Why I’m a Physical Therapist

Rejected Title: Why do I do this?

I think the New Year is a good excuse to remind myself and inform my readers of why I do what I do. I also wrote about the strength coach side of this over on my other blog.

I am a physical therapist. I have a doctorate in what I do. I work in orthopedics and specialize in shoulders, knees and low back pain. I am self-employed as a PT.

Commitment to Helping Others

As cliche as it may be I feel I have a commitment to help others. Like almost all folks who work in healthcare I want to help people. 

Eagle scout

I swore my Oath as an Eagle Scout back in 1998. Part of the oath was to “country” and also, “to help others at all times”. It took me a while to figure out how to live up to those parts of the oath. But they were the parts that resonated most for me, so I felt the need to do so.

I actually tried to enlist in the Army first. But they didn’t want someone with terrible eyesight AND allergies. 

I studied criminal justice with the thought of becoming a police officer. Thankfully I was saved from that fate by my mother. While I was taking classes in community college she got me a job at the hospital where I worked. And it was there that I finally understood that I really wanted to work in medicine to help others.

Public health

Many years later I got my Exercise Science degree from UMass Boston. Unlike the other UMass campuses, the Boston campus’ exercise science program had a strong public health component. This resonated with me. 

As a physical therapist I play a small role in the greater project of improving long-term public health outcomes. Because I help people stay physically active. This reduces their likelihood of a wide variety of diseases such as cardiovascular disease and diabetes, amongst others. I’d already worked in a skilled nursing facility (what’s commonly called a nursing home) and seen first hand how much one’s life degrades from these diseases. And I also understand the tremendous burden that these diseases impose upon society. 

Mechanic

I like being a mechanic for people. My first healthcare job was as an orderly in the OR. And before that I had extensive first aid training, mostly thru Scouts. I enjoy the hands-on nature of this kind of work. I would never be satisfied with the more “look at test results and prescribe things” style of medicine that exists in many other specialties outside of orthopedics. 

I like basic physics and I like understanding how machines work. People’s musculoskeletal systems are weird, complex machines. It’s really neat! And fascinating. 

Puzzle solving

And I like the puzzle solving aspect of, “this machine is broken, how do I fix it”. Unlike with a car mechanic, I never just pull out a broken part and install a new one (tho that is amazing surgery and I am happy to work on those patients). I have to use what bits of the machine still work and take into account how well each part is working and develop a solution to the puzzle. 

I really appreciate the intellectual pursuit of this aspect of being a physical therapist specifically. 

Improvement

I like watching my patients improve. It is really satisfying to work with a person who starts off unable to do something important to them, or unable to do it without pain, and bring them to a point where they are capable again. Watching people’s pain get better or watching them resume physical activity or sports is really a joy for me.

One of the things that was clear to me from my years of prior healthcare work that differentiated PT from other orthopedic careers was this aspect of really seeing my patients get better. 

Bringing it All Together

Physical therapy is a vocation that allows me to: 

  • Help other people
  • Help my community
  • Work hands-on with patients
  • See my patients improve
  • Solve puzzles

That’s why I do this. 

Alas, actual jobs in physical therapy are terrible and exploitative so I work on my own as an independent physical therapist. If you’d like to help support me then you can contribute thru Ko-FI. Thanks.

VR for Back Pain!

Isn’t the future amazing. Just think how excited Mark Zuckerberg was to see that the Metaverse could treat real ailments.

But let’s back up. 

By ESA, CC BY-SA 3.0 igo, https://commons.wikimedia.org/w/index.php?curid=62840930

But before that

I work professionally as a Physical Therapist and Strength Coach. If you are interested in my services you can contact me at: hirsch.sm@gmail.com or thru Trainerize.

FDA Regulation

If I survey a bunch of folks I expect that most would agree that we want the FDA to regulate medical “stuff” for the following things:

  • Efficacy – does it actually treat the condition
  • Safety – does it hurt you
    • And what side effects does it have
  • Content – does the product actually contain what it says
  • Purity – does it NOT contain other stuff

(Except for Libertarians they’d disagree with the whole premise because the “market” will sort it out better than the Government. But recorded history shows them to be factually incorrect.)

And what medical “stuff” do folks want regulated this way? Well, again, I suspect that most folks would want this list of stuff covered:

  1. Pharmaceuticals i.e. what’s usually meant by drugs in this context
  2. Homeopathic preparations*
  3. Natural and herbal remedies*
  4. Medical devices
  5. Surgical procedures
  6. Other medical treatments not covered by the above. 

* Sellers of homeopathy and herbal remedies would claim that FDA regulation is unnecessary because they “know” it’s safe and effective etc.

So what on that list is regulated by the FDA the way most folks want it to be? Item #1 only. That’s it. Formally #2 is also but the FDA only recently started to and they still devote minimal resources to it. 

Medical Devices

Leaving aside the lack of FDA regulation for safety and efficacy of surgery or the things that PT’s like myself do, let’s talk about medical devices. 

The FDA does not “approve” medical devices. They authorize them. This is a key distinction in their lingo. Approve means that it’s tested for all the characteristics at top. Authorized means the device is safe and it may even work. They apply a lower standard of evidence for what works. 

Drugs require multiple double-blind studies showing a clinically significant effect size. As well as a good balance of adverse events and side effects against the dangers of the condition being treated. 

Devices need to be safe. So an e-stim or TENS device for relief of chronic low back pain must only shock you in the specific way that it is intended to do and not randomly shock you in a way that causes injury. They are regulated for content in the sense that the TENS unit has to actually deliver electricity. And for purity in the sense that it can’t be secretly a drug delivery method. 

Now e-stim actually works for temporary relief of back pain and is appropriate in very limited cases. I’m not knocking on the authorization for it. But it is not approved and not subjected to the same level of testing as pharmaceuticals.

On to the Metaverse!

The FDA authorized marketing for a VR program to treat chronic low back pain. Note a key word in there: marketing. The FDA auth is for selling and advertising. It is not for FDA approval. While the company is likely to tout the “FDA AUTHORIZATION” all over it’s marketing, without breaking any rules, you can safely bet that third party promoters will muddy the waters by saying “approved”. 

The FDA’s own description of the single study of this product’s efficacy leaves a lot to be desired. Such as evidence that it works.

They tout percent decreases in pain such as 30% and 50% and for how long those effects lasted. The numbers look impressive. But pain relief is not normally reported that way in the literature I’m familiar with. 

Pain relief is normally reported the way the next paragraph reports it.

“To evaluate the effectiveness of EaseVRx, at the end of the eight-week program, participants were asked to rate the following outcomes on a 10-point scale, with 10 being the greatest value: pain intensity, pain interference on activity, pain interference on mood, pain interference on sleep and pain interference on stress. On average, participants experienced a decrease in pain intensity of 1.31 points over the eight weeks of treatment. Participants also reported a decrease in pain interference for all measured outcomes that ranged from .95 points to 1.27 points down from their respective scores at the start of treatment.”

https://www.fda.gov/news-events/press-announcements/fda-authorizes-marketing-virtual-reality-system-chronic-pain-reduction

But those results are not clinically significant. It is standard for me to ask patients to rate their pain on a scale from 0 to 10. It is normal for them to reply with two numbers, such as “1 or 2” or “5 or 6”. Humans don’t really differentiate pain on an 11 point scale. A five or six point scale is probably closer to our actual precision. 

This is formally known as Minimum Detectable Change (MDC). Imagine that two businesses are selling sticks of various lengths. And one business claims that, on average, their sticks are 1/4” longer than the competitors. BUT it turns out they did their measurements with a yardstick that was only marked in 1 inch increments, with none of the smaller lines between inches. Would you still trust their claim to be 1/4” longer?

No, you wouldn’t trust the claim. Their instrument for measuring lacks the precision necessary to make that claim. Well, we have just that data for the Numeric Pain Rating Scale (NPRS) – and it’s the same for the Visual Analog Scale (VAS) (just multiply by 10). That data shows a MDC of about 1.5. So any result below 1.5 cannot be trusted as a real difference. 

But I said clinically significant. This term refers to whether or not the difference matters to the patient and clinical outcomes. We measure this characteristic in part with Global Rating of Change (GRC). As well as other methodologies. And from this we generate a Minimum Clinically Important Difference (MCID). The MCID for that pain scale is about the same as the MDC, which isn’t surprising given the subjective aspect of pain. If the patient can tell that the difference is real then it matters to them. 

Does this new device work?

Short answer: no.

Longer answer: not according to the evidence so far presented.

Why do I summarize this evidence as, “no, does not work”? Because the burden of proof is on them to show their device is efficacious. The correct assumption for any novel treatment is that it does not work. 

Why does it seem like it worked in the study?

The control group was poorly designed. Or well designed if your objective was a false positive result. The study is described as double-blinded but the control group got a 2D experience with no therapeutic aspect while wearing a VR headset. They knew they were in the control group. No doubt about it. 

The basic reason for the experimental group, with the 3D therapeutic experience, to report a small improvement is an Expectancy Effect. There are a lot of other factors that go into why treatments that don’t work will lead to positive outcomes in poorly designed study. Enough that it would be it’s own long, multi-part series of posts. (if you want that I’ll need a Patreon first).

Conclusion

I would love a more accessible approach to improving chronic low back pain. But this is not even that since a typical VR set up requires more space than most people’s homes.

It was an interesting experiment. But the real results were negative. Which is important to know. However, the product should not be authorized by the FDA but the FDA is following the laws that they have been given. 

“Core” “Strength”

Is this post going to be snarkier than general? Quite possibly. I assume you’ve noticed that I put both words of the title in their own quotes after all.

The concept of “core strength” gets thrown about a lot in both physical therapy and exercise circles. I don’t like the usage of either term. 

Core Strength without quote marks

I work professionally as a Physical Therapist and Strength Coach. If you are interested in my services you can contact me at: hirsch.sm@gmail.com or thru Trainerize.

What is Core anyways?

This term is one I try not to use because it’s so squishy in it’s meaning. Different people are referring to different muscles when they use this term. Or they place different degrees of importance on specific muscles. 

Usages of the term core that I have encountered and sub variations:

  • The abdominal muscles: internal and external obliques, transverse and rectus
    • But with lower emphasis on the rectus
      • Or emphasis on the “lower” abdominals specifically
    • Maybe also the pelvic floor muscles
  • As above but with the muscles of the low back included
    • Or with specific emphasis on the small interspinal muscles* to the exclusion of the big erector spinae
    • Of course, the latissimus dorsi are not included by most people despite the large action they have for low back stability
  • Includes hip flexors i.e. the psoas
    • But only sometimes including the rectus femoris
  • Includes glutes, like the medius and maybe minimus
    • But usually doesn’t include the maximus

I’m going to use the term core to collectively refer to the rectus abdominis, internal and external obliques and the transverse abdominis. These muscles ordinarily work in concert to produce everyday functional movements. I do also refer to them as the abdominal muscles.

In conversation between professionals we can just use the names of the relevant muscles. We know those words. 

When talking to clients I can see the use of the term core to indicate a vague concept. But as a professional I know I’m just using a mushy term to avoid a longer explanation for my customer.

What kind of strength are we talking about?

Because I only learned about one kind of strength in the course of my two degrees in this field. And that is maximum force production. In exercise science the meaning of strength is literally maximal F=ma. Sure you can differentiate between single muscle strength and the coordinated strength of a multi-joint movement. Or the difference between strength in a real world application versus a gym exercise. But they are all force production. 

But if we look at the exercises that are labeled as being good for core “strength” we see a lot of variation in what they are actually doing.

There are exercises like these:

Plank Rotations
Shoulder Taps

Which are a dynamic version of planks, these particular variants actually mostly benefit the shoulders. 

There are exercises like these:

Medicine Ball Plank

Which is a stability plank. It’s arbitrarily harder than a regular plank, but not in a way that requires increased force production, it’s a variation that requires increased coordination to meet the stability demand. 

Of course, I have video of myself doing these exercises because I feel that they have legitimate use for shoulder stability, which matters given my injury history and sport – historical fencing. But I don’t do them for my “core” or it’s “strength”

Other examples are isolation exercises. These include any of the various transverse abdominis isolation exercises like drawing in your belly button. But isolating a muscle contraction in a way that’s not like any real world usage is not the same thing as strength**.

Then there’s the Sahrman which is labelled as being a strength test or a “stability” test for the abs or core. But really it is just a skill test. (And I put stability in quotes because it’s not clear what’s stable here or what it has to do with any real world application)

I had an instructor straight-faced tell me that everyone starts off with a low rating on the Sahrman test, but that everyone gets better quickly. That’s a skill test then. Not a strength test. Because it takes longer than a few weeks to develop more strength. 

We did the Sahrman in class too, so I’ve tried it from the perspective of the client/patient. At the time I was deadlifting over 100% of my bodyweight with no pain. I also started low on this test and got better quickly. It demonstrably did not correlate to any real world issues in my life. 

Actual Strength = Force Production

So what does training actual strength of the abdominal muscles means? It means increasing their capacity for force production. We can do this two ways.

Fewer Muscles, Same Resistance

We can reduce the number of muscles involved but use the same resistance, usually our bodyweight. Fewer muscles with the same resistance requires more force from the muscles being used.

This is what’s going on in a one-arm plank, or a one-arm and one-leg plank.

One-arm, One-leg Plank

Same Exercise, More resistance

That’s what’s going on in a weight plank.

Weighted Plank

So this is a regular plank with, in my case, 50 extra pounds, or about +25% resistance. 

It doesn’t take exercises like this to have good core strength though. I had not done this exercise in nearly two years when I shot this video. I did mostly basic exercises like bench press, deadlift and variations, squat variations, rows and pullups. If you look at the muscles used for these exercises it is clear that they use the abdominal muscles. And that they use them functionally. And that they are going to be put under high load that develops strength if you do these basic exercises at high load. (I love feeling my bench press in my hip flexors.)

I think strength of the abdominal muscles matters. Just not in the way I normally see it presented in both physical therapy and personal training. 

* There’s a debate as to whether these muscles even produce motion instead of just being positional sensors. Compare their leverage and size to the other abdominal muscles.

** Yes, of course, I am familiar with the theoretical underpinning of why TA isolation is thought to be useful, but I’m not going to explain the evidence that shows it is not, in this particular post.

No, I don’t need to Just Try It

One of the common responses I get when I provide critical* feedback of a diet or exercise idea, is that I should, “just try it”. But no, I shouldn’t. And the suggestion that I should indicates a lack of understanding of science. Either the science underlying the specific topic or of scientific methodology in general and why it is the way it is. 

Science underlying the topic

For the topics of both nutrition and exercise science we have 70+ years of published research. The research is not all confined to ivory tower laboratory experiments and deals with people eating in the real world and athletes competing in their sport. 

We have enormous amounts of research to back our conclusions. Many landmark studies that exist have been running for decades. 

The basic findings of these research programs have all been repeatedly replicated with enough variations to demonstrate broad generalizability. Outcomes are clearly predictable. 

As such, no, some new (or old) exercise tool is not going to be some exception to these patterns.

And, no, some new diet is not going to show that actually, this, that or the other was actually the key all along. 

Nutrition is NOT always changing

The obvious comeback to me pointing out that there is more than half a century of research backing nutrition science would be the claim that it’s always changing. I even had a nutrition professor say that during the unit on the history of nutrition science. But if you look at the basics and broad eating patterns instead of focusing on details, there has been little change. 

  • Every US food guideline has said that Americans should eat more vegetables and fruits and fewer calories added with sugar and oil/fat.
  • Eating fewer calories than you burn is the key to weight loss – everything else is single digit percentage fiddling with details.

There are more consistencies than just this and there is more consistency than changes.

Scientific Methodology

My personal experience with an exercise or diet is basically irrelevant. When the published, replicated results and my personal experience disagree then the correct conclusion is that I am wrong. 

Personal experience with a topic is not an experiment. You are not controlling for confounding factors in any way. 

With dieting this usually just a matter of a person liking whatever diet was the one that they could best live with. When my friend uses a low carb diet with periodic fasting to get back down to a healthy weight then more power to them. But if they say I should do that they are going to run into the brick wall that I am miserable when fasting and really like carbs. 

Or the person has bought into bogus health claims. Your diet is not making your blood acidic. So if the low-acid diet** gets you to eat more vegetables and less high calorie density foods then your improvements are from the fiber and better calorie balance. You didn’t control for confounding factors and you are attributing success to the wrong thing. This is exactly why understanding the basic science and doing controlled experiments are so necessary. 

Ye Olde exercise tool is not great for everything. No tool is. But if adding that tool got you to actually do more than you were doing before you will see some improvements. It is basically true (for most things) that more exercise will produce some improvements even if they are modest or inefficient. 

If your shoulders are getting tired from holding your sword up then sure, gada exercises will help with that, but that doesn’t prove they are good for anything else. Or that they are cost-effective. Or safe.

I will, however, reserve the right to get grumpy about specifically dangerous diets and exercises.

The history of this

The history of what was learned by humans who “just tried it” is well illustrated by the history of medicine. Because there are a staggering number of medical treatments documented in historical sources that just don’t work. But some humans tried them and became convinced that they worked. And then it ended up being written down by somebody called a doctor (or equivalent in their language). 

In short, humans have hyper-active pattern recognition; it’s hard-wired into our brains. This is useful in many basic life situations but can also go badly wrong. We think that A caused B when they are in fact unrelated. 

Good reasons to do things

There are of course plenty of good reasons to do something that don’t have to do with optimal outcomes. Where I get grumpy is when a person is really just describing their personal preference as if it were the best idea for everyone.

Exercise plans that fit your circumstances, equipment and motivation are great.

Eating patterns that are sustainable for you and improve nutrition are great.

But don’t insist that I need to just try it.

*critical here in a technical sense, not just destructive criticism

** the low-acid diet I’ve seen actually recommended eating oranges which are the most acidic food that humans eat 😀

Strength Training for Kids

Or how the AAP article drives me nuts

I have a child! Woo hoo!
I’m a strength coach professionally. At some point I’m going to want my kid to start strength training. So, let’s mosey on over to the American Academy of Pediatrics website and see what they have to say about strength training in kids: https://www.healthychildren.org/English/healthy-living/sports/Pages/Strength-Training.aspx (not on the AAP website per se but linked from the AAP as the top hit for my query)

Yikes! Looks like they forgot to talk to somebody who is familiar with the topic before putting this out.

Credit Where It Is Due

Certainly, plenty of this page is good. They recommend strength training. Usually starting around age 7 or 8. They recommend a reasonable approach: 8-15 reps, full ROM, appropriate supervision, progressive increase in resistance.

They talk about the benefits of strength training. They point out how strength training is both safer than other activities and improves the safety of other activities. 

This is all great and if the whole article didn’t also bother my professional sensibilities I could leave it at that. 

But . . .

The first paragraph has this sentence: “[strength training] is not the same as Olympic lifting, powerlifting, or body building, which requires the use of ballistic movements and maximum lifts and is not recommended for children.”

And, um, did they talk to somebody who knew about these things? Sure seems like they didn’t. They treat this trio of activities like they are all the same, which just shows a staggering lack of knowledge.

First they categorically state that this trio of activities are not strength training. Which is objectively nonsense. 

  • Powerlifting is specifically the sport of maximizing strength. 
  • Olympic lifting is specifically the sport of maximizing power – which is inseparable from strength in exercise physiology. 
  • Body building is resistance training and therefore, compared to not doing resistance training, will necessarily improve strength, even though that’s not the focus as such. 

Incorporating Olympic lifting into one’s training does not require maximum lifts. Competing in the sport does, but it is absolutely a reasonable component of strength training for athletic development. Strength training for athletic development is something I’ve done in (U.S. NCAA) division I athletes. Useful outcomes for athletic development can be done at only 5RM. And Olympic lifting based variants can be done with lower loads, such as the dumbbell snatch, that are low load on the body overall but still worthwhile.

Maximum lifts are part of the competition in powerlifting, and I wouldn’t recommend power lifting per se for children. Ballistic movements are not part of powerlifting. 

Maximum lifts are not at all a part of body building. The program actually recommended lower down in the article could function as a low-end body building program. Ballistic movements are not necessarily part of body building and are rather uncommon in that. 

Ballistic movement are not recommended

Uh, so children shouldn’t jump. Like, at all? Because seriously, the actual measured forces on the body from jumping, just on level ground, are significantly higher than the forces from Olympic lifting. 

The actual research into Olympic lifting doesn’t show any particularly higher risks for children from the activity. A significant factor in reported problems seems to be unsupervised children and home equipment. I’m totally on board with strength training being a supervised activity for kids.

The real determining factor in when to start Olympic lifting with children seems to be maturity/cognitive development. The child needs to be able and willing to follow instructions and refrain from playing with the equipment. (I’ll stress here that a kid who doesn’t want to do Olympic lifting is clearly higher risk than one who is engaged and intrinsically motivated.)

Programming

They recommend a strength training program that is only 20-30 minutes, PLUS 20-25 minutes of warm-up and cool down. That’s not good. The most efficient program I can write has six separate exercises in it. With 2 sets per exercise and appropriate rest periods, plus the reality of setting up/taking down exercises and switching time and water breaks, this program takes 24 minutes. This is the most minimal program that is still useful. 

A more reasonable program is 8 exercises and 2-3 sets – which takes 48 minutes. With acceptable warm-up and cool down this takes 60-65 minutes.

It is not always necessary to do 10-15 minutes of warm-up. Appropriate warm-up times depend on several factors. Cool down time is just overemphasized. 

Exercise Selection

This video from the AAP is their Upper Body Strength Training Recommendation. Their are just three exercises recommended: push press, biceps curl and what the presenter calls a deadlift high pull, but really ends up being more an upright row. 

The presenter just straight up acknowledges that the biceps curl is probably not the most helpful – but is still using up one of the only three exercises on it.

These three are presented as if they are a complete program for either upper-body strength training (the title) or overhead athletes (the presenters words). Neither is even close. 

I would not call complete an overhead athlete program that doesn’t include a rotator cuff oriented exercise. Even just a DB row. 

The “program” includes no conventional pulling exercises and only vertical pushing. It’s not complete. It’s just bad.

The video also specifies an intensity of 15RM or lower! The written guidance says 8-15RM. 15+RM isn’t even strength training. 

One other note about this video – the instructor to student ratio is higher than the AAP recommendation. And I agree that there are too many students.

I’m not going to spend time on how silly I think doing these exercises one-legged is, “for balance”.

Bodyweight is Better?

The accompanying general video is by the same guy, but isn’t consistent with the other video. In this video the presenter says that the exercises should be all bodyweight – in the other video the kids are using dumbbells. The presenter says, ”as long as they use their bodyweight it’s totally safe”.  This is a nonsense statement. Like, “does this person know what numbers are?” level nonsense. And what it really shows is that the person uncritically accepts “conventional wisdom” without applying any rational thought to it. 

This same presenter emphasizes the need to use light weights both in this video and the other video. But that’s not what bodyweight is. It’s actually plenty of weight for many exercises. It is perfectly normal for a person to struggle to do 8 push-ups when they start. That means that the bodyweight exercise is more intense than the AAP guidance recommends. For some children a push-up will be a maximal lift i.e. something they can only do once. That’s not safe according to them. 

The response necessarily requires some magical assertion that because it’s bodyweight it’s different without describing how. The muscles, tendons, ligament and joint surfaces can’t tell the difference between a 1RM pushup and a 1RM bench press. They are the same.

The fact is that bodyweight is frequently too low for lower body strength training and too high for safe upper body strength training. 20 air squats just isn’t strength training.

Conclusion

Sigh. Superficially it’s fine. And if somebody got their kid into strength training based on these pages and videos then that is great. And it is better than not doing so. Certainly.

But it really comes across as a minimal effort, barely better than nothing set of info.

Additional reading: https://www.fitpro.com/blog/index.php/olympic-lifting-for-children/

What Is Urgent Care Good For?

In replying to a friend’s questions about what to do regarding their mysterious pain, one commenter, intending to be helpful, suggested going to an Urgent Care. I argued against doing so. And then I was accused of being dismissive of every doctor who works in one and, ya know, other things.

In actuality I had also DM’ed my friend advising them on what I thought was the correct course of action, although that course was harder. And for a different post.

Urgent Care Clinics 

I’m not sure when the idea for these first appeared. And my first exposure to them was working in an ER that had a separate Urgent Care side. I really liked that model. But I don’t think that’s what most people are thinking of when they recommend an Urgent Care. They are instead thinking of the numerous stand-alone clinics. Frequently in strip malls. And there are some limitations to this model. 

The Good

Providing easy access to urgent care without the difficulties of an ER is valuable. Those difficulties include long waits and higher bills. Those waits are longer because an urgent patient is not an emergency patient – and they have to tend to the emergency patients first. (This is also why I like the alongside model that I worked at)

Better hours and no need for an appointment certainly solves problems for folks who have limited ability to get a quick appointment otherwise. Like being a member of One Medical, a service that is rich-people-only expensive. 

The Bad

The problem that is solved by what I mentioned above is one that could be solved another way. By providing for better staffing at Primary Care offices. But that’s not the for-profit primary care model. Primary Care wants lean staffing and as many appointments as possible so that the schedule is always crammed tight. Greater use of Advanced Practice Clinicians – NPs and PAs – would help address this, but is also a separate topic. 

So, in part, what bothers me about urgent care clinics is that they are a symptom of a dysfunctional healthcare system. 

The stand-alone clinics are run by for-profit companies as well. But with a model built from the ground up to achieve that profit in a different way. And that’s also a way that stand-alone clinics are different from ER ones. 

The Urgent Care just charges more. Which usually translates to a higher co-pay for the patient and the only benefit they get from that greater cost is convenience. I’m okay with paying more at a convenience store – for the convenience – but not with medical care. 

The Urgent Care structure is also one that incentivizes more testing regardless of utility. Although, of course, that’s a problem across the whole U.S. healthcare  system. I suspect it’s worse there. 

The trigger for my conversation on the friends’ wall was my guess that they’d have an ankle x-ray ordered even though it wasn’t useful. Which is unnecessary exposure to radiation. And contrary to the American College of Radiologists guidelines. 

The Ugly

*Personal experience warning* – the only place I’ve been to that was supposed to have an x-ray but it wasn’t working was an Urgent Care. I’ve had that happen multiple times. Which is consistent with my cheap before good expectation of their model. 

Limited Expertise

Just like an ER, and every possible other specialty in medicine, the folks who work in an Urgent Care are good in their domain and not everything else. So what are they good for? Simple orthopedic injuries and simple infectious diseases. These are the two kinds of things that are low enough grade to not require an ER but still require care faster than you can get at a primary care office. 

My friend who was suggested to go to an Urgent Care had a weird neuro problem. They weren’t going to be able to do anything for her or have the expertise to address it usefully. 

Limited Treatments

An Urgent Care also has limited treatment options available. Infectious diseases usually require supportive care and sometimes antibiotics or antivirals. And they can handle that well. 

Simple orthopedic injuries may require imaging, splints and/or sutures. They can handle that well also. 

My friend was only going to be able to get powerful painkillers that provide only temporary relief. That’s not nothing. Sometimes it’s critically important. But it’s very limited. 

All of these treatments are things the Primary Care could take care of if they had appropriate staffing. 

Conclusion

I want our healthcare system to be better. I really do. And a lot of that is structural changes. And I see Urgent Care clinics as a symptom of what’s wrong. Which biases my view of them.

But they are definitely useful. And I’d rather have a bad solution that helps address our flaws than leaving a hole in our system. 

Kettlebells are Still Overhyped

or

Why Fitness Fads Annoy Me

I recently came across this article on “9 Kettlebell Exercises for Everyone” and it is typical kettlebell ad copy (propaganda?).

It starts with:

Everyone can benefit from kettlebell exercises. Kettlebells have a unique shape which lets you blast your body in ways dumbbells can’t. You can pull, push, twist and swing kettlebells to get leaner, stronger and more powerful. Plus, kettlebells are easier on your wrists than dumbbells. Also, because of their offset weight, the gravitational pull of a kettlebell goes straight down, instead of from side-to-side with a dumbbell (which is shaped like a teeter-totter).

Let’s break this apart.

  • Everyone can benefit from resistance exercises. Kettlebells are not a special kind of mass. Ask a physicist. Or an exercise physiologist.
  • “Blast your body in ways that dumbbells can’t” is such advertising nonsense that I’m surprised that there is not a link to a product the author makes money off of.
  • Any kind of resistance can “pull, push, twist or swing”. Kettlebells are still not special.
  • Every kind of resistance training can help you get “leaner, stronger and more powerful”. If programmed correctly. Kettlebells actually aren’t good at power!
  • How are kettlebells easier on the wrists? No explanation is given.
    • Kettlebells are harder on your hands though, because the handle will twist against your skin causing more abrasion and callouses.
  • Uh, the gravitational pull of a dumbbell is also straight down. That’s how gravity works. Not side-to-side. This is a made-up problem about dumbbells.

Not an auspicious start.

So, what are the exercises?

Exercises with Kettlebells

There is only one Kettlebell Exercise™©®, Bottoms-Up presses. It’s the only exercise where the unique characteristics of a kettlebell are both necessary and useful. An argument can be made also for the swing. But I don’t buy that argument.

Everything else is just exercises that can be done with kettlebells. All of these existed before kettlebells were getting hyped. All of them can be done well with dumbbells or barbells. These exercises, done with barbells and dumbbells, are used for athletic performance development and have demonstrated track records (literally) of being the best approach for athletic development.

So what exercises made the list?

In the linked article we see the following:

  1. Deadlift – like seriously, that’s where you start your article? The deadlift is an exercise clearly best done with a barbell, as that let’s move the most weight. Do you want to do a deadlift with form that mimics the kettlebell? Great, do sumo deadlifts. Problem solved.
  2. Swing – the other exercise that is arguably better with a kettlebell besides the bottom’s up. But this exercise was done with dumbbells before kettlebells. And using a KB causes rotational stresses on your hand that rip up your skin. Some folks find this manageable but other don’t.
  3. Squat – you are limited by your ability to get the weight into place, an upper body limitation more than a lower body limitation. Barbells do this better. And the version depicted – goblet-style – can be done just fine with dumbbells.
  4. Snatch – NO. Just no. Unless you actually compete in kettlebell snatches there is no good reason to do them. They risk breaking your arm for no benefit. Even if you don’t break it, you’re going to get bruises and welts from the weight landing on your forearm. Do them with dumbbells for the exact same fitness benefit without the risk. Or do them with barbells to really train power. The weight limit imposed by doing them with KBs means they can’t do a good job of training power.*
  5. Clean – can be done with dumbbells. Are better done with barbells. Rotating sleeves. Higher weights. Better outcomes.
  6. Turkish** Get-up – can be done with dumbbells. There is no benefit to doing them with kettles.
  7. Push-press – do I have to repeat myself at this point?
  8. (kneeling) Halos – Can be done with anything. I’m not sure why these are being shown kneeling. No explanation is given. Also, do I really want to “blast my core”? What does that even mean?
  9. Counting error in original article. Seriously.

Cults

Seriously. The kettlebell gets pretty cult like. They have certifications and instructors and competitions and great ad copy. They charge a lot of money for a cheap lump of iron.

Nothing does everything well

I love barbells. I own four, and lots of weight to go on them. I do a lot of barbell exercises. And I acknowledge their limitations. Anyone that says something is good for everything is wrong. And they are probably selling something.

Fitness Objectives

On this blog I’ll talk about strength training or cardiovascular training and similar terms. Where we focus on the fitness objective in defining the exercise, instead of focusing on the tool. And that’s one of the big differences between a sensible training program and exercise fads.

 

Also, I’ve talked about kettlebells before on my old blog: Fight with All Your Strength.

 

* Also, the idea that a one paragraph description of how to do a KB snatch is sufficient is just irresponsible and dangerous. The author wrote more on the push press than the snatch.

** I’ve been worried for a while now that this term is racist, just because of human history. But I can’t find anything on that. And what I can find about just it’s origin is inconclusive.

Bad News Everybody!

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On How I Continued Strength Training with a Broken Finger

About a month ago I broke a finger. My right index finger, proximal phalanx. Yes, I’m  right-handed.

I broke it sword-fighting. (For those who don’t know I do Historical Fencing at Athena School of Arms.) My opponent’s sword hit a gap in my protective gear. The hit split my skin all the way down to the tendon. There was a visible, longitudinal defect in the tendon – that I got to see in the ER. And there is a diagonal fracture along the length the bone. Minor as far as fractures go – not displaced or open.

And so I was put into a heavy duty splint. It immobilized me from the tip of the index finger down to the carpal bones. With the middle finger included in the finger splint, almost like buddy taping the fingers. And it wrapped around the base of my thumb. I could barely get my thumb and pinky finger to grip.

But I Did Strength Training Anyways

I’m not convinced the OT who created my splint would have really approved of my exercise routine, but . . .

There was no chance I was going to stop unless it was impossible.

Lower Body Strength Training

Squats, and variants thereof, were alright, it was just harder to grip the bar solidly to stabilize it. I’ve just been concerned with the fail state – if I had to ditch the weight I can’t move my hand out of the way as easily as usual.

Deadlifts are right out because I can’t generate the grip strength necessary. So I replaced them with barbell hip thrusts. It’s possible to move a surprising amount of weight with this. I’m up to almost 300 pounds with this. Single-leg deadlifts were still doable because the weight was light enough to grip.

Upper Body Strength Training

This is where it got interesting. I couldn’t do any pushing exercises because the splint came down across the heel of my palm by the thumb. And of course I had trouble gripping for pulling exercises!

I solved this with a lifting hook. This is like the more common lifting straps, but I went for something more intense, these: Lifting Lab Weightlifting Hooks. These put almost all the pull into the strap around my wrist letting me do pulling exercises pretty close to normal. I even reached a point where I could do pullups!

The other workaround I used was to put an ankle strap around  my wrist and use a cable column machine for flyes, reverse flyes and front raises. This allowed me to target both the pecs with the flyes and the deltoids with the raises. Thereby covering the same muscles I would work with typical pushing exercises. This preserves the muscle performance.

When I got back to bench press last week my plan had worked and I had maintained nearly 100% of what I was at when I broke my finger (5 pounds away from finally benching 2 plates!)

And the reverse flyes hit the mid-back muscles until I was able to return to doing rows instead.

Olympic Lifts

. . . were right out. Boo. But I continued with box jumps to keep up my lower body explosive power.

Progress

At my follow-up appointment last week the splint got reduced to just a finger splint, freeing up most of my hand and allowing me to go back to doing regular pushing exercises. Hooray!

Finger splint

After a few weeks like that and now I can even take the splint off and type normally.

The Physical Therapy Attitude

I didn’t let my injury stop me anymore than absolutely necessary. I kept up with every exercise I could and adapted those that were not doable in the usual manner. A big part of what I see physical therapy as being good for is this concept of maintaining function and adapting instead of stopping activity. We keep people moving. No matter what (almost).

Good News Everybody!

After half a year of job hunting I’m finally employed as a full-time physical therapist. I am working at ProSports Therapy in Waltham. It is an outpatient clinic with a primarily orthopedic patient population. I appreciate working alongside a Boston Sports Club because it gives me access to the sort of equipment necessary for working at higher levels, especially with athletic patients.

It may seem odd but I’ll probably post more now that I’m working full-time. The job hunt was incredibly stressful and depressing for me. And left me feeling unmotivated.

Now that I’ve got patients to discuss I’m happy to be looking up research and thinking about physical therapy.

Woo hoo!