Category — Performance
I recently had the pleasure of being interviewed by Joe Heiler for his website, www.sportsrehabexpert.com.
To listen to the interview CLICK HERE.
April 29, 2013 2 Comments
I have talked about my Physiological Buffer Zone concept a few times (in THIS article about movement capacity, in THIS article regarding stress and allostasis, and in my lecture during the Strength in Motion Seminar).
The concept is centered around three components of performance:
- Stress and Stress Resistance
- Movement Competency
- Fitness Level (both general and specific)
A recent study by Lisman and colleagues published in Medicine and Science in Sports and Exercise (Functional Movement Screen and Aerobic Fitness Predict Injuries in Military Training) looked at two components of the Physiological Buffer Zone – Movement Competency and Fitness Level – to help understand the association between injury risk, fitness level, exercise and injury history, and Functional Movement Screen (FMS) scores in Marine Recruits.
Marine Corps Officer Candidates, ages 20-25, who were enrolled in either the six (n = 447) or ten (n = 427) week candidate training program. While both programs consist of similar training activities due to the shorter time frame the six week training program is considered to be the more intensive of the two.
The standardized Marine Corps Physical Fitness Test consists of (performed in this order):
- Pull ups to exhaustion
- Abdominal crunches completed in 2min
- 3 mile run for time
The seven test FMS was used to understand the candidates baseline movement competency:
- Overhead Squat
- Hurdle Step
- Inline Lunge
- Shoulder Mobility
- Active Straight Leg Raise
- Trunk Stability Push Up
- Rotary Stability
Each test is scored on a 0-3 scale. A “0″ is scored if the individual experiences pain during a movement. A “1″ is scored if the athlete is unable complete the movement properly. A score of a “2″ is awarded if the subject can complete the movement but has some level of compensation and a “3″ is scored if the subject performs the movement correctly without any compensation. The highest possible score an athlete can achieve is a “21″, which would be a “3″ on all seven tests.
Finally, a questionnaire was administered to the subjects to understand their previous injury history as well as their prior exercise routines (modalities and frequency) prior to entering candidate training school.
Some of the Key Findings
- Slower 3-mile run times (>/= 20.5min) indicated a higher risk of injury
- Lower FMS scores (</= 14) indicated a higher risk for injury
- The pull up test and abdominal crunch test were not significantly associated with injury risk
- Subjects where at a higher risk of injury if they reported a prior lower limb injury
- A lower general exercise frequency, as reported via the questionnaire, was associated with a higher risk of injury
Some Words on FMS Scoring
Kiesel and colleagues (2007) found that NFL athletes were 12 times more likely to suffer an injury when their scores were </= 14 compared to those who scored >14. Thus, it would appear that the cut off point on the FMS is a 14. However, Gray Cook and Lee Burton (two of the developers of the FMS) have stated that the number may not be as important as obtaining a score of symmetrical “2′s” on each of the 7 tests. Two of the FMS tests (Overhead Squat and Trunk Stability Push up) are performed bilaterally while the other 5 tests (Hurdle Step, Inline Lunge, Shoulder Mobility, Active Straight Leg Raise, and Rotary Stability) are performed in a unilateral fashion and the lower score between the two sides is factored into the overall score. An individual with movement asymmetry is often at a higher risk of injury (Note: The human body is inherently asymmetrical and several sports may have asymmetrical tendencies. That being said, there is a rather larger range of what a two can look like on the FMS tests allowing us to have some individual asymmetry but still have relatively symmetrical movement competency. In other words, it is very hard to score a “3″ and it is very hard to score a “1″ but it should not be that hard to score a “2″ if you have some basic levels of both mobility and stability). Therefore, an athlete may be able to score a “14″ by obtaining a “3″ on the trunk stability push up and a “1″ on one of the asymmetrical tests but this may still place that at a higher risk of injury. So, the goal should actually be to obtain at least a 14 with no asymmetries.
I think this study was a good first step at trying to understand the association between fitness and movement competency. When FMS scores were low (</= 14) and when 3-mile run times were slow (>/= 20.5min) the subjects were 4 times more likely to sustain an injury. These findings were similar to an earlier study by O’Connor and colleagues (2011) who also evaluated the FMS and fitness level as a model of injury prediction in officer candidates and found that those with a score of </= 14 were at higher risk of injury compared with those who scored >14 and that those with better physical fitness scores were significantly less likely to suffer injury compared to those who had poorer fitness scores.
Interestingly the pull up test and the abdominal crunch test were not associated with a higher risk of injury. I wonder how much this may have to do with the type of activity that the subjects participate in during officer candidate school? Obviously they use their upper body to do pull ups, push ups, and lift/carry things but the lower extremity seems to take the most punishment during this time period as the candidates would appear to always be running or on their feet (standing, lifting, or carrying things).
Together, some sort of fitness screen and some sort of movement screen appears to offer us, as fitness professionals and strength coaches, some valuable information to help not only understand our athletes but also program appropriately for them. A lower fitness score would indicate that our training program needs to focus more on general fitness and aerobic capacity. One of the difficult things about officer candidate school may be that there really isn’t time to develop an individual’s level of fitness. Everyone is supposed to show up fit, in shape, and ready to face whatever is thrown at them from a fitness standpoint. Unfortunately, this isn’t always the case, as evident by the fact that having a lower level of fitness and a lower frequency of general exercise training prior to officer candidate school led to a higher risk of injury. Essentially, the individual shows up unprepared to handle the stress that is placed upon them and they “break”.
Additionally, the FMS is not just a screen used to assess movement competency but it can also be used to influence program design and exercise selection. If you know what tests the individual is poor at or asymmetrical in and you understand the corrective exercise hierarchy (I talked a little bit about this in an article 3yrs ago on Developmental Kinesiology and Client Assessment and I encourage anyone interested in learning more about the FMS and the corrective hierarchy to attend one of the courses put on by Functional Movement Systems) then you can begin to develop a specific training program that not only meets that athlete’s needs but can also be re-tested and monitored to ensure you are moving in the right direction. Kiesel and colleagues (2009) found that a 7-week offseason training program, individualized for each athlete based on their FMS scores, improved the FMS scores of 62 NFL athletes with 41 of them being free from asymmetry at the end of the 7-weeks compared to 31 at the start of the study. Oftentimes people see the FMS and think it is a reason to be soft or not train hard. The FMS can tell you what not to do but it also can tell you what you can do and when you find things that the person can do you should be attacking those those things, loading them, and training hard while you concurrently improve upon their limitations (always keeping in mind that you must come back and re-test to ensure that you are improving the test and moving in the right direction).
When assessing individuals it is important to be holistic and take into account all aspects of the Physiological Buffer Zone. One part of the Physiological Buffer Zone is not more important than any other and I think, as professionals, we all have our biases towards subject areas we feel most comfortable – “I’m a movement guy” or “Fitness is the most important thing! Movement isn’t as important as getting guys fit” or “Strength is more important than anything. Just get them stronger and everything will be better.”
Rather than staying in our comfort zone (based on our previous experiences, education, etc) we should try and open up and be more aware of all things that may impact an athlete’s ability to appropriately adapt and tolerate the stresses that we, as coaches, apply to them in training (that stress resistance piece of the Physiological Buffer Zone is a really big piece and you can read more about it in my article on Allostasis and Physical Preparation).
Furthermore, the testing should in some way influence our training program. Don’t just test to test or do an FMS (or any other movement screen) just to say that you do it. Use these tests to provide you with information about the individual and then take that information and put together a program that reflects that individual’s needs and abilities. From their, the tests serve as a means of re-assessing to understand if your program is doing what you intend it to do or if you need to make some adjustments.
April 8, 2013 2 Comments
Crossfit is an incredibly popular training system at the moment for a variety of reasons one of which being that the workouts are extremely challenging and demanding. A study recently published in the Journal of Strength and Conditioning Research set out to evaluate the fitness adaptations that take place during a 10 week Crossfit training program (Smith MM, et al. Crossfit-based high intensity power training improves maximal aerobic fitness and body composition. J Strength Cond Res 2013. Published ahead of print.).
The study began with 54 healthy participants of varying fitness levels; however, only 43 completed the study (23 males/20 females) and were able to return for the post training re-test (more on that later).
The subjects body composition and Vo2max were tested at the start and end of the study to evaluate for changes.
Following the initial testing the subjects performed a 10 week, periodized, CrossFit training program at a CrossFit affiliate gym. The program utilized basic gymnastic activities (handstands, ring work, etc) and multi-joint exercises such as the squat, press, deadlift, and Olympic lift variations. The training program had some variation to it, adding an element of periodization, where some exercises were performed as a time trial (best time) and others were performed in an as many reps as possible style for a prescribed time domain (E.g., 10 or 20min).
The subjects who completed the entire 10 weeks (43 of them) all experienced significant improvements in both VO2max and body composition changes (decreases in body fat percentage) leading the researchers to conclude, “Our data shows that high intensity power training (which is what they refer to CrossFit as in this study) significantly improves Vo2max and body composition in subjects of both genders across all levels of fitness.”
My Comments (The Nitty Gritty)
First I’ll begin by making some obvious statements which, may not be so obvious given that marketing and hoopla tend to cloud rational thinking:
1. CrossFit is not that novel. Circuit training and calisthenics have been around for hundreds of years. Training over a broad range of mixed time and modal domains is certainly not a new thing.
2. What CrossFit did do is create and environment and a culture that made that stuff cool and exciting for people, “Hey, it really sucks to suffer when I work out hard but if I suffer with a group of my friends it really isn’t that bad!” In that regard, I think CrossFit has done a great job motivating a lot of people to get off their butts and exercise. This is a good thing.
3. High intensity interval training or really hard aerobic power type activities, which make up the brunt of the energy system demands during a CrossFit workout, have been shown to improve things like VO2max and Body Composition so do these results really come as a surprise? This stuff has been looked at in hundreds of studies by now.
Now to the not so obvious stuff – the devil is in the details
While the fitness and body composition results seen in this study are certainly impressive, as they are in many studies on high resistance interval training (as I alluded to in point number three above) the most concerning thing about this study and the biggest thing that concerns me with CrossFit is that of the 54 original subjects only 43 were able to complete the study. Nine of the subjects dropped out citing overuse or injury (two of the 11 dropouts cited time restriction as a problem in completing the study).
This sort of dropout rate is a bit hard for me to handle and I believe it has to do with the type of activities chosen from CrossFit workouts, the intensity with which those activities are performed, and the frequency of high intensity workouts within the training week (IE, poor sequencing of training intensities over the week). We don’t see this sort of dropout rate in traditional High Intensity Interval Training studies (usually performed on a bike, treadmill, or rower) and yet we similar exercise benefits. This sort of stuff makes me question the utilization of CrossFit as a training system because the risk seems to outweigh the reward.
My Take Away Conclusions
1. Hard workouts are great. Hard workouts are fun. Pushing yourself is awesome. But, you need to do so with safe exercise selection and have a training program that takes into account your abilities to adapt. This means you need to look at the training week and sequence things properly to ensure that you aren’t killing yourself in the gym everyday and training yourself into a rut. A training program should make you a healthier person, not crush you and deteriorate your body.
2. Olympic lifting exercises should not be used as exercises to be performed “as many reps as possible”. They are highly technical exercises and the athlete should have adequate rest before performing their set.
3. Things like deadlifts and exercises that place the spine in a compromised position as fatigue sets in should not be performed for “as many reps as possible”. This is just asking for trouble.
4. Qualify people to do certain exercises. Sure, gymnastics skills are great and can be a fun addition to a workout; however, not everyone is immediately qualified to perform these activities – just like not everyone is immediately ready to squat, deadlift, or olympic lift. Make sure you have some sort of way to qualify individuals to perform these exercises. This goes beyond skill and technique and should first include ensuring that they have the requisite joint ranges of motion and stability to handle the exercises. Once they are qualified then spend time on technique. Once technique is solid then condition. Do not just throw people to the wolves.
5. Structure your training in phases so that you don’t go high intensity all the time and run the risk of breaking down. The body can only tolerate so much high intensity or maximal effort work. All high intensity interval training programs should have phases where that intense stimulus is removed or minimized to allow the body to not only recover but to also work on developing the aerobic system, which can be helpful in moving the lactate threshold further to the right and allowing the individual to tolerate greater amounts of high intensity work once you get back into that phase of training.
March 1, 2013 26 Comments
I just finished reading the book Allostasis, Homeostasis, and the Costs of Physiological Adaptation edited by Jay Schulkin. The book is fantastic and while it is not written specifically about physical preparation for sport the information contained inside has everything to do with physiological preparation for sport.
Homeostasis and Allostasis
Homestasis is a term most are familiar with and generally the word gets thrown around when we talk about training – “The goal of training is to disrupt homeostasis and force the body to adapt and get stronger.” There is, however, a difference between homeostasis and allostasis and understanding that difference may help us better understand the ramifications of our training program. While the authors who contributed chapters in Schulkin’s book all seem to agree there is a difference between homeostasis and allostasis they do have subtle differences in regard to how those terms are applied and the physiological processes they are applied to. Rather than getting so focused on those subtle differences I think that just grasping the basic concepts would be helpful before I try and put this into the context of physical preparation for sport.
The concept of homeostasis dates back to Walter Cannon’s work (1935) and for a broader understanding of Cannon’s work I suggest checking out his book, The Wisdom of the Body, as it is a classic in the field of physiology. Cannon used the term homeostasis to refer to the processes needed to preserve constant conditions within the body which are centered around specific set points and governed by negative feedback loops.
A common example of homeostasis often cited is the thermostat in your home. If you set the air conditioning to 80 degrees in the summertime the thermostat does not kick on until the temperature in your home rises above 80 degrees (the set point), providing negative feedback to the thermostat and requiring it to take action and regulate the temperature back to normal, achieving homeostasis. Of course, if you opened a window in the house the temperature would rise and be constantly above the set point of 80 degrees causing the theromstat to remain on for a significant period of time, as it attempts to maintain the homeostasis, until you finally either close the window or the thermostat breaks down because it has overworked itself.
One of the issues with the homeostasis model in health is that the medical community takes body set points very literally and thus we end up with a large number of medications being prescribed to help people maintain specific numbers considered to be “normal”. This issue was confronted by Sterling and Eyer in 1988 when their research led them to coin the term allostasis.
Allostasis, Allostatic State, & Allostatic Overload
Schulkin notes three distinguishable features of allostasis (pg. 7):
- Allostasis – The process by which an organism achieves internal viability through a bodily change of state
- Allostatic State – Chronic overactivation of regulatory systems and the alterations of body set points
- Allostatic Overload - The expression of pathophysiology by the chronic overactivation of regulating systems
Noted stress physiologist, Bruce McEwen, goes on to further differentiate between these features of allostasis and homeostasis by making the distinction that homeostasis applies only to a few physiological systems that are essential for life – pH levels, body temperature, and oxygen tension. These systems are so essential to human survival that slight fluctuations for a brief period of time could lead to death.
Thus, allostasis is not so much focused on constancy as homeostasis is, but rather, is able to fluctuate and alter set points in order to meet demands that are placed on the body. Additionally, rather than only being dependent on negative feedback loops, the allostasis model indicates that the body can be predictive and anticipate stress and react based on feed-forward information.
High blood pressure is a good example to use when trying to understand the difference between allostasis and homeostasis and how this has influenced the medical community, as I alluded to earlier. “Normal” blood pressure is often cited as being 120/80. If a patient presents at the doctors office with a blood pressure of 160/90 they are classified as being hypertensive and prescribed medication to try and bring their blood pressure back down to the “normal” 120/80. One of the issues with taking this homeostatic approach to blood pressure is that this individual’s blood pressure set point may have shifted for a reason. Perhaps they live an incredibly stressful life, they sleep only 4 hours a night, and they keep a poor diet. Their blood pressure is simply adjusting its set point in order to try and still be effective and get the job done. Prescribing medication means that you are not acknowledging all of those other important things going on with the individual’s health and well being and attempting to focus on the adaptation (allostatic state) that is rightfully taking place in the presence of these stressors rather than addressing the true problem – life stress, sleep, and diet. Additionally, the medication which is being used to treat their high blood pressure may do so at the consequence of other physiological systems, as there are often side effects and other systems need to adapt to the medication, placing these other systems into an allostatic state. Of course, if this allostatic state of high blood pressure goes on for a considerable period of time the individual may find themself in a state of allostatic overload – potentially life threatening.
Limitations of Selye’s General Adaptation Syndrome
Hans Selye, whom many consider to be the “Father of the Stress Response”, defined stress as a nonspecific response by the body to any demand whether it is pleasurable or non-pleasurable (eustress or distress). Selye broke stress down into three phases – alarm, resistance, and supercompensation:
The Alarm phase takes place when we encounter a stressor, causing the body to break down. The Resistance phase is our bodies attempt to combat this stressor in order to not only restore homeostasis but to actually put our body in a better position to resist that same stressor should it happen again, thus reaching a state of Supercompensation. Of course, if we continually breakdown and do not provide the body ample time or opportunity to resist the stress we are placing on it we reach a state of Exhaustion.
This model was revolutionary at the time as Selye literally discovered the stress response on accident by making some errors in his lab with the way he handled the mice he was studying. However, like most things, the picture is a bit incomplete and many stress physiologists look at adaptation in a different way. This stereotypical, non-specific response to all stressors, pleasurable or non-pleasurable, in no longer considered accurate. Rather, different situations and different stressors can mediate allostasis in different ways depending the response needed and the body’s ability to cope with the stress. Thus, there is a degree of specificity that stress has on the body and the perception that the body has to this stress will help to determine how it reacts.
Physical Preparation and Allostasis
Similar to the discussion regarding General Adaptation Syndrome, it is important to note that stress can have positive or negative outcomes depending on the amount of stress applied to the body and how the body adapts to that stress. While not discussed in the book, the term hormesis comes to mind. Hormesis is a term of biology used to explain how low levels of a toxin can produce a favorable biological adaptation to the cells while high levels of that same toxin would lead to cell death. This concept can apply to training, much like the model of allostasis discussed in the paragraph above, where a little bit of training can produce a favorable adaptation to the body – the appropriate amount allows the body to cope with the stress of the training session – but, if we push too hard and overload the individual they may achieve an allostastic state, where the biological systems become overactive as they attempt to adjust set points in response to the stress. If we then continually apply training stress we end up with a negative result and force the individual into allostatic overload – the toxin, in this case training, when applied at a low level led to favorable adaptations, however once we did too much it ended up becoming toxic and damaging to the system.
An allostatic state, where the body systems become overactive and adjust their set points in response to training stress, may not be such a bad thing. This would probably resemble a brief period of overreaching and, provided we monitor the athlete appropriately and do not push them over the edge, would lead to favorable gains as the increased set points for things like hormonal output, cardiovascular function, and central nervous system firing would result in the athlete getting stronger, faster, bigger, and more fit.
Thinking through this model of allostasis it makes me consider how training influences the three aspects of my Physiological Buffer Zone (which I discussed on the Strength In Motion DVD):
1. Good Movement
2. High Level of Stress Resistance or Stress Tolerance
3. High level of Fitness
All three aspects are governed by the same allostasis model and the amount of training that one can tolerate is highly individual. Some athletes need more focus in one area of the buffer zone than others and collectively, if we can raise each aspect as high as it possibly can be for the individual, we have a chance of developing someone that is highly resilient and able to tolerate a great amount of stress without breaking down. Essentially, their biological set points are higher and their body is able to anticipate stressors that may be applied to it – for example the psychological stress of game day, the physiological stress of the game, the stress of going into preseason where coaches usually run them into the ground, or the stress of travel from one competition to the next – and mount the appropriate stress response without becoming overactive and leading to potential allostatic overload and breakdown.
The Allostatic Model and Pain
As I read through the book I couldn’t help but think about the topic of pain when referencing this allostatic model. Pain is an output from the brain, a perception, based on all of the information coming in from the environment. When an individual suffers from chronic pain sometimes signals can get crossed and the person gets stuck in this state of protection where the brain is extremely hypervigilant and protective of the painful region. Thus, this individual finds themself first in an allostatic state where the system is hyperactive and set points – in this case perceptions of pain – are altered in order to initially protect the area from further potential damage. If this continues for a lengthy period of time the individual may then find themself in a state of allostatic overload where there is chronic overactivation of bodily systems that lead to a pathological state of chronic pain characterized by changes in the nervous system (central sensitization), changes in movement and motor programs, psychological changes (depression), and changes in behavior (fear avoidance).
The Allostatic Model and Hands on Therapies
Another place where it is interesting to consider this model is in various hands on or touch therapies (IE, massage and manual therapy). Touch may be one potential way in which we can help to influence the allostatic state and sort of “pull the person back” in an effort to preventing them from reaching a state of allostatic overload. Massage, when used appropriately, may help some cope with stress-related symptoms by decreasing anxiety and enhancing psychological well-being. Additionally, during periods of intense training or frequent competition (IE, the in season period) massage may be help to increase an athlete’s stress resistance and ability to cope with stressors when used at the right time during the week. This approach is essential during a long season to help maintain the health of the athlete and prevent them from breaking down and not being able to perform at their best during game time.
The allostasis model underpins everything that we do as strength coaches. Understanding this model can help us see the bigger picture when it comes to the training programs that we write and how different individuals may adapt to those programs. By understanding the unique ability of each athlete to adapt to the stress we place upon them we can begin to increase the athlete’s physiological buffer zone by increasing their biological set points and enhancing their bodies ability to be predictive and anticipate potential stressors.
February 25, 2013 No Comments
The role of the Fitness Coach (or Strength & Conditioning Coach, or Coach of Physical Preparation, or whatever you want to call it) is to raise the athletes’ level of fitness to its highest potential in preparation for sports competition. With a variety of movement based rehabilitation courses available these days, many fitness coaches have gravitated towards them as a way to “branch out” and extend their services. However, I feel that, in the process of doing so, we (as a profession) have gotten away from developing fundamental fitness qualities in our athletes, as we have gotten so bogged down with focusing on only one aspect of their development – movement.
I certainly will never (ever) discourage a coach from taking more courses and advancing their learning and I do believe that it is important for coaches to educate themselves on various rehabilitation methods to allow themselves to effectively communicate with the medical staff and be a part of the solution when an athlete is injured or returning from injury. Just as I would encourage medical professionals to learn about basic conditioning methods so they too can discuss with the fitness coach and not hold athletes back, which can sometimes happen, because they don’t understand the possibilities of training when injured or preparing the body for sport when returning from injury. Additionally, I do feel that there is something that strength coaches may be able to gain from a number of these courses in terms of how they see things within an athletes movement, which may lead them to select a certain exercise over another.
However, many Fitness Coaches have gotten so far away from developing the fundamentals of fitness and focusing on movement that they actually have athletes who may move decently but lack basic fitness competency. What ends up happening is that as fatigue sets in during the competition the athletes “good movement” begins to break down and the athlete ends up in this vicious cycle of injury, rehab, competition, injury, rehab, competition, etc…This was part of the reason Charlie Weingroff, Joel Jamieson, and myself got together to record our Strength in Motion DVD – to show coaches how to combine a movement based approach with concepts that are essential to being a great strength coach and developing well-rounded athletes.
Requisite competencies are the aspects of training that I feel are essential to develop in all athletes. These are the fundamentals. The basics. If you focus on only one area or aspect of these requisite competencies then you end up with a deficient athlete who lacks a well-rounded fitness base. The three requisite competencies, as I see it, are:
- Movement Competency
- Work Capacity Competency
- Locomotion Competency
Many fitness coaches live here and do a good job with this (as I stated earlier). In this area the key goal is progress the athlete to a level where they can move efficiently and fluidly in all three planes of motion, they have appropriate joint ranges of motion to satisfy the needs and demands of their sport, and they have basic competency of fundamental exercises – push, pull, squat, hinge, and lunge.
Work Capacity Competency
Work capacity is essential to general preparation for sport. This competency should be focused on developing a very robust level of fitness that can tolerate high amounts of work and allow the individual to be resilient when it comes to recovering from hard training or competition. Having a well developed aerobic system is a good starting point and how you develop this will depend on the methods you choose and, to a certain extent, the sport the athlete is training for – sports specific work capacity being the ultimate goal.
Movement competency deals with how an individual performs movement statically while locomotion competency deals with how well the person propels them-self through space (how they loco-mote). One can loco-mote in a variety of ways and they should all be developed – crawling, walking, skipping, running, and jumping (plyometrics, hopping, leaping, bounding, etc). The goal of locomotion competency is to develop athletes so that they have a very large catalog of locomotion options that they can call upon when participating in sport.
These are the fundamentals. They are not sexy by any means but they are an essential starting point when planning training. The role of the Fitness Coach should be to enhance all of these qualities and set the athlete up for success in their given sport. Focusing on only one component of the above requisite competencies ends up leaving athlete deficient and preventing them from attaining their highest potential. I know most coaches will read this and think, “I already know all that. We already do this stuff!”. But I would encourage you to really look at your program and think long and hard about whether or not you are doing the basics well. I think many believe that they do these things (when in fact they may only do one or two of them well) but they may be leaving some things on the table when it comes to developing requisite competencies.
November 26, 2012 10 Comments