Empowering Flexibility with Dr. Jen Crane, DPT

[00:11] Dr. Linda Bluestein: Welcome to Bendy Bodies with the Hypermobility MD, your podcast to learn all about the benefits and complications of being bendy. This is Dr. Linda Bluestein, joined today by my co-host Jennifer Milner. Before we introduce our very special guest today, a couple of quick reminders. Please subscribe and leave a review. This really helps to grow our audience. Please also email your questions and feedback. This podcast is for you.
[00:36] Today, we are incredibly fortunate to be speaking with Dr. Jen Crane. Dr. Crane is known for her innovative approach to injury prevention and performance optimization in circus arts. As a dually accredited physiotherapist and athletic trainer, she spent her career working with athletes and artists of all levels, from recreational acrobats to Cirque du Soleil artists and Olympic gymnasts. Jen loves leveraging her knowledge on the human body to exceed her clients' circus goals, from contortion headsets to dynamic aerial work. Jen specializes in troubleshooting barriers to goals that you'll never find in textbooks.
[01:09] In addition to her physio work, Jen is currently training and performing in Montreal with a focus on dance trapeze, aerial straps, and hand balancing. Dr. Jen Crane, hello and welcome to Bendy Bodies.

[01:38] Dr. Jen Crane, DPT: Hi, I'm so happy to be here. Thanks for having me.

[01:41] Dr. Linda Bluestein: Absolutely, and it's great to talk with you again today. Jen Milner.

[01:46] Jennifer Milner: Of course, as always.

[01:47] Dr. Linda Bluestein: Fabulous.

[01:49] Dr. Jen Crane, DPT: Yeah, you have to specify which Jen today.

[01:51] Dr. Linda Bluestein: I know, I know. It's so exciting. So, Dr. Jen Crane, we are so excited to speak with you. You're doing such amazing work in the space of safely training hypermobile athletes and artists. Can you start out by telling us how you got into working with such a specific population as circus arts?

[02:11] Dr. Jen Crane, DPT: Yeah, absolutely. So the only reason that I'm doing this at all today is because I stumbled upon a rock climbing gym about 7 years ago that had aerial silks classes. I walked in planning to rock climb, and then I looked up and I was like, oh wow, that looks really cool. I think I'd rather be doing that. So I started taking aerial silks classes and really just dove into all of circus.
[02:33] I was at a really interesting point in my career where I had just finished my residency and had one of my first kind of normal jobs that didn't include working 80 hours a week at a university. So I had some extra time on my hands to really get into a new hobby, and I just totally fell in love with it. I grew up doing dance and ballet, so my background is in performing arts, and it really was just a very natural fit for me to transition into all the circus arts.
[03:12] Once I'd been there for a while and had traveled around a bit and taken classes with different coaches and worked with different students, I really saw how much of a need there was for a physical therapist or any sort of healthcare provider who really understood the demands of circus. Because even though it's similar to dance aesthetically and there's a lot of crossover, the physical demands are just so different. I kept seeing all of my circus classmates getting injured or having that nagging shoulder issue or back issue, and I would always say, why don't you go see a physical therapist? That's what we do — help people like you fix their bodies so that you can perform or train or do whatever you want to do.
[03:58] And the story was always the same: well, I went to see a physio or I went to see a doctor and they looked at me and they tested me and they told me that I was strong enough and flexible enough, and they either didn't know what to do with me or they just told me to rest and gave very blanket advice. And I was like, that's a pretty big gap in healthcare. I was uniquely positioned to fill that gap with my background. As a physio and as an ATC, I've worked with a lot of mainstream sports athletes, and I had my dance background and had been doing circus for a while. So I was like, well, I can think outside of the box, I'm pretty good at that, and I might as well give it a try because no one else is. And it turns out I absolutely love it. There was a need, and it's been the greatest career shift I've ever made.

[05:03] Dr. Linda Bluestein: That's fantastic. I love that story. And the field of circus arts is expanding so quickly. As it becomes more mainstream for people to try things recreationally, and as circus arts begin blurring boundaries with things like Broadway and Las Vegas, how do you see circus training changing? Is it becoming more codified, or should it? Do you see cross-training becoming more mainstream to help athletes who have worked in such specific ranges of motion?

[05:35] Dr. Jen Crane, DPT: Yeah, that's such a good question and there are a lot of different components involved. It's definitely becoming a lot more mainstream and people are really starting to have my kind of story — I saw aerial silks at this place or at this pole studio. So it's definitely getting a lot more media coverage, but there's also still a huge lack of healthcare providers who can help us and at least understand what we need to be able to do.
[06:09] From a sports medicine perspective, it's interesting because from what I've seen, circus arts seems to be about 5 to 10 years behind dance and gymnastics. We have a lot of the same kind of history of the art form where it's based in a more traditional lineage of, you know, my coach learned from this coach who learned from his coach, and we've always done it this way, and this is how it will always be done because of history. I know that's the same story in dance and gymnastics, and we're just still going by that line a lot. I think it's only fairly recently — in the past couple of years — that there has even been acknowledgement that this is maybe not the best approach to training and working with circus artists in a coaching or healthcare setting.
We do seem to be slowly moving in the direction of normalizing cross-training and talking about recovery and treating circus like a sport. I think it's similar to dance in that a lot of circus artists see themselves as artists and don't see themselves as athletes, even though the demands they put on their body are exactly the same as a high-level athlete. So I've started to see this shift in mentality where circus artists — even recreational ones who aren't trying to perform or make this their main career — are starting to think of themselves as athletes, and then they treat their bodies differently. That's really cool to see. But we're slowly starting to get on board with cross-training and the things that are just standard practice in mainstream sports that haven't quite made it all the way to performing arts and circus arts.

[08:03] Jennifer Milner: Well, and do you see — and Linda and I have talked about this before — as you mentioned it's always "this is the way we've always done it," a resistance from coaches in the form of, well, I had to go through it, so you should have to go through it too? And maybe there are we are asking circus artists to do such crazy things, but there have to be healthier ways to get to those crazy things. Maybe there's a reluctance to seek those paths just because, well, we went through this, so it's your turn. Do you see that, or is that just dance?

[08:40] Dr. Jen Crane, DPT: Yeah, I see some different variations of that. There's absolutely kind of this unspoken mentality of, yeah, circus hurts, we just got to push through it. Especially depending on what skill you're working on — there are some skills that are just known to be very painful because you're hanging from your foot skin and that's not going to ever feel good, but your nerves do acclimate to that. So there's definitely the unspoken "I did it, and if you want to be better, you have to do this too." But I don't see that vocalized a whole lot, which is great — that's a step in the right direction.
[09:22] Beyond that, there's also — and this is one of the things I advocate for so much — there's definitely been more of a push to stop and think: is that actually necessary? Okay, circus hurts. What kind of hurt? Is it productive discomfort or is it non-productive discomfort? And really starting to at least introduce that verbiage so that we can talk a little more intelligently about what we're feeling and whether that's normal. There are definitely so many amazing coaches out there who are really pushing for that too, so I think as people see that represented, it will continue to become more of the norm.

Jennifer Milner: Nice.

[09:58] Dr. Linda Bluestein: And you just touched on the good hurt versus the bad hurt. I think that's such an important concept for everybody, whether you're not doing any athletics at all or all the way up to — I mean, I think of circus performers as just — what they ask their bodies to do is really crazy. I love, love, love to watch circus performers. It's amazing. They have to be incredibly brave. Do you have any suggestions for determining good versus bad hurt? Do you have tips you give people, because I think we can all use help with that.

[10:43] Dr. Jen Crane, DPT: Yeah, absolutely. This is something I see so often across all performing arts — that mentality is really ingrained. Something that is really helpful, when I'm having an initial evaluation with a patient and I'm asking, "You said your shoulder hurts when you do this — can you tell me more about what that feels like?" I'll usually start with: does it feel like productive discomfort? Like, if you keep doing it, will it make you stronger or better or help you achieve your goals faster? Or does it feel like if you keep doing that thing, it will hinder your progress and is giving you that alarm signal from your body?
[11:23] So I think just distinguishing — is it good hurt, is it productive discomfort or non-productive? And if you keep doing it, will it help you or hurt you? Just really stepping back to those basic foundations, because so many of these artists have been so conditioned to label any negative sensation as "It's fine, push through it, this will make me stronger." It's almost the opposite of what we see in chronic pain patients where everything is a threat — here, nothing is a threat but there is physical tissue damage that needs to be addressed. They're like polar opposites. The first time I recognized that, I was like, oh my gosh, this is fascinating from a nervous system perspective, just from that total systems approach, to see how these artists have literally wired their bodies differently.

[12:15] Dr. Linda Bluestein: Right, and that's a big reason why Jen Milner and I are doing what we're doing — we're trying to catch dancers, circus performers, and others while they are still able to do their sport, their activity, their performing art, and help them be as functional as possible so that they don't end up in chronic pain. Because once that happens, it becomes so much harder to get the nervous system back to a healthy place.
[12:38] So I'm curious — were you always interested in hypermobility, or did that come along as you dug deeper into working with circus artists?

[12:52] Dr. Jen Crane, DPT: I've always been interested in it personally. Early in my career I just didn't work with patients who had that very often, so it was never something I really pursued. It was also something that kind of came and found me. I'm hypermobile — I have hypermobile EDS — and I've been pretty lucky personally with how much it has and has not affected me. But it's really — once you see someone who has EDS or hypermobility, or experience what that's like yourself, you can pick them out a mile away and be like, oh yeah, you probably also have this. Let me talk to you a little more about this. And it helps me look at some different things that I might not if I didn't get that visual cue.
[13:45] I think the most fascinating thing to me is the stigma surrounding it and the type of education that these artists get from most healthcare providers, which I think is so much more detrimental in general than helpful. Because basically when they're diagnosed, most of the stories I hear from my patients and students go something like, "Yeah, well, they diagnosed me with this. They said I was very fragile and if I kept doing what I want to do I will break myself. So they told me to stop training and I don't know what to do." And that's really what grabbed me and pulled me in to think, this is a problem. I need to talk about this and look a little more into all the issues surrounding this population.

[14:35] Jennifer Milner: Right. So basically stop moving and wrap yourself in cotton wool, right? Exactly what they're doing.

[14:40] Dr. Jen Crane, DPT: Yeah, that's literally the worst thing you can do for yourself.

[14:45] Jennifer Milner: Yeah. I have so many dancers who are hypermobile, and when they retire they're like, I'm just going to take a month off and do nothing. And a month later they're like, oh, it hurts so bad. You have to keep moving. You have to stay healthy and keep moving in a healthy way.

[15:02] Dr. Jen Crane, DPT: Yeah, absolutely.

[15:05] Dr. Linda Bluestein: And you did such a fascinating study a couple of years ago, talking about the different impact that visits to healthcare professionals would have on people. I've done similar kinds of studies, though I don't think I got as many really descriptive narratives from people as you did. I was fascinated when you shared that information. Is there anything from that survey that you want to add, while we're talking about experiences people have had and what led you to where you are today?

[15:53] Dr. Jen Crane, DPT: Yeah, and I just want to clarify — using the word "study" is incredibly generous. Thank you. But yes, this was basically a survey I created and put out to all my Instagram followers and my mailing list, asking those who were performing artists and had a diagnosis of EDS. I was really curious what their experience was with healthcare. I got mostly US-based responses, but there were a few from Canada and from Europe as well.
[16:27] I was really interested to know: if people had an EDS diagnosis, did they feel it was something that was helpful for them, that helped guide their treatment — basically, was it something that empowered them, or was it a huge downer, like, "Oh, I have this disease, I'm fragile, my life is over"? I just wanted to know what the implications of seeking care were.
One of the most fascinating things — and this is a question I get all the time, and I'm sure both of you get it too, from people who are hypermobile and think they have EDS but aren't sure it's worth getting tested — is: would getting tested change anything in my quality of life or how I treat this, or do I just strengthen and be smart regardless? That's a great question, especially if we step back and look at the broader picture of US health insurance, where there are a lot of potential implications of seeking a formal diagnosis. I know a lot of people are very hesitant to do that because they're afraid it will give them a stamp of a pre-existing condition and alter what care they get moving forward. Whereas people in Canada actually have the opposite experience — if I get a diagnosis, that gives me access to more care and doesn't negatively impact the health insurance side of things. I was really fascinated by that.
[18:03] But most people felt that the diagnosis alone was incredibly helpful for them, at least in that it gave them a sense of understanding that what they were feeling was valid, that their symptoms have a reason, and that there's a name for what they're feeling and there is a path moving forward. They at least now know what types of questions to ask and what providers to go to. Because when you're experiencing all the symptoms of EDS in isolation, it can be really confusing and incredibly isolating. You feel so helpless if you have all these things and don't know if you're making them up, and maybe your healthcare providers are gaslighting you without meaning to. It's also a really significant mental health issue. So that was one of my most interesting findings from that survey.

[18:58] Dr. Linda Bluestein: That was an awesome survey. And I think that's exactly what happens when other people doubt us — it's very common to doubt ourselves.

[19:02] Dr. Jen Crane, DPT: Yeah.

[19:15] Dr. Linda Bluestein: And all three of us have had dance as a significant part of our lives. You're used to pretending like everything's fine because you have to for the audience, right? So you can pretend, pretend, pretend until you get to a certain point and then you can't pretend anymore because the problems start to get too big.

[19:35] Dr. Jen Crane, DPT: Yeah, absolutely.

[19:35] Dr. Linda Bluestein: So what advice do you give hypermobile athletes looking for a career in circus arts? Do you see hypermobility in a performer and worry about their long-term ability to stay injury-free?

[19:50] Dr. Jen Crane, DPT: I don't worry about that directly, but if I can catch them early enough in their career I'm like, ooh, I need to tell you a few things before you get out into the rest of the world of healthcare providers who may be more of the fragility narrative type.
[20:10] One of the things that's been really interesting for me to see is that so many — it's exactly like you were saying earlier — starting circus and starting any activity that has a high strength-building component is so good for all of the symptoms involved in hypermobility and EDS. So the narrative I try to tell my patients is a lot more along the lines of: okay, we know you're hypermobile, we know — whatever diagnosis they have or don't have — that this is something you deal with. There are a lot of different things you can do to help manage any symptoms you have, and it's super important that we work on specific strengthening for circus because you have to work at your end range. If your body doesn't know how to protect you in that position, if all your stabilizers don't know how to stay strong there, then you — like others — are at a higher risk of injury. People who are hypermobile do have a slightly higher risk of that. But really, that's a risk factor I see across all of my circus patients: if you aren't strong at your end range, you're more likely to get hurt.
[21:33] And then I also try to spin it toward the good news: the exercises and strengthening drills we're going to do to get you strong at end range will also help your active flexibility. So all of your tricks will look better too.

[21:47] Jennifer Milner: So it's —

[21:48] Dr. Jen Crane, DPT: That's the easiest thing to get buy-in on. Oh, you want better inverted splits on your apparatus? Great, let's do these drills. It'll also help your hypermobility.

[21:59] Dr. Linda Bluestein: That's fantastic — rather than them feeling like they have to choose. And what about your approach to patients depending on age and whether or not they've already developed some more persistent pain problem? How does that change your approach to working with them?

[22:20] Dr. Jen Crane, DPT: Yeah, it depends on a lot of different factors, but anytime there's the presence of pain, I always want to take a moment to talk about — anytime your body feels that pain signal, whatever drills you're doing aren't going to be as productive. So it's not going to be the most efficient way for you to further your training right now, even though you're injured. Even if you're not training, there are still so many things you can do to get stronger and help rehab the issue. But I really try to keep hammering on that pain narrative: more pain is not always better. It's not no pain, no gain.
[23:02] Depending on how old they are or how long they've been in circus, that will sometimes also change the type of education I give — especially around recovery. As we age, we need more time between training sessions. We need to give our bodies more time to recover. I think there are a lot of really helpful metrics that are very readily available in this world of technology to help understand recovery a little better. So I usually talk about that: everyone's different, this is how you can track recovery, and this is how you can tell when you're ready to move on to the next training day or if you need another active recovery day.

[23:54] Jennifer Milner: So that's usually some form of that dialogue.

[24:58] Dr. Linda Bluestein: So I wanted to circle back to something you said earlier. You said that circus has a high-strength component, and when outsiders think of circus, they think high tricks first — that's what they think of: what kind of tricks, what kind of flexibility, what kind of crazy stuff can they do. So I love that you said you start with the strength component, but everybody wants to talk about stretching. How do you approach stretching for hypermobile circus artists, especially in their end range? What kind of conversation do you have with them, and what kind of guidelines do you give?

[25:35] Dr. Jen Crane, DPT: Yeah, absolutely. Again, it depends on whether there's a person with pain or a person who's hypermobile but does not have pain. I think the pendulum of passive stretching has swung really far one direction and then really far the other. When I was growing up and dancing, we were all super gung-ho passive stretching — just sit in your oversplits, get pushed, this is how it's always been done. Then in the past 5 to 10 years, I've seen the pendulum swing to the opposite direction: passive stretching is always bad, this will hurt you, this is damaging, only active flexibility.
[26:15] I really think there is a happy medium. I don't think there's anything inherently wrong with passive stretching, but where it does go wrong is when people just relax completely in a stretch. I have no problem with static stretching in the absence of pain in people who are hypermobile, if they're aware of all of the muscle engagements that need to happen from their feet to their core. It's a very active position and an active stretch. If they understand that and can do it and don't feel pain, I'm pretty okay with it.
[26:54] My main focus is on active flexibility and range control, and I emphasize that in all of the programs I create with my students. But there's often a static stretching component that's more of a long endurance hold. I think the pendulum is okay to return to the middle, and most hypermobile people do need to focus way more on active flexibility, strength, and control. But once they have that, I don't see any problem with holding that position.

[27:29] Jennifer Milner: So I want to make sure everybody heard this, because this is something I try to work with on my dancers. When we talk about active stretching, it doesn't necessarily look like what people picture — some people think active stretching means you're lunging for your foot and really working hard to reach it. Active stretching sometimes looks more like exercising, and it's hard for me to convince my dancers that doing these exercises makes you more flexible. Will you elaborate a little bit on that?

[27:59] Dr. Jen Crane, DPT: Yeah, absolutely. When I have that patient who's like, I don't know if I believe this, I usually talk about the nervous system. If we think about it from a systems control perspective: if our body is flexible and can get to this super high end range oversplit, but if our body doesn't know how to control and stabilize that position — A, you're going to be at a higher risk of injury, and B, you can continue to stretch passively and relax into your stretches, but you're not going to make nearly as much progress because your body knows that you're not strong there.
[28:43] Maybe you'll make some improvement within that session, but typically what I see is that after a stretching session, if they don't solidify it with active end range control drills, their nervous system just rewinds and takes those steps right back. So you just don't make any progress — it's not efficient, it's a waste of your time, and you're not doing what your body needs. I find that if I can talk about how it's actually way more efficient, and tell them that they'll get more out of their static hold stretching if they also do these active drills — that usually lands well.

[29:21] Jennifer Milner: That's great.

[29:23] Dr. Linda Bluestein: I wanted to ask you to elaborate on this one too, because it's so incredibly important — everyone wants more and more flexibility, especially now with social media. In terms of what that feels like, or when you're talking about the drills, could you elaborate just a little further for people who might not know what they're looking for in their body when they're doing this?

[29:54] Dr. Jen Crane, DPT: Sure. The active flexibility drills — the end range control ones?

[29:59] Dr. Linda Bluestein: Yes, exactly.

[30:00] Dr. Jen Crane, DPT: Yeah. So I usually talk about a standing leg scale. If you're standing and you grab your ankle and pull your leg towards your head as far as you can — that's a passive stretch we see all the time. But if you take that position and look at yourself in the mirror to see how high your leg is, and then let go and have to actively hold it there — how much of a gap is there? Does your leg drop a lot? If so, that is the range you need to work in.
[30:34] I usually use that as a kind of snapshot for buy-in: see how much of a difference there is between when you're holding your leg versus when you let it go and your muscles have to do that work? It would be nice if you could just hold it there, right? You want that? Yes? Cool. Then we wind it back to: in that position, what joint or area needs to be strong that currently isn't, and what other parts might be compensating?
[31:09] For example, our low back muscles tend to compensate a lot in arabesque skills — if our leg is behind us and we're lifting it, the low back contributes a lot to that movement. But if we look at how much hip extension we can get with only the glutes working, I'll assess this in a lumbar-locked position or a modified child's pose with one leg back and sitting on the other. If you can have them lift their leg there and feel how difficult that is compared to the arabesque, that tells them, "Oh my gosh, I can't lift my leg at all here. Wow, my glutes are really not doing the work — okay, I get it." If I can just show them where their area of weakness is, that is super helpful. And then, in that isolated position — whatever position isolates the muscle that isn't doing what we want for that end range control — if we can show it to them and tell them, this is what it should feel like, engage the muscle you feel working now, that is super helpful for them to understand the importance of it and its relevance aesthetically.

[32:25] Jennifer Milner: Thank you, that's a great elaboration. I appreciate that. So, talking about working on strength — do you approach strengthening people with hypermobility differently than people who do not have hypermobility? And we're talking not just a little flexibility, but significant hypermobility or hypermobility issues.

[32:46] Dr. Jen Crane, DPT: Yeah, I think anybody with hypermobility definitely needs a lot more supervision for technique in the early phases of strength training. Education on things like: when you're doing this, you're standing with your knees locked out, or in this position, your wrist really needs to not be that deviated to the side. I find that they just can't get away with nearly as many technical faults in a basic strength exercise as someone without hypermobility. So they require a lot more supervision and understanding of what they need to be doing and why it's so much more important for them than for others.

[33:28] Jennifer Milner: And along with that, do you see proprioceptive issues as well?

[33:38] Dr. Jen Crane, DPT: Yeah, it's really hard to tell in circus, because if we're talking about an aerialist who is an upper-body dominant athlete, almost all of us have terrible proprioception on the ground upright. So it's very different from dancers, where the baseline level of proprioception is so high. We don't really have that in circus unless they're a ground acrobat. But as far as upper extremity proprioception, if I had to make a general statement about what I see with hypermobile circus artists, their upper extremity proprioception is definitely less than their non-hypermobile counterparts — though it depends on what body region we're talking about, because the baseline is a little different than for a dancer or ground acrobat.

[34:34] Jennifer Milner: Sure. Going a little further with that — how do you approach working with circus artists who have some sort of joint misalignment? That's even less proprioception, I would think, but specifically working with people who have a tendency to subluxate or dislocate — how do you approach that?

[35:05] Dr. Jen Crane, DPT: That's a little harder to generalize. If we're talking about common things like patellar subluxations or shoulder subluxations, I usually try to talk a lot about the sensation in the moments leading up to that happening. Because most people know, "When I'm in this position I feel unstable." So then it's a conversation of: let's find an exercise that takes you right up to that point where the instability starts, back off a little, strengthen there, get strong there, and then we'll reassess at what point in the range that feeling of instability occurs. That can be our litmus test moving forward.

[35:46] Jennifer Milner: Excellent. I love that approach, and it's very similar to the active stretching you were talking about — let's find that range of motion, go right behind it, and strengthen there until we can get to where we want to get to. That's great.

[35:58] Dr. Linda Bluestein: And that's also a lot like when people who have migraines can get auras, but they can also get pre-auras. If you can treat their migraines when they have the pre-aura and not even wait for the aura, it's even better. I love that — it's really getting people in tune with their bodies and helping them identify those things.

[36:21] Dr. Jen Crane, DPT: Yeah, hearing the thing before the thing.

[36:25] Jennifer Milner: Right, right.

[36:27] Dr. Linda Bluestein: Well, and I have a shoulder that subluxates all the time, and that's how I try to train myself — I go right up to that point, I feel it, and then I try to work right before that point just to see if I can get it stronger.

[36:40] Dr. Jen Crane, DPT: Yeah, I have the same experience. Before I started circus, my shoulders were so floppy and would sublux when I sneezed. It was ridiculous. But just starting aerial training — maybe 6 months after I really dove into a lot of aerial work, my shoulders never felt better. My neck pain went away. Just building muscle is so helpful. Just hypertrophying muscle to support the joint.

[37:05] Jennifer Milner: Wow.

[37:06] Dr. Jen Crane, DPT: Little issues that were associated with hypermobility — it's just incredible.

[37:17] Dr. Linda Bluestein: That's so interesting, because I think about aerials and I'm like, I can't imagine working in silks with my shoulder. But I should push myself to try to strengthen it more. So, go ahead, sorry.

[37:31] Dr. Jen Crane, DPT: No, I felt the same way before I started, so I understand that for sure.

[37:33] Jennifer Milner: So one of the things we wanted to touch on was social media and how it affects the younger generation coming up — they see these tricks, they see the crazy flexibility, they see all these amazing things. What would you say to the younger performers who are looking at social media and being influenced by it?

[37:35] Dr. Jen Crane, DPT: It's probably similar to the dance world in that a lot of us in circus who are on social media post the best of whatever we did that week. What you don't see is all of the 45-minute warm-up leading up to it, all of the technical skill prep, all of the times we've worked with coaches. You really just see that end result.
[38:31] So I would just encourage people to recognize that and also to seek out accounts that show everything that goes into training, because there are a ton of accounts that talk not only about the finished product, but how hard it was to get there, how much work went into it, and what that process looked like. I encourage them to take a step back, look at the whole picture, and understand that what they're seeing is such a small snippet of real life.

[39:00] Jennifer Milner: Yeah, every time I see a dancer I follow post a video of them falling out of a pirouette, it makes me so happy, because my dancers need to know people fall out of pirouettes. And the next time you try it, maybe you'll do 7. It's good to know that even great artists don't always have a perfect pirouette coming out — and for the good ones, that moment is just them saying, well, that didn't work, what should I try next? So I love that you encourage them to seek out accounts where you can see what works and what doesn't. Are there any other trends you've observed over the past few years in circus? You've talked about the desire to codify things and you've talked about seeing the passive stretching pendulum start to swing. Is there anything else you've noticed?

[40:05] Dr. Jen Crane, DPT: From a sports medicine perspective, I think the most interesting shift I'm seeing is just that one that's starting to happen where artists are really starting to take their work as athletic work — that mental shift. Once everything is reframed through that lens, I'm seeing a lot more interesting questions from these artists: you tell me rest days are important for high-level athletes, and I think that's me — how do I know when I need a rest day? How do I know if I'm overtraining? Now these questions surrounding recovery and periodization are coming up, and that's really cool. That's where I'm just starting to see a lot of people get super into that realm.

[40:57] Dr. Linda Bluestein: With more people doing that, do you see any difference in terms of injury rates or ability to heal from more minor injuries?

[41:07] Dr. Jen Crane, DPT: Yeah, absolutely surprising nobody, cross-training is so good for everyone regardless of sport.

Jennifer Milner: Shocking!

[41:14] Dr. Jen Crane, DPT: Shocking, right? Please listen! Yeah, I think in circus it's just amplified how helpful it is because nobody's cross-training. This is not a seasonal sport. If you're a professional artist, often you're touring year-round and you get maybe a week break every few months, or you have 10, 11, 12 shows a week in a really grueling stretch for a long time. So if you throw in any amount of periodization at all, it's just crazy how much it helps.
[41:56] I can't tell you how many messages I receive from artists after I have the really hard conversation with them about needing to take an active rest week where you don't train your primary discipline — focus on a nervous system reset and then come back to training. The thought of that is horrifying to all circus artists. One of the popular hashtags on Instagram is #circuseverydamnday, and that's such a good example of the mentality in circus. But when they finally take their rest week after we have that spirited debate for at least a day or two, they come back and I get a message that says, "Oh my gosh, I finally got this skill I've been working on for a year," or "I finally trained flexibility or contortion and I didn't have back pain." It's always about unlocking a new skill. And that's what I think is so fascinating — it really strengthens the argument and the buy-in, because I have so many of these screenshots that I can just show and say, look, it's not just me.

[43:05] Jennifer Milner: It's not just me making it up. Yeah.

[43:07] Dr. Jen Crane, DPT: Yeah.

[43:10] Jennifer Milner: That has to be so immensely gratifying for you — to see the hard conversations you're having and the work you're putting in bear fruit, with them taking ownership of their bodies as athletes and giving themselves more longevity in their careers.

[43:27] Dr. Jen Crane, DPT: It's awesome. It's so gratifying for me and so empowering for them, and everyone's happy and everyone wins.

[43:36] Jennifer Milner: Well, and I've had so many conversations with my dancers at the end of Nutcracker season talking about that active rest and saying, you're not allowed to dance — go bike riding, go bowling, do something, but don't dance. Just give yourself that break, do something else. And when they do that and come back feeling better, you're just like, yay!

[43:59] Dr. Jen Crane, DPT: Yeah, and it's like a positive data point for them. They don't lose all of their skills if they take a week or two off. They're still going to be there.

[44:09] Jennifer Milner: Right.

[44:10] Dr. Linda Bluestein: Do either of you find resistance — particularly from ballet teachers maybe — when you say, take an active rest week off? Do you find resistance from other people involved in working with these athletes and artists?

[44:32] Dr. Jen Crane, DPT: Depending on the setting. In a recreational setting — if someone has a day job and just does circus for fun but does it like 5 days a week and is really into it — those coaches usually see the problem and are like, yes, take the week, listen to Jen, do the thing. I think it's a little different from dance in that respect. There are certainly some old-school coaches who will put up a fight, but I'm not going to change that coach's mind if they've been that way forever. The patient is really who I'm invested in. So I kind of just let that be, and if I work with a lot of that coach's students over a period of time — this happened to me when I lived in San Francisco and worked at Circus Center there — they watch and they see me working with people, and maybe 6 months pass and then they're like, "Hey, so what do you think about this person? Do they need a rest week?" And I'm like, this is the greatest ever. It's the long game. You have to show results, because healthcare providers have a really bad name in circus. We don't have a history of fixing things quickly or helping artists, so we have to show that we know what we're talking about.

[45:54] Jennifer Milner: Yeah, that's so true. Dance-wise, I see — which I think you do too — it's either all or nothing. You go to the doctor who says stop moving for a month, put on the boot, sit on the couch, eat your chocolate ice cream, and in a month that injury will be magically better. Or you see the ones who are afraid to have the artist stop moving, so they say, just keep going, keep limping through class, do the best you can, adjust as you need to — because they're so afraid that if the artist takes time off they're going to lose everything. And there's something in between that's going to be smarter and more efficient, and they're going to come back better. That's the hard part for them to grasp until they see it. Like you said, once they see it, they're all the way in.

[46:42] Dr. Jen Crane, DPT: Yeah, for sure.

[46:43] Jennifer Milner: Well, is there anything else you wanted to talk about? Anything else burning on your heart? And also, where can people find you?

[46:51] Dr. Jen Crane, DPT: I think we had some great topics of conversation for the hypermobile bendy bodies. I can be found pretty much everywhere online — Instagram is where I'm most active. My Instagram handle is @Cirque_Physio. I'm on Facebook too, but not nearly as much. My website is CirquePhysio.com, and one of the things I offer is a flexibility program that was really founded on the principles of hypermobility. It has all of the active flexibility drills. It's a slightly different type of flexibility assessment than we normally do in circus and performing arts, where the question is usually just, can you do a split — check yes or no. It's more of a physio perspective assessment. That's also on my website.

[47:50] Jennifer Milner: Is that something — I know several of my dancers probably heard that and were super interested — is it something they can do online? Like an online course they can sign up for?

[47:59] Dr. Jen Crane, DPT: Yeah, so it's basically a 2-in-1 educational course and product where you learn things about flexibility from more of a biomechanics perspective with my physio brain. And then it's also a guided self-assessment where they log on to the website and are guided through all of the different parts of a total body assessment. I look at things that a lot of flexibility coaches might not look at, like sciatic nerve tension or hip internal rotation — both of which have a big bearing on hamstring flexibility, pike, and oversplits. I take them through the whole assessment, they submit their results, I look at the results and their flexibility photos, and then I make them a customized program that they can log in to and just follow along, stretch with the video. That's most of what I'm doing right now from a flexibility coaching perspective.

[48:53] Jennifer Milner: That's amazing. That sounds like a great program, and I think several of my dancers are logging on right now.

[49:07] Dr. Jen Crane, DPT: It's great for dancers and artists who really want to know more about why their body is hitting plateaus. It's more of a, what's the rationale behind this — teach me more about my body so I can implement these things in the future. It's definitely dense, so you really have to want to be — you have to err on the side of, I am nerdy and interested in flexibility. It's all very accessible from a vocabulary perspective, but you have to want to know a little more, because it's definitely an investment cognitively.

[49:41] Jennifer Milner: That's great.

[49:43] Dr. Linda Bluestein: That does sound fantastic. And even if you're hypermobile and maybe you aren't dancing or doing circus anymore — if you don't stretch, you're going to get tighter and tighter and tighter. So I'm glad you brought up neural tension, because these are the kinds of problems that by the time they come to me, people are saying, "Yeah, I did gymnastics, I did dance, I did all these things quite a long time ago, but now I'm incredibly tight." And they go to a regular — quote unquote regular — doctor or physio who doesn't identify them as hypermobile at all, and it wouldn't even be on their radar that that could have been a problem in their past.

[50:22] Jennifer Milner: So that's so great. Well, thank you so much for coming on and for this great conversation. You have been listening to Bendy Bodies with the Hypermobility MD. Today our guest has been Dr. Jen Crane, performing arts physio and travel physio with Cirque du Soleil, aerialist and dancer and flexibility coach. Dr. Crane, thank you so much for taking the time to come on the Bendy Bodies podcast and for sharing your knowledge with us today.

[50:50] Dr. Jen Crane, DPT: Thanks for having me.

[50:52] Dr. Linda Bluestein: Thank you for listening to the Bendy Bodies podcast. Please visit our website www.bendybodiespodcast.com for more information and to access the show notes. If you are enjoying this podcast, please remember to subscribe and leave a review. For a limited time, you could win an autographed copy of the popular textbook Disjointed: Navigating the Diagnosis and Management of Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders just by giving us a shout out on Instagram or Facebook and tagging @bendybodiespodcast. The thoughts and opinions expressed on this podcast are solely those of the co-hosts and their guests. They do not necessarily represent the views and opinions of any organization. The thoughts and opinions do not constitute medical advice and should not be used in any legal capacity whatsoever. We'll catch you next time on the Bendy Bodies Podcast.