Barbell Medicine - From Bench to Bedside

Belief that you can perform a task is an essential component to beginning the process of mastery. There are a host of both internal and external motivational factors that can either help, or hinder those beliefs. In this article, we will primarily focus on the relationship between demands and resources. The perceived demands of the task (overall workload & degree of skill required to complete) contribute to the typical willingness to begin or continue a task.  We typically think of this more in the domains of work or education, but the same applies to sports. As this is a Barbell Medicine Review, the rest of this piece will be framed through athletes and exercise, although there is ample evidence demonstrating this principle in other domains.

Introduction

The demands of the exercise are balanced by the resources an athlete can rely on to accomplish the task. Resources, in this instance, include the social support upon which an athlete relies and from which they gather their information. An athlete surrounded by a supportive group with good information available to them will be more resilient and will be able to balance higher demands. The relationship between the demands and resources of the task determines a person’s ability to succeed and the potential for either not starting exercising, or developing burnout.Maslach 1982 

Burnout is a psychological syndrome that is associated with motivational, psychological, and performance difficulties.Hill 2016 The original work on this is attributed to Maslach and Jackson, focusing on three core symptoms:Maslach 1976

  • Emotional exhaustion: general feelings of being overextended by demands placed on the individual.
  • Depersonalization/Cynicism: indifference or detachment from others 
  • Evaluation of personal competence, accomplishment, or efficacy with a lower rating correlated with a higher level of burnout.

Specific to sport, the exhaustion is not only inclusive of the emotional component, but also physical exhaustion. This could sometimes be considered in the same domain as what is often referred to as overtraining. Indifference also manifests through a lack of desire to participate in training or sport. Raedeke 2001 Increased demands placed on an athlete with insufficient resources can result in first the symptoms of exhaustion, followed by the beginnings of indifference to training. From this junction, athletes will develop a reduced sense of accomplishment and the probability of burnout is increased.Lee 1996 

These demands can come from overall programming paradigms, which are likely the most obvious, but there are also demands placed on athletes from their coaches, their peers, and in youth sports, their parents. Here, the social support that would typically be a resource, can end up being an additional demand. Specific to the current article, this arises as an expectation of perfection in performance. The expectation that an athlete, and especially a youth athlete, needs to be perfect in their performance can begin to facilitate a need for perfectionism within an athlete. 

What is Perfectionism?

Perfectionism is defined as a personality characteristic that involves setting exceedingly high standards of performance which are accompanied by tendencies for overly critical evaluations of behavior.Frost 1990 Perfectionism is currently understood to be multidimensional, comprised primarily of two traits perfectionistic strivings and perfectionistic concerns. Stoeber 2018 

  • Perfectionistic strivings: aspects of perfectionism associated with self-orientated striving for perfection and the setting of very high personal performance standards.
  • Perfectionistic concerns: aspects associated with concerns over making mistakes, fear of negative social evaluation, feelings of discrepancy between one’s expectations and performance, and negative reactions to imperfection.Gotwals 2012

These attributes of perfectionism have demonstrated correlations with cognitive, affective, and behavioral outcomes.Gotwals 2012, Stoebber 2006 Studies demonstrate that perfectionistic strivings can occasionally enhance performance and do not possess many demonstrable negative consequences. At face value, this would seem obvious as the strivings would require more process oriented behaviors (e.g. focusing on getting better at the task at hand, not the overall sport) and an individual holding themselves to a high standard. They are associated with problem-focused coping, higher subjective-well being, and higher athlete engagement. Gandreau 2012, Jowett 2016 However, in the face of failure, perfectionistic strivings predict decrements in performance, negative cognitions, and negative emotions towards the task and self.Anshel 2005, Hill 2011 

Perfectionistic concerns demonstrate much more negative consequences entirely. These have been linked to greater threat assessment, anxiety, and avoidant coping mechanisms.Dunkley 2003, Hill 2010 Here external expectations and criticisms are perceived to be high. This is where outside influences such as coaches, social media postings, and influencers with high quality graphic designers can play a role in facilitating beliefs. If these individuals increase perfectionistic concerns in athletes, they likely do so at the expense of the facilitation of avoidant coping strategies. An athlete with high perfectionistic concerns is at greater risk of the accrual of stress and, therefore burnout. The belief that there is a miniscule window for what is considered acceptable technique places athletes within a narrow margin for what is deemed “normal” movement. Any deviation outside of this technique can be interpreted as a failure from the desired goal, increasing the probability of negative consequences. 

We typically belabor the point that words matter when coaching individuals, whether in the rehabilitation or performance settings. In both instances, there is often discussion of what constitutes normal technique whether for landing mechanics, cutting, or squatting. The tighter a coach or influencer places the window of what is normal, the less acceptable range there is with which to perform. If an athlete is expected to be perfect on every repetition, they would be remiss not to be concerned with the slightest deviation away from that expectation. Here, the demand of the training is now inclusive of the social support which would typically be seen in the resources. This increased demand could predispose an athlete towards burnout, or even discourage individuals from beginning a task outright due to feelings of inadequate performance.

What Does the Science Say?

A 2019 study by Madigan et al.  on youth athletes can help us examine the relationships between coach and parental pressure to be perfect and perfectionism in sport and, additionally, whether coach and parental pressure to be perfect would predict changes in perfectionism in sport over time

Study Design

The study consisted of three cohorts of junior athletes with demographics provided in table 1. The role of cohort 1 was to examine the cross-sectional relationship between coach pressure, parental pressure, perfectionistic strivings, and perfectionistic concerns. Cohort 2 was used to examine the extent to which coach and parental pressure predict change in perfectionistic strivings and perfectionistic concerns over a three month period. Cohort 3 used a 6 month time frame for the same design as cohort two. 

Informed consent was obtained from all participants and from parents of participants under the age of 18. Questionnaires were distributed upon recruitment with cohorts 2 and 3 completing follow-up questionnaires at 3 months and 6 months respectively. Perfectionism, coach pressure, and parental pressure were measured via the Multidimensional Inventory of Perfectionism in Sport (MIPS). The MIPS is comprised of four subscales:

  • Striving for Perfection
  • Negative Reactions to Imperfection
  • Coach Pressure to be Perfect
  • Parental Pressure to be Perfect

Both the coach and parental sub-scales are designed to reflect the athlete’s perceptions that their parents and coaches expect them to be perfect and criticize them if they fail to meet expectations. The scores have been demonstrated to be both reliable and valid.Madigan 2016, Stoeber 2009 The striving for perfection and negative reactions to imperfection have also been found valid and reliable indicators for perfectionistic strivings and perfectionistic concerns. Gotwals 2012, Stoeber 2016 

The authors elected to use a mini meta-analysis of the initial time point to determine the strength and direction of cross-sectional associations between pressure and perfectionism.Goh 2016 The analysis computes the inverse variance weighted mean correlation coefficients across samples. The authors then calculated Cochran’s Q and I2 to quantify the degree of between study heterogeneity. The first of these statistics allows for quantification of the total variance in their meta-analysis, while the second demonstrates the variance in the meta-analysis explained by between study differences. Cochran’s Q, if statistically significant, reflects substantial heterogeneity in effect sizes, with I2 proportions of 25%, 50%, and 75% representing low, moderate, and high heterogeneity.Higgins 2003

The authors performed a two-step multiple regression on the effect of coach pressure and parental pressure on changes in athlete’s perfectionistic striving and concerns using cohorts 2 and 3. Step 1 of the regression, athlete’s perfectionistic strivings and concerns at time 2 were regressed on their perfectionistic strivings and concerns at time 1. In step 2, the time 1 coach pressure and parental pressure were added to the model in step 1 to determine whether the pressure explains significant portions of variance of perfectionistic strivings and concerns at time 2. 

Results

Less than 5% of item responses were missing. Those were replaced with the mean of the item responses of the corresponding scale. The author’s then calculated Cronbachs alphas for all variables which were all satisfactory. Cronbach’s alpha is a measure of internal consistency, that is, how closely related a set of items are as a group. It is considered to be a measure of scale reliability. 

Mini-meta analysis demonstrated inverse variance weighted mean correlation coefficients that were positive, significant, and small to medium sized. In lay terms, both parental and coaching pressure is important in the development of an athlete’s feelings of perfectionism. The proportion of variance between samples that was not due to chance, with I2, was quite large with values ranging from 40-56%. This demonstrates large variability in correlation coefficients and may give pause when interpreting the size of inverse variance weighted mean correlation coefficients.

For the multiple regression analysis associated with Sample 2, both step 1 and step 2 demonstrated coach pressure to be perfect predicted increases in perfectionistic strivings and perfectionistic concerns from time 1 to time 2 but not parental pressure. For multiple regression analysis associated with sample 3, coach pressure predicted increases in perfectionistic strivings and perfectionistic concerns from time 1 to time 2 but not parental pressure. 

Why Does This Study Matter?

There is a never ending debate regarding the role of technique in training with two camps seemingly dichotomized into “technique needs to be perfect prior to progressing weight” and “technique does not matter.” As with most debates, the actual positions are likely more nuanced, with each position arguing over the degree to which technique matters. That being stated, many of these debates transpire on social media where individuals with doctoral titles, specialist certifications, and phenomenal graphic designers disseminate reductionist content. While there is another layer of debate around which professions have the right to refer to themselves as “doctor,” many of these content generating individuals would be comfortable with the title of “coach.” As such, it carries with it the weight of that title in working to facilitate progress towards an individual’s goals.

The Role of the Coach in Development of Perfectionism:

The current study was performed on youth athletes, however a correlation was found between a coach’s pressure to be perfect and an athlete presenting with both perfectionistic strivings and concerns. The relationship between coaching pressure and perfectionistic concerns should cause reflection for individuals in a coaching/influencing role. Coaches have to be careful that they are not painting athletes into narrow corners with what they deem acceptable movements. Currently, in America, only 22.9% of U.S. adults aged 18-64 meet physical activity guidelines.Blackwell 2018 This is certainly a multi-factorial statistic with no one variable being the driving factor for the current state of inactivity. However, it is certainly worth contemplating how much of this is influenced by narratives such as twisting your spine will “slip a disc” or “running/squatting is bad for your knees.

Should we strive for perfect technique, absolutely. Should we be concerned if there are repetitions that are far from perfect, absolutely not. Technique does matter, but it should rarely be the rate limiting factor in our ability to train. There are more efficient ways of performing some tasks such as squatting or picking up a heavy stone from the ground (one of which does involve a rounded back) but this does not mean that there is inherently increased risk of injury from performing the task another way. Technique has a range, and we learn from errors. If a coaching paradigm consists of demonizing technical errors or using narratives that we are fragile, the likelihood is we will not want to make errors and come to see ourselves as fragile. This does not bode well for overall learning and development. Let’s look at the progression of exercises as it relates to technique through three different scenarios and how the consideration of normal may play a role in the development of perfectionistic concerns.

Scenario A

This is the scenario often seen in social media postings involving the red “x” or green “check.” Implying a correlation between any deviation from whatever the coach deems ideal technique and risk of injury does not facilitate resilience in athletes. If anything, it facilitates the increased threat assessment associated with perfectionistic concerns. The narrative that athletes need to be ideal all the time with technique undermines an athlete’s ability to learn and progress through training. In all three scenarios that will be presented the line for progression remains the same as there will be instances where gains increase more rapidly and others where this is not the case. The main theme in any scenario is that training must continue in order for progress to occur, weighting consistency in pursuit of goal over perfectionism. There is ample evidence that beliefs related to what is deemed a problem have a profound effect on what is actually deemed a problem.Darlow 2015, Darlow 2013 As seen from the current study, coaches do have an effect on the development of perfectionistic concerns in athletes. If coaches are to minimize the negative consequences of this, attention does need to be paid to the narrative being pushed. 

The current study was specific to youth athletes, but evidence exists the role of beliefs and attitudes regarding physical activity span the lifespan. Quicke et al found that older individuals who possessed higher self-efficacy toward exercise and higher expectations of a positive outcome from exercise were more likely to engage in physical activity. Quicke 2017 The narrative that moving wrong will hurt or wear out joints does not contribute to increased self-efficacy and positive expectations. 

Scenario B

This is the scenario for what constitutes normal movement to which we would ascribe for the majority of the population. Here, there is a range of what constitutes normal movement patterns. Allowing for individual differences gives a margin of error in which to work. In this set, athletes would continue to train, even if these were flaws in technique. This is not to say that there would not be frequent work on technique. If we constantly focus on how someone is performing a movement, it is too easy to forget to encourage them that they are moving. 

The Multidimensional Inventory of Perfectionism in Sport contains metrics such as “during training, I feel the need to be perfect” and “after training, I feel disappointed if my performance was not perfect.” While the first does allude to perfectionistic strivings, the second is related to perfectionistic concerns. The role of a coach is to define the range of what constitutes perfect for athletes. If the range is set too narrow, then athletes will be met frequently with failure to achieve the desired results. Rarely does a training session go perfect but it often falls within an acceptable range. In the same regard, if a clinician tells a patient that there is only one way with which to move properly, they have given an impossibly narrow window in which the individual can move. In both instances, the coach and the clinician could be facilitating frustration and inadvertently creating a barrier leading to the athlete or patient not wanting to move. 

Scenario C

The third scenario is likely the best representation for the progression through sport. In the novice phase, there is a wide array of what should constitute normal movement. While skills and technique training should always be a part of programming, the acceptable window for participation at more novice levels is quite wide. As an athlete progresses through higher levels of sport, technical proficiency optimizes competition so the window will narrow on what is acceptable for success. 

In youth sport, there should be little expectation that athletes perform every kick, throw, or cut with ideal form. This does not mean that time should not be devoted to the development of these skills. Rather, spending time on skills training has been demonstrated to reduce the risk of injury in these athletes.Emery 2015, Faude 2017 Any proper training program should emphasize work on technique, but the degree of emphasis is where the problem lies. As with scenario A, a novice athlete should not be instructed that their technique needs to be perfect every time, especially under the narrative that if not they will be injured. There is a quote attributed to Michael Jordan, arguably the greatest basketball player to ever play the game, that sums Scenario C best:

“I’ve missed more than 9000 shots in my career. I’ve lost almost 300 games. 26 times, I’ve been trusted to take the game winning shot and missed. I’ve failed over and over and over again in my life. And that is why I succeed.”

Even at the most elite level athletes experience failure, and that is part of the process. There will be times when technique is not ideal, there will be instances where what was an RPE 7 last week is an RPE 9 this week. That does not mean that progress has stalled. It means that training is not a linear experience and external factors have an influence on our experience more than just the external weight on the bar. 

How-To Facilitate Resilience Over Perfection

At all time points in the current study, coach pressure to be perfect influenced perfectionistic concerns. Coaches and clinicians should not expect their clients to be perfect when they move and realize that in many instances, the definition of perfection is arbitrary to the coach. There needs to be a push towards advocating that people in general need to be more active. There is some figure of authority advocating that just about every movement needs to be perfect before an athlete can progress. Narratives such as squatting is bad for your knees, lifting with a rounded back will destroy your back, or running will “wear out” your knees need to stop. 

None of us are perfect on every rep, nor should we ever expect that to happen. We should continue to work towards an ideal, but it is likely never achievable. Basketball players will always miss shots, football players will miss tackles, golfers will miss putts, and knees will occasionally go into valgus when we squat. If the expectation is in place that those shots should not be missed and all putts should be made, the sport ceases to be enjoyable. This is the first phase of burnout. 

If there are technical flaws, they do need to be addressed, but not at the expense of either stopping training or believing the flaw will cause injury. We should all strive for perfection but not be concerned knowing it will never be achieved. There is one especially damning question on the MIPS, “my coach is disappointed in me if my performance is not perfect.” We should never be disappointed in our athletes or clients, they are showing up and working hard to be their best. It should ultimately be our goal to help them achieve that.

References

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About Derek Miles

Derek Miles is a residency trained physical therapist currently working at Stanford Children’s Hospital as the Advanced Clinical Specialist in the rehabilitation department. He worked at the University of Florida prior for 10 years in sports medicine treating a variety of athletic injuries from overuse to post-operative. He is involved in the peer review process for academic journals and has spoken at national level conferences within the physical therapy profession. If not treating patients or in the gym Derek is likely either cooking some form of meat or reading books related to various random topics. He occasionally brews a pretty good American Pale Ale as well.

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