How to Build an Online Service, Training Obese Clients, and Building Relationships

The difference between in-person and online consultations

Erik Kreuger: Zac. Talk to me about your overall philosophy.

How does it differ between working with someone in person to working with somebody online. You can start with the rehab side and then go to the training and performance side or wherever you would like to start.

Zac Cupples: The Philosophy is really the same, but the methods are different.

I’m trying to intervene in as many ways possible that are non-invasive. If you look at my interventional model–social support, movement, nutrition, distress management, and sleep–all being ways we can intervene still rings true whether I’m seeing someone in person or or online. And it’s about manipulating all those variables to help meet that client’s goal.

Now the big difference between online and in person is I can’t touch people online. So as I tell my attendees in Human Matrix: “whatchu gon’ do ’bout it?”

What I have to do is find surrogate testing that gives me just as much information as my in-person exam. If you know what you’re trying to achieve and manipulate within the body, then it’s not that different from an in person assessment.

If we’re talking about restoring variability, the difference is in how I can coach.

I have to be a verbal coaching machine online, and it’s been a really good challenge and it’s helped me grow a lot because I’ve had to find the best cues to elicit the adaptations I’m trying to get. But the test-retest is still there, still driving similar adaptations. It’s just the methods are slightly different.

For training, I still do the same things. We still do an assessment, but the only difference is I’m taking whatever we decide that person needs and then I’m just trying to reproduce those same things in many different contexts as possible.

For example, if I have someone who can’t extend the hips on either side, I am going to reinforce it with some type of reset. I’m going to reinforce it with a squat variation that I choose. I’m going to reinforce it with upper body variations by choosing half kneeling or tall kneeling to drive that extension. I’m going to reinforce the conditioning, such as sled pushes for repeats to drive hip extension.

It’s how many ways can you expose that person to the thing that they can’t do. And my hope is that it elicits the changes that were were trying to get them.

EK: With those the changes that you’re looking at getting, what were the surrogates tests you used online?

ZC: It’s been a lot of trial and error.

Michelle Boland: I think that was my biggest thing is I wanted to go see him like biomechanical testing. Do you have people walk? Do you look at their gait?I’m sure you look at their infrasternal angle (ISA). Do you do a toe touch or a straight leg raise?

ZC: Well we have to look at the big decision making tools we have.  I can’t make many decisions off of gait necessarily because there is too many moving parts going on, so I don’t know why a person is going to be doing something.

Now if someone’s hurting and have a specific movement that hurts, I’ll most certainly look at that. I’m using that more though as a can comparer after intervening than I am to base decisions off of. But Coach Bo, what are the big things that we need from a movement standpoint when we’re working with people? What are your are your four or five big things that you’re trying to change right from the get go?

MB: If I’m assessing someone I’m definitely going to have a conversation. Subjective information is important. What they think their limitations are. What they think their strengths are so you can maximize their strengths.

But I’m going to go with ISA and hip extension first.

ZC: Those are my big two as well. I also would look at a shoulder external and internal rotation, and then I look at shoulder flexion.

I have squat and toe touch, but I have been looking at them way less. My big things that I look at are these seated tests: trunk rotation and shoulder horizontal adduction, which tell me what can the scapulae do on this rib cage. With horizontal abduction, can the scapula abduct and internally rotate? With trunk rotation, can one scapula adduct and internally rotate while the other abducts and externally rotates.

For hip rotation, I don’t base many decisions off of that. It’s more of a comparitor at this point.

I always look at ISA, but I often don’t retest it because it’s kind of challenging to get an appreciation for changes online unless it’s dramatic. You’re having clients self-measure, and more often than not they don’t get it perfect, so you have to guesstimate it.

The Shoulders are a work in progress. I used to test shoulder flexion in hooklying, but I found that it’s easy to cheat because you can only see one view at a time.

What I do instead as I go with a standing shoulder flexion and I can look at if the scapula is upwardly rotating?  Are they hitting you like 170-180, and are they doing any compensatory activity downstairs to make that happen?

MB: Do you have them possibly take their shirt off to see that better?

ZC: Yes. Or sports bra for a female.

Shoulder external rotation is pretty easy, which I test in hooklying. Shoulder internal rotation is the bugger. Some people can have full passive IR, but then they don’t get that far actively or they’re doing some funky things with their elbow. I just haven’t found the best surrogate test for that yet. The Apley’s scratch has too many movements going on there. I’m not super pleased with it, but I do see changes.

EK: I’m using similar to what you’re using right now. I’ve struggled with pretty much the same ones you have. Shoulder IR is really big, especially if you have them in hooklying. It’s really hard to see where scapula is moving.

Regarding ISA, if a person tests as a wide or narrowly ISA, are you just making your coaching decisions off of that first test knowing that online you may not see the changes that you might see in person. Are you keeping that as the continuum or is there a time period then when you’ll reach back in and be like I’m going to check in and see the ISA?

ZC: Really, the ISA just tells me which breathing strategy I need to utilize and where I should start arm positioning to capture lower rib cage position.

My real big test-retests will be half kneeling to get hip extension and then I really like the standing propulsion test made by Bill Hartman. It’s like the wall acceleration drill, but you’re looking at how well one person can flex the hip while maintaining hip extension on the contralateral side.

If you’re uncertain if they are getting hip extension, I’ll look at a split squat, single leg stance, basically anything where one hip has to extend while the other maximally flexes. These are the best online gauges for if the pelvis is dynamics or not.

MB: You just have someone get in front of you with a camera and tell them to get to a kneeling position and then you look out from a side angle?

ZC: Yes, and I’ll have them change multiple angles often.

EK: I know for a while you’ve been using an active midstance test. Have you still been finding that useful or have you been kind of straying away from that?

ZC: Donezo. Rest in piece AMT, yeah you know me.

I have to give credit to Bill, but I question the utility of looking at single plane specific things because I don’t think we ever operate on a single plane.

Bill and I did a cadaver dissection in August, and you look at the muscle fibers, and there is no such thing as a fusiform muscle. They are all curved, and we likely move in curves, morph, and adapt That has dramatically influenced my treatment in the sense that I’m trying to combine as many directions as possible at once to elicit a particular adaptation.

It’s never just hip extension. It’s hip extension with adduction or with a little bit of abduction. Or I’m doing hip extension with hip flexion. Did you have a similar experience, Michelle?

MB: Yes. The Intensive and Human Matrix combined. I had them pretty much back-to-back. What does your subjective questionnaires look like? Do you include subjective information in terms of retesting and building that into your program?

ZC: So subjective. If it’s a movement consultation I ask three questions because I would rather have a conversation with someone as opposed to just filling out these specific questions. My three questions are: 1) what am I seeing you for? What makes it better or worse? 2) Have you had any treatments for this in the past? That way I know not to do the same thing or just kind of see where they’re coming from. It might dictate my education. If I see that they’ve been seen by certain practitioners, I may have to debunk or dethreaten some of the things that they’ve said. I see a lot of people who seem many practitoners. 3) What is their medical history?

Performance or training goes a little bit more in-depth. I’m encapsulating the model of social support, sleep, etc.

MB: And having a good referral system.

ZC: Yeah. I ask what are their goals? With the goals that they’ve mentioned, what does success in those areas look like? That’s probably how you bridge the gap from what you need to do to where they want to go, and that will also give you some KPIs to give someone. If someone is seeing me for fat loss, they’re going to say “success is: I look good naked and I have X amount of body fat.” OK, then we need to start measuring things along those lines.

Most of the people who I see post rehab and want to feel better when they move. The KPIs for them are how they feel with their day-to-day stuff? Is this workout going OK?

Then I ask what type of training facility we’re working at so I know what constraints we have? I ask what’s your diet? How your sleep is, including hours and quality? Medical history? and anything else they want me to know. I wan to see how many habits we need to build to support the client’s goals.

MB: In relation to fitness goals, how are you building testing into your program? Say someone wants to get stronger or improve aerobic fitness. Are you doing open sets? Are you going for distance on a bike?

ZC: That’s typically not my population. Most everyone is post rehab, or I had seen them for a movement consultation, or they have been training with other people and that hurt. So, I want to see if we can build a movement foundation. Most of my clients just aren’t there yet.

I have one man who I’m training right now. He’s really into playing a lot of different sports, so I always ask him feedback on how he plays. That said, performance testing overall is an area I could probably do better in, but it also doesn’t seem to be relevant for the current population that I have.

EK: Is there any big testing that you’ve been looking at, Michelle?

MB: Yes. I deal with a little different population than Zac, so I try to build testing into programming. I’ll put the open sets in, which is keeping the same weight and see how many reps you can change from week one to week four, For aerobic fitness, go 3 minutes on a machine and see how far you can go. We may not be max repping, but we’re still working towards a goal or outcome that we periodically reassess.

ZC: Are you using open sets to gauge endurance in a specific movement? It’s a great idea.

MB: Yeah. You can also like argue that it’s a psychological factor too, just like building fitness.

If you wanted someone whose goal was specifically Max effort strength, of course you could 1-RM test.

ZC: It’s just a little bit dangerous, especially if you don’t have someone to spot you. Most of the people I train train alone.

MB: Most of the people I train, max effort testing isn’t a necessity.

EK: Most of mine are relative strength anyways at that point. It’s rarely going to be max effort unless it’s a powerlifter. I use open sets and distance. We’ve also been programming a push, poll, and lower body circuit, while seeing how many reps you can accumulate in a set period of time.  Not ideal, but if measures what they can do from a full body perspective.

MB: You can also do that in terms of when you create circuits for high volume or conditioning days. You create a circuit and then see how much time it takes that person to do it. It then becomes an indicator of some sort of progression.

ZC: I can dig it.

Successful behavior change methods

EK: Switching it back to you, Zac. Regarding behavior change, have you found anything in particular that has been working well with patients or clients that you may only check in with once or twice a week versus someone you may see more often in a more typical type setting.

ZC: Online is actually easier than it is in the insurance-based clinic I work at.  I think the reason why is because when people are paying you cash, they have a much greater incentive to execute what they need to execute. That’s a big incentive to create behavior change.

I will say this though I think with a lot of the people who have worked with establishing just a consistent exercise program that to me is probably the number one habit forming thing that I’ve probably been able to accomplish with some of the people who have worked with online.

MB: Yes I think that was probably my biggest mistake early on. Doing too much too soon, such as giving them three days a week when realistically they probably only needed Itwo days a week.

EK: I found that too. Your expectations are different than what the client is perceiving as both hard work and the amount of time they’re willing to invest into the program. And I think the biggest change for me is how can you hit them with what they want in two days a week instead of three? Maybe just because you have someone in a post rehabilitation setting that may not have enough time to do all that we want to do.

A big shift for me in the last year is setting the expectations for getting that patient what they truly want and really how much time that actually takes is up to them. I mean they can commit to three to four days a week you can sell that as you know that may in turn over the long term get them out even say faster results, but ideally we’d say more optimal results, but I don’t even know that anymore after looking at some of the research that 2 days may be just enough for someone like that.

ZC: One thing that I think is also helpful if you’re trying to establish good habits would be the order at which you try to elicit behavior change on someone. So I think the exercise program is an easy sell because that’s what we do. And you’re ingraining a habit like you’re doing with two times a week.

But if you’re trying to go beyond movement in terms of what would impact decision making and impact how well someone can maintain habits,  what do you think would be the next big thing to go after? When can’t you think as clearly if you don’t have this?

EK: I’m going to say sleep.

ZC: Yeah. 100%. Think about it. You aren’t going to do much of anything if you’re sleep deprived. How well do you think your nutrition program that you want to give someone is going to go if they sleep in five hours a night? Well they’re probably not going to get as good of changes as they could get from that program and they’re probably not going be as consistent with executing it.

EK: So I guess leading off of that side with yeah. So do you attack sleep first? Have you almost jumped over the consistency of the exercise program?

ZC: I think just because of my job the exercise program is the first one to go because that’s what they’re coming to me for. But once we have that established and they’re pretty consistent, I might start jabbing them a little and say “hey hey hey listen, are you blocking light at night? Are you getting sunlight in the morning?” And it may just be one habit at the time because most of the people who you work with if you ask them how they sleep they will say atrocious.

If you give them something very simple that profoundly impacts their sleep, it’s a domino effect.

I had a woman and she hadn’t slept through the night in years. And I made just one suggestion: turn the house temperature down to 67. She called me two days later and said she slept through the night.

These habits are are very simple to execute. But if you can get someone sleeping on a regular basis, they’re going to better follow through on other behaviors.

MB: Or if they are going through a very stressful period of life you may have to dial down the amount of exercise they’re doing in their program.

Creating systems to maximize efficiency

EK: What systems do you use to be efficient online??

ZC: This is a complex one because there’s a lot of moving parts to this. So when I first got back into being online after my time in the league, I had a little bit of downtime to try to set up some systems. I read “The Four Hour Work Week,” which made me think a lot about how can I streamline all these processes to minimize any time leaks that I might be undergoing.

I’m not perfect by any means, but that book was essential for me. So what I’ve created to make things go quickly was I have my form that I have people fill out that automatically goes to my e-mail. Now initially I was taking those e-mails that I would get from the people and I would send a replying based email saying that some of the questions that I mentioned for all of those and for many of my e-mails I have canned responses set up in Google so I don’t have to type the same e-mail over and over and over.

Now I’ve gotten to the point because my e-mails are too much. I’ve actually hired someone to go through my e-mails for me. So that’s another way that I’ve streamlined the process so I don’t have to spend time doing that.

In terms of scheduling, you want to do all in your power to minimize the back and forth because you’re going to miss a lot of clients that way and it’s going to waste your time and the other person’s time. So I’ve played with a couple of things, but the best scheduler by far has been Calendly. You input when you’re available in your schedule you can do some really cool things with it. I have mine set up so where I see a person for an hour and then I have a 30 minute block before someone can book me again. And I really like that because then it gives me a little bit of time to send any debrief emails, reflect a little bit on how things went. That’s been essential in terms of the scheduling.

If there’s any paperwork I’m working on using Docusign for waivers and things like that is just to minimize the number of steps that the clients have to take. If I send a waiver and have them print it out, sign, and and then scan and put it back and that’s going to take too much time for them. I don’t want to waste any of their time doing some of the needless things. Docusign is going to I think be way better because then I’ll just have all the forms. One you fill out this out. Sign your name and you’ll be in bidness.

MB: What about the payment system that you use?

ZC: I use Venmo or PayPal. I prefer Venmo because there’s not a fee with Venmo.

MB: Yeah I use Stripe and there’s a 3 percent fee. You can add that 3 percent fee to whatever you’re sending them with the invoice you’re sending them home.

ZC: Paypal is about 3 percent as well. If you work with international people it’s a little bit more since something with the conversions. But Venmo for me is preferred because it’s cheap and there’s no there’s no fees. I mean I can’t even fathom how much I paid PayPal which stinks.

EK: Have you found a way to keep track of budgeting? Is there anything ever lost in the shuffle?

ZC: No. Because I’m very anal with my money. I have two excel docs that I run. I have a revenue coc and I have a expenses doc because I try to expense as many things as I possibly can so I don’t have to pay a bunch of taxes. When someone pays me I’ll get an alert my email and I’ll have my virtual assistant write off the totals that I’ve made for the day. And then I just look at that one number and put it in my revenue and that’s it.

I don’t want to automate that because I want to get an idea in terms of how I’m doing that month. I’m by nature a spendthrift. I just spend money on stupid things. I mean I couldn’t tell you how much business related stuff I spent money on. So if I am just making myself aware of what’s going in and out more frequently, I’m less likely to do that. So I will make that sacrifice in efficiency. Make sure I’m not spending a bunch of money on things I don’t need, except books. I’ll always be able to spend money on books.

MB: Do you expense those?

ZC: Absolutely! Anything that I could fathom as work related, I will expense it.

I’m working with Ben House. He’s trying to help me not bloat every time I look at food, and it’s going really well. I’m going to blog on my experience with him and make sure he gets a lot of people sent as way, which he’s probably going to hate because Ben is Ben,  But I’m going to expense the bloodwork in that case because that to me is content material that I’m going to write for I could potentially make money off. Anything that is health and fitness related that would help me perform a job expense.

If you are running an online business I believe you can expense your rent. You have to have a office right? One of my buddies told me about that that he was expensing his rent. I mean anything you could think of that is essential for you to get your online business or Internet service. Your phone. Yeah expense as much as you can. If it’s helping you with your business.

Handoff Between Practitioners

EK: So let’s say you have someone that’s coming to you. They had seen someone previously. They may just kind of want to tune up or something where I’m hurting, but I want to go back to just my own thing or possibly somebody else in their area that doesn’t do what we’re looking to do or wanting them to accomplish. How are you framing that for them that you’re working with them for two to three months and then they’re going to go back and experience something completely different which may or may not be what we’re looking for that on our heads.

ZC: The only time I’ve ever had experiences with this was when I was in the league and for those people I don’t think–I mean yes ideally we’d love to have control of everything that they do–but you don’t want to ruin a relationship that someone has with someone.

One of my pillars is social support. So if you eliminate that person from their social support are you really doing them a service by doing some of the movement things that maybe you and I espouse? If we can give them concepts to to carry over into whatever it is they’re going to be doing and that’s all that we get out of it. Maybe it’s as simple as hey you want to make sure you exhale and you do some back pocket tucks when you’re deadlifting, then  I think that’s a win. But I think most people are not going to harm whoever they’re working with unless they’re just completely egregious.

MB: We don’t do things the same way but we might be able to get the same results doing something differently. You can’t just take away someone’s belief system and then send them off to that person, or say that you do things better when they’re working or someone else. They’ve got to believe that what they’re doing is working for them. That’s all that matters.

ZC: I think what you have to ask yourself here it is: “Is this person’s situation that he or she is going back into is that going to be more beneficial to them or is it going to be completely maladaptive?”

If you have a therapist who has a relationship with someone where as soon as they feel any type of pain, they have to go to that therapist and get put back into put back together. I will gladly try to do all I can to squash that because that’s not cool for that person.

But if someone’s going back to get straight Barre gains, that’s probably not doing anything but at least are moving and this probably will not stop maladaptive.

Training and Rehabbing Obese Clients

MB: Any thoughts on working with overweight cleints?

ZC: How overweight are we talking here?

EK: 300-350 pounds.

ZC: Tree fitty? Like Loch Ness Monster big boy. Here it happens quite a bit.

I have two extremes. I have one woman who I was seeing who had an ankle surgery and she was fairly large; 300-350. Really, nothing changed in the approach. She was pretty active in her job. Worked at a hotel as a maid, and she had to do a lot different things: get up and down, change beds, etc.

So for that type of person there wasn’t much different except I had to choose a lot of positions that didn’t necessarily reinforce her being in ab egregious amount of extension. She had a rather large derriere, and good luck getting those back pockets tucked. If we did something where she couldn’t even get some semblance of a tuck, she would be getting back pain and tension.

So I had to do a lot more things for her where she is a little bit more in a forward bend position and create a little bit of a hinge action during split squats or during some type of my throws or whatever we were doing. And that seemed to work for her.

I have a woman right now who’s whose weighs probably more than that. And this woman as uses a walker to get around had back pain is very sedentary and bathes once a week because she can’t get in and out of the tub.

For them, you’re still going after the same things, it’s just everything is throttled down. I didn’t really perform much of an assessment on her. Besides looking at the hip rotation, and I worked out some measures in sitting. We just picked positions that were comfortable for her that she could drive the adaptations that we thought she needed, and she was doing really well. She was seeing me for back pain, and is now pretty much pain-free.

She’s just decondtioned so we’re working that. Her program started with a lot of seated activities where we were doing a lot of just reaching or kicking, going after hamstrings. Then eventually I went to a supported in her walker squat. Now I have her doing deadlifts, alternating pressing and pulling to work upper body.

You find what movements a person can or can’t do and you do them. And I think for the obese client it’s no different than someone like me who has limited shoulder flexion. I can’t do overhead pressing because it looks terrible, turrible even. So you have to find other ways for me to get the adaptations. Apply that exact same principle to someone who is obese.

MB: What about friendships with clients how do you feel about that?

ZC: I’m not a very friendly person.

In the clinic and when you’re working with someone from a rehab standpoint, I try to avoid being friends. Partly that’s because of HIPAA.

Michelle, say I worked with you in the clinic–heaven forbid you live in Susanville–but then I saw you at Safeway. You would have to acknowledge me first, not vice versa. I’m supposed to act like I don’t know you because of the relationship we would have.So I think in clinic it’s an easier sell of keeping that professional distance.

My in-person training was mostly in the league.  I wouldn’t go partying with the fellows because that’s just not my scene anyways, but going to grab lunch with someone? I don’t think there’s any harm in that, and if anything it’s going to enhance the relationship and buy-in even further.

I never saw any harm in doing that in terms of they weren’t going to listen to me, because if anything it showed that I cared about them more because I was going to give them an hour of my time to just chill.

Even the same with with my mentees. If you work with me in the mentorship program, I consider your friend, and a lot of times I’ll just talk with my mentees informally. And in that sense I think it’s OK. I think that’s ultimately what it morphs into. Start with a formal relationship, end as friends.

MB: In the athletic world I think people take this word boundaries like too far it’s like sometimes I feel like really dehumanize athletes to an extent like yeah of course you’re not going to go out like drinking and partying with family. If you’re a professional, but you can go grab a coffee and go to lunch, and things like that, and get to know them as a person. I just I see a lot of coaches and staff, they’ll never have a personal conversation beyond small talk or what they’re doing on the field, or just never ask where they’re from, or how’s your family. They’re so afraid of crossing these boundaries, but you’re not treating people like humans.

EK: Have you found how you’re different and integration in a setting that’s helped you with principles you wanted to buy into the weight room and performance and health?

MB: Yeah I think the biggest thing for me this past year in person. I’ll go grab a coffee with a player before a game when we are walking to the rink and I’ll ask them how like construction on their family houses going and things like that.

I just find that I get to know players a lot better than their coaches ever try to, and I think it makes a huge difference in terms of play on a field which, is the most important thing, because now they have someone to trust, and they have a sense of community. It builds team dynamics. I’ll try to encourage people to get to know each other on a team. Things like that. So it seemed like a big difference for including that stuff and prioritizing that.

I’m working on something with one of my friends, Mike, of actually programming that throughout the year. How are you including that within  your coaching and actually designing some sort of model and actual progressive program that includes stuff that focuses on team dynamics?

Zac talks about this all time: task, organism, environment. A lot of the things that we do are very task-oriented, and only including things that we know which involve the weight room which we overemphasize. Fostering the environment they are in is probably the most beneficial thing you can do. How much can you control it?

I see coaches complain all the time about what people are eating. Well, are you you fostering an environment where you’re supplying them with the right things? You’re complaining about them being stressed out and fatigued, but are you fostering environment we’re they’re able to talk to someone, or including academic and personal stress into their physical preparation? I think that’s something that we neglect. And I think that’s completely looping back to friendships with athletes. I don’t think there’s anything wrong with that at all. I mean, you’re not going to find me on a Saturday night with them, but I’ll definitely go grab a coffee and ask about their families.

ZC: Being a good person will get your way far.

I think that’s great, People are going to buy into people they trust. And if you just keep things superficial, it becomes much harder to build that trust.

MB: I’ve seen where people try to keep a distance, and it turns into a fear or threat culture because they don’t feel like they can talk to anyone they’re scared to. see that a lot.

ZC: I like that your periodizing it almost in a way. They make apps for that.

MB: I used to do that in a summer I used to mark off in my calendar text message certain people on certain days so I make throughout the summer I’m calling every athlete on the hockey team and text messaging them. Yes. I mean apps tell me to do that would be nice.

ZC: Well if I get a random text from you Michelle…Michelle must be on the Z’s.