time training for epic bike feats (my race did go well, exactly according to my training plan in my last post, despite wiping out 100' from the finish line and bloodily dragging my bike and its broken chain the rest of the way -- I was actually SO pleased with the way I landed) and more time training for that whole "being a doctor" thing. I did, however, resume teaching Spinning classes for the first time in 2 months (the longest I've ever been away in my coaching career -- and to be honest, I'm a little stale. Ick.)

The weekend before my Burlington classes started for the semester (I teach on a college campus, so group fitness classes go according to the academic calendar), I *drove* to NYC for 14 hours and taught my old Sunday AM class. (Yes, I drove into Manhattan proper. I was SO proud.) The aesthetics of NYC Spinning studios (lighting, sound, general ambiance) can be quite powerful, if maximized to their potential. I happen to be good at that, which hid my staleness until I psychologically/emotionally warmed up to the task at hand. But as a sub (I moved a year ago -- though some regulars flocked when I announced my return, most of my "old class" isn't really my class), I was mindful of how stuck I was about correcting form.

Though I cued general form tips, there were more extensive interventions that I would have liked to pursue. But didn't. Were they dire safety issues? No. But could they have improved someone's efficiency and/or comfort? Absolutely. Did I feel like, as a sub, I had enough "street cred" to effect change? No. Hence my silence.

On the morning of my first class back in Burlington, the New York Times ran a pseudo-interesting article about trainer and participant perceptions of feedback on form. It didn't say anything ground-breaking. It's common sense that there is a continuum of effective feedback, and a continuum of how people perceive feedback. But there were a couple of comments that reminded me of a theme I try to bring to my coaching all the time -- that is, gauging people's goals and expectations -- yet often forget to apply to the issue of form.

A few months ago, I wrote on my other blog about an experience I had (as a sub, no less) in intervening into what I deemed a safety issue in a Spinning class I was teaching. Though I felt intimidated and ineffective, I reminded myself of my commitment to this theme of identifying people's values and educating them about framing various choices in the context of those values. Choosing a medication, a surgery, a heart rate training zone, a handlebar height, an angle of an SPD cleat, a pelvic tilt, a knee alignment -- they're all the same. That's always what every choice is about.

I feel strongly enough sharing the above-linked post (which presents this story as part of a larger point about synergy between my "medical student" and "coach" worlds) that I'll excerpt part of it:

The other day, a woman in an NYC class I subbed was executing all kinds of safety-contraindicated stuff: mashing her legs, cranking the resistance too heavy to even turn the flywheel, letting go of the handlebars. As a life policy, my interventions begin with general guidance to the group. This is usually sufficient; "offenders" often hear what I say, appreciate the inconsistency between what they hear and what they are doing, and make the appropriate adjustments. If this fails, I describe my corrections in alternate ways. If this still fails AND I think this is a major safety risk, I mute my mic and approach this person individually. As a sub, my threshold for individual intervention is pretty high -- I'm more concerned with pissing people off and inspiring them to cause a scene. So after 6 or 7 "group" interventions and very unambiguous "this pertains to you" signaling, I gave up. I knew that speaking to her privately during class would likely alienate her, and wouldn't actually have an impact on her training practices once I walked out of the room and out of her world.

I couldn't make a difference, so why bother? I gave up on her.

Then I remembered that I wasn't wearing a particular "hat." I was just ME, the cycling coach who knows what the hell she's talking about, who also just so happens to be training as a physician. Time to start acting like one.

I'd given up on this rider who ignored my educational pleas for health and safety. Just like a doctor giving up on an obese, hypertensive patient with Type II diabetes who eats terrible, drinks too much alcohol, smokes, and doesn't take his or her meds. That's what I just did. I didn't find a way to connect, so I blamed this woman as "refractory to cues." No. I just didn't find the right cues. Yet.

At the clinic where I'm working this summer, I'm running a survey that examines patient attitudes towards medications, taking medications, their involvement in their treatment plans, etc. I included an open-ended question that probes patients' reasons for skipping doses of meds. It was my goal to demonstrate that mismatches between patients' goals/values and the regimens prescribed by their providers, or misunderstandings/miscommunications mattered. That calling this phenomenon "non-compliance" is a cop-out -- and that by asking people a really basic question about their obstacles to a desired outcome, we can learn from this and improve said outcome.

Could I apply what comes so naturally to me in medicine... here?

After class, I approached her.
"Hey, I notice you have really strong legs and a great pedal stroke," I said to the woman.
Her eyes perked up.
"But let me ask you something. I notice that you often let go of the handlebar. I'm always interested in the thought process of the people who take my classes -- when you do that, what goes through your mind?"
"Oh, well, I'm pregnant -- and I don't like reaching over. It's uncomfortable."

Really? That's all this was about? Turns out, "non-compliance" doesn't exist on a Spin bike either.

Now I understood her obstacles to heeding the information I presented; now I knew how to frame my message in a way that was consistent with her values. I showed her how to raise the handlebars so that she could hold on without hinging forward too far, and educated her about how riding without holding on places undue strain on her lower and middle back. We then had a lovely conversation about exercise intensity and pregnancy and... get this... heart rate monitoring. By the end of those 5 minutes, she really would not ONLY always hold onto the handlebar (my goal) -- but would be investing in a heart rate monitor, and thus investing in her health and that of her future child.

It was an important reminder on what can happen with a commitment to not giving up on people. It's tempting to detach, to focus one's energy on causes more likely to yield the greatest impact. But the likelihood of impact is also inextricably linked to one's belief in one's ability to have that impact. Like anything else, it's all in the way one talks to oneself.

Take-home points?
1) Believe that fine-tuning form is important.
I will refer to you two previous posts:
"Do Your Riders Know Why They're Riding?" --
details the merits of explaining each and every form cue, and includes a ride profile based on educating people about why various aspects of their form matter. I forgot this exists, and I'm going to use it in my class on Tuesday. Sweet: one less new ride to make.

"Practical Applications of Life on a Spin Bike"
-- where I described super-subtle changes I made to my form (pelvic tilt, wrist rotation, seat adjustment) that made LIFE-ALTERING changes in my ability to comfortably ride my first 70-mile and 107-mile rides outside. Just want to demonstrate that subtleties in form TOTALLY matter.

2) Believe that you are a useful and knowledgeable resource.
As a medical student, I struggle with this issue every day of my life. I spend so much time mindfully acknowledging that I know very little in the big scheme of things, and that I haven't actively earned many of the privileges bestowed upon me to learn them (i.e., the generosity of patients allowing me to practice rectal and vaginal exams) that it often distracts me from learning. But as a coach, 99% of the time I genuinely believe that what comes out of my mouth is informed, precise, and useful. When I am in that 1% mentality, that's when I don't speak up about form.

I refer you to a really long/verbose/annoying but probably one of the best posts I've ever written:
Trust Your Judgment: Evaluating Yourself... and Evaluating Others - describes my evolution from an unconfident "newbie" to a more confident, more effective (though, of course, always still evolving) coach, and suggests a few parameters for evaluating influences to which you are exposed.

3) Find multiple different ways of describing the same form cue
I took a FABULOUS, FABULOUS workshop at WSSC 2008 with Luciana Marcial-Vinson about identifying your most frequently (over)used cues and brainstorming alternatives to them. At that time, I hadn't realized how stale my cues were. Going through the process of physically writing down the things I said all the time was scary and occasionally horrifying. But by forcing myself to own my staleness, I could commit to improvement.

Common sense suggests that people respond to different things -- one way might "click" for someone and mean nothing to something else. So when we say the same thing all the time, there may be people falling through the cracks. If we deliver the same concept in multiple different ways, we have an increased likelihood of "reaching" more people. So where do you get your cues? The creative process can be accomplished in SO many different ways: Take continuing ed workshops. Take other instructors' classes. Read blogs and books and websites. Ride by yourself and think about the subtleties of what you're doing. Spend 10 minutes just being THOUGHTFUL, and you will come up with beyond-useful material.

4) Ask the questions.
I'm taught in medical school that 95% of diagnoses come from the patient's history. Not fancy lab or imaging tests -- just by asking subtle questions, and listening to what a patient tells you (and does not tell you). I think about that as a coach, too. The story I cited above in asking the "cue-refractory" woman who would NOT hold onto the handlebar about how she came to make that decision, I learned that she thought she was accomplishing x goal (i.e., avoiding discomfort in pregnancy). When I learned that, I could educate her about different means to accomplish x goal safely (i.e., raising her handlebars) AND how what she was doing wasn't actually having the desired effect she intended. Had I never asked the question, I would never have been prompted to educate her about those specific points. By asking the question, I made my feedback relevant.

Putting this all together:
Basic Cue: "Keep your feet nice and flat. Drop your heel as you pull back on the pedal, keeping your toes straight ahead."

Improvement #1: Tell Them Why
"By dropping your heel, you engage the muscles in the back of your leg for a more powerful pedal stroke."

Improvement #2: Make It Relevant
"Here's why we care about a powerful and efficient pedal stroke..." -- be sure to include relevancy for both outdoor and non-outdoor riders

Improvement #3: Alternate Description

"Think about a magnet on your heel. The floor is metal. Allow your heel to be drawn towards the floor, and pull up against that force to bring your heel towards your butt."

Improvement #4: "Intervention"
"I notice that [insert some sort of positive, empowering feedback]. That's awesome. I notice that you're pointing your toes a bit -- does it feel that way to you/are you aware that that's happening? If yes: What were you hoping to achieve by doing that, so that I can help you find a way to think about it. If no: Yeah, most people can't tell. I figured it was accidental. Here are some ways you can think about it instead, and here's why it matters..."

I need to stop writing massive blog novels when I'm supposed to be studying. I think *I* need an intervention.