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!

Medical Marijuana and “What’s the Harm

Recently I posted this article on my Facebook: Marijuana Beliefs Outstrip Evidence. I summarized a key point thus, “The only use for which marijuana has reasonably good evidence of effectiveness is for nausea.”

Note, I am all for removing marijuana from schedule 1 of FDA regulation and allowing for comprehensive research of the ways in which marijuana derived substances can be used medically. However I am firmly of the belief that they should go through the exact same FDA process as all other drugs.

The responses I got were predictable. One of the key points made by many was that if it helps people then what’s harm? I am going to set aside the point that it’s not helping most users and focus on the old “what’s the harm?” gambit. It is a standard part of the responses to criticism of alternative medicine.

So, What is the Harm?

If a treatment is just a placebo, and does not provide actual benefits then these are the harms that may result:

Money. These are hardly ever free. And especially in a country where medical expenses are the most common cause of personal bankruptcy the cost of a treatment that doesn’t work is harm.
Time. The time spent going and getting a treatment done, transportation etc. are all costs for the patients and these are things that have a tangible monetary value and therefore refer back to the above point. Is the patient giving up time at work spending, money on transportation and so on? If so that is a very real harm.
Delayed treatment. If a person delays getting effective treatment because they mistakenly believe that this placebo is actually treating their condition then that is an unambiguous harm which has demonstrable negative effects in a wide variety of diseases.
Side effects. Marijuana very clearly has side effects if we are viewing it as a medicinal substance. It is used specifically for its mind-altering effects. Remember the point of this drug originally was that it got you high, that you are stoned while you’re taking it. This is incompatible with most jobs. And even when it’s not it’s still constitutes a set of risks. FDA-approved drugs go through a risk assessment process comparing the benefits to the risks. And as detailed in the linked article above there are very clearly side effects from marijuana use.
Purity and content testing. FDA approved drugs are rigorously tested for their purity, that is their absence of toxic substances and adulteration. As well as that the medication actually contains what it says on the package. Marijuana for medical purposes lacks all of these protections.
Addiction potential. While marijuana does not have the same addictive properties that opioids do it still possesses a risk of becoming habit forming, as can any behavior, especially when it is a mind-altering one such as marijuana use.

This list is not intended to be comprehensive. But does at least hit the highlights of the potential harms of medical marijuana.

An additional range of harms from the current approach to medical marijuana also includes the fact that it increases the danger to children for accidental ingestion and poisoning, especially with the prevalence of edibles and related products that are in similar packaging and have similar names to candy, as detailed here: More Marijuana More Problems for Young Children.

Conclusion

Ultimately, my position on this topic is that all medical treatments should be subject to a uniform study and approval process. The FDA is not perfect but they have a very good track record. The objective should be to lobby for marijuana to be removed from Schedule I, not to create a carve out from regulation where marijuana gets a free pass written by legislators.

Links: Processed Food and Disease

One of the other blogs I follow is the Angry Chef. I aspire to be as entertaining as that blog. But also to be seen as serious – which I think are mutually exclusive goals.

Recently posted was a two-parter about “Ultra-Processed Foods” and the dietary guidelines of Brazil and the World Health Organization.

Rise of the Ultra Foods, part 1 and part 2.

I encourage you to read them. But the short version is that the new nutrition guidelines of Brazil have a lot of positive characteristics about them. They encourage enjoying food, acknowledge the cultural and familial components of eating and meal times. These are good things. But they also go off on the concept of ultra-processed foods. Which is never defined. And the available evidence just doesn’t support the idea that UPF are inherently problematic

There exists this anti-chemical strain of though that modern processing of food is intrinsically bad. Because chemicals or something. That somehow the rise of lifestyle diseases like cardiovascular disease and diabetes are because of the chemicals and not calories and poverty.

There is already an enormous body of evidence that calories consumed are the primary driver of increased lifestyle diseases. And that the biggest confounder in this type of research is the known effect of poverty on health outcomes as well as on food choices/availability.

All of the various safety studies of chemicals used in processing food fail to show any evidence of harm.

Why then should we consider the idea that the “real” problem is processed foods? Well, as The Angry Chef points out, at least one researcher is actually performing a study to address this question. As opposed to just blaming the chemicals. It’s a randomized controlled study comparing matched diets of processed and not processed foods. Here’s the study at ClinicalTrials.gov.

I await the results of this study. And will update my understanding of the topic based on the results if they show that I’ve been wrong so far.

No. I Prefer Food. Not Protein Powder.

I asked a colleague if she had any suggestions for topics. She suggested protein powders.

I said, “ugh, no. I prefer food.”

So she suggested I explain why. And fine, I will.

Protein Powder for Strength Gains

The basic concept behind protein powder and supplements is that they “help” or are even necessary for strength training. Because you need sooo much protein (I resisted the urge to insert an eyeroll emoji). I saw some pretty big numbers for protein requirements for strength training, as big as 400g per day! And if you really believed those numbers then sure, protein powder would help you hit that number.

To the research!

How much protein do people need? The USDA gives a value of 0.8 g/kg/day. This number is set to be sufficient for 97.5% of the population. Let’s assume that people who are serious about strength training make-up the 2.5% who need more (not actually a reasonable assumption, but let’s pretend). But remember that plenty of folks actually need less than the RDA.

The American College of Sports Medicine (ASCM) recommends (PDF) 1.2-1.7 g/kg/day for strength training. With a floor of 1.5 for novice lifters recommended by the National Strength & Conditioning Association (NSCA).

Published research from the National Health and Nutrition Examination Survey (NHANES) shows that most people are getting enough protein. The average American is actually already getting enough protein to be engaged in serious strength training without having to change their diet or add protein powder/supplements.

The exceptions found in the NHANES study were that a small but significant number of adolescent and elderly women who were not getting enough protein. That’s it.

If most people are getting enough without doing anything extra then why is there such a business in protein powder sales?

Protein Powder is Easy

If you’re worried that you’re not getting the gains you want then protein powder provides an easy route to thinking you’ve solved the problem. Just buy something and you’re all set! You don’t have to actually analyze your diet, activity, form or program. Just buy something.

But protein consumption doesn’t trigger muscle building. If I deliver a bunch of construction materials to a local builder they aren’t going to just build a building because I provided the supplies. And you won’t build muscle just from eating protein. You need to do the strength training. You need to have a sensible program, with proper rest periods and enough work etc.

From looking around the gym it seems like a lot of the folks who are consuming the protein powder are already doing a reasonable program and are probably doing just fine with building muscle. In which case the powder is just a placebo. It does nothing but helps them feel like their approach is great. That feeling that they are doing all the right things probably helps with motivation and effort – which improves the outcomes. But the powder still isn’t actually helping.

But why not use it, just in case?

Because it’s false.

Because it’s a waste of time.

Because it’s a waste of money.

Because it causes some people digestive problems. And telling those people they “need” to do it is a problem.

Because facts matter.

But maybe I’m not getting enough protein.

Then use MyFitnessPal and check. The app is free, unlike the powder. Or any other fitness and nutrition app – I can personally vouch for liking this app and finding it useful and having heard almost universally positive reviews.

Odds are you are getting enough protein, though.

Don’t use the target number the app generates. Use the math above.

Vegetarians and Vegans

Folks with these types of diets are more likely to be not getting enough protein. For meat eaters it’s pretty easy to get enough protein. For non-meat eaters is frequently takes a bit more effort and planning. But it’s still perfectly possible to do so just using food. And they need to make sure they’re protein sources are complete, which most vegetarians and vegans seem to already be aware of. Vegetables and fruits do have protein and a quick Google search brings up plenty of lists of high protein plant foods.

Conclusion

Protein powder is unnecessary and if you really are having trouble getting enough with the foods you are eating then I encourage you to first try upping your intake of protein rich foods to hit the goal. In particular vegetables and fruits. The real reason for preferring food though is the benefits of the micronutrients and fiber contained in the food. Both of which are good for health.

Bibliography

Fulgoni, V. L. (2008). Current protein intake in America: analysis of the National Health and Nutrition Examination Survey, 2003–2004. The American Journal of Clinical Nutrition, 87(5), 1554S-1557S. https://doi.org/10.1093/ajcn/87.5.1554S

protein-intake-for-optimal-muscle-maintenance.pdf. (n.d.). Retrieved from https://www.acsm.org/docs/default-source/brochures/protein-intake-for-optimal-muscle-maintenance.pdf

Szedlak, C., & Robins, A. (2012). Protein Requirements for Strength Training. Strength & Conditioning Journal, 34(5), 85. https://doi.org/10.1519/SSC.0b013e31826dc3c4

Appendix: Looking at Online Searches

I expected to find that most of the links I clicked would overestimate protein needs. And perhaps my results are associated with my search history and particular search terms, but I was pleasantly surprised to not find that. In fact WebMD even low-balled the protein estimate (and didn’t even say I had cancer!). Many of the sources I found just quoted the USDA and/or ACSM recommended numbers, which is encouraging.

But the hits weren’t all good. Strength training oriented sites (like BodyBuilding.com) tended to recommend higher amounts than actually needed. With the International Sport Sciences Association (ISSA) recommending 2-3 g/kg per day. Which is almost double the actual need. The reason I highlight this is the fact that ISSA does personal trainer certifications. Which shows that the cert isn’t necessarily a reliable indicator of knowledge. (I’ll also point out that they provide references for the rest of the info on that ‘myths’ page but have no reference for this recommendation.)

In general the hits I got were for sites emphasizing the need to get enough protein and generally taking the attitude that you need more or need to make sure you’re getting enough. But the reality is that most people already are. So the emphasis is all out of whack.

Benefits of Strength Training

I’ve written before about the benefits of strength training, on my previous blog. Now recent research backs up one of the reasons I’ve long suspected.

As I’ve brought up before, it’s important not to over-interpret preliminary evidence or attempt to extrapolate from basic science to clinical reality. So while I’ve long suspected that strength training would have a benefit when it comes to diabetes development, I’ve avoided actually saying that.

And so it’s always nice when the clinical studies back up what I suspected. Hooray!

One of the things I learned from my exercise physiology education was that strength training upregulates GLUT4 on muscle cells. GLUT4 is an insulin triggered transporter for glucose. This means that strength training increases the ability and sensitivity of the of the muscle cell to take glucose out of the bloodstream and put it in the muscle cell.

Theoretically, this should reduce the likelihood of diabetes. But does it?

To the research!

I recently came across this study from JAMA: A Prospective Study of Weight Training and Risk of Type 2 Diabetes Mellitus in Men. The large Health Professionals Follow-up Study was used to track physical activity in 32,002 men for 18 years. Any physical activity reduced the risk of developing or dying from diabetes. Strength training was more effective than cardiovascular training. Both was better than just one.

Things to note about why this research is notable for this conversation:

The size of the study. Tens of thousands of subjects followed for nearly 2 decades is a lot.
The effect sizes are large. For relative risk, reducing the number of cases by up to 1/3, of one of the most common and expensive lifestyle modifiable diseases, is a big deal.
P value was tiny. P < .001. This wasn’t one of those, “if I hack it I can get P to equal .05” types of studies.
Dose response. There is a clear, fairly linear, dose response of more weight training leads to lower risk.
Normal living humans. Study was conducted on humans. The people were not having their lives dictated to them by researchers.

The best results were seen at 150+ minutes per week of weight training, cardiovascular exercise and for both. This may seem like a lot, but it’s hitting the gym 3 times a week and going for a 30 minute brisk walk most days.

There are limitations to the study, of course. It’s not randomized, but the best studies of this type of question can’t be because it’s hard to control behavior for that long in free-living humans. It’s only in men. Weight training is not necessarily defined the same as strength training.

Conclusion

As I’ll keep saying, the best outcomes result from a complete approach to physical activity which includes strength training, cardiovascular exercise, flexibility/range-of-motion and neuromotor (balance/agility) training.

Reference

Grøntved, A., Rimm, E. B., Willett, W. C., Andersen, L. B., & Hu, F. B. (2012). A Prospective Study of Weight Training and Risk of Type 2 Diabetes Mellitus in Men. Archives of Internal Medicine, 172(17), 1306–1312. https://doi.org/10.1001/archinternmed.2012.3138

Oh no, Carbs

(Updated for clarity based on Facebook feedback)

There is a lot of hullabaloo about carbs in nutrition circles, especially in clean eating types of diets. Especially if those carbs are from sugar. And extra especially if that sugar is high-fructose corn syrup. But the reality is that for weight loss and general health goals* carbs are not, in and of themselves, a big deal.

The science is clear that low carb and low fat diets produce the same long term outcomes when measuring weight loss. These two links do a good job of addressing this:

Low Fat vs Low Carb – No Difference

Sorry, but Low Carb and Low Fat Diets Get Pretty Much the Same Results

This is the study being discussed: Effect of Low-Fat vs Low-Carbohydrate Diet on 12-Month Weight Loss in Overweight Adults and the Association With Genotype Pattern or Insulin Secretion

So, rather than repeat that content, I want to address why this is the more reliable research. Because, of course, there will be replies about research showing that low carb works better.

To analyze diet science we need to look at a couple of factors:

Time

How long was the study? Any study of just a few months can show weight loss. The reality is that if you can’t show weight loss in a 12-16 week study then you are just bad at your job. Any possible diet strategy can show weight loss in this time frame. Such results are meaningless to this conversation.

The health outcomes that are important for this kind of research are ones that evolve over the course of decades. Some of the landmark studies in this field have been running longer than most of my readers have been alive.

So let’s be clear. 6 months or less is short. Too short for me to care about. Too short to inform human interventions. 1 year is the bare minimum to matter.

But why are studies like this even done if they are not meaningful? Well, they are preliminary research. Preliminary research plays an important role in the process of science but they are clearly not the end point. News stories about them are usually counterproductive and they shouldn’t be used to guide interventions in humans.

A preliminary study might just be used to determine in an approach is feasible, or to determine dosing, safety and similar characteristics. But they don’t tell us if an intervention works.

There is, of course, another more cynical reason for short-term diet studies: using them to sell stuff. Since positive results are just about guaranteed in a short-term study they create an easy way to apply the “clinically proven” sticker to your diet and resist FTC objections.

Petri Dishes and Animals

A lot of the objection to sugar and carbs is the result of a belief that calories from those sources are particularly bad for human health compared to protein or (good) fats. However, this comes pretty much entirely from research in petri dishes or animal studies.

Again this is another example of over-interpreting preliminary research. The results of applying a substance directly to a cell in a petri dish cannot be generalized to the whole human body. There are so many other factors at play in understanding how a substance will affect clinical outcomes. How is it digested? How does it interact with other substances in the body? How do homeostatic mechanisms operate to limit any changes? Etc.

And while animal research is a useful step in health research for humans we are, forgive me for stating the obvious, not mice. Or rats. Or guinea pigs. Or regular pigs. Or even monkeys. The question of what animal are we most like, a mouse or a rat, suffers from the fact that it depends on what part of the human system you are studying. And even then, we cannot just blithely assume that any animal results will apply to humans.

Biomarkers!

An extension of the last point is research into biomarkers. In short biomarkers are substances found with chemistry tests that are thought to indicate a particular (disease) state. Some are well validated, like troponin for a heart attack, others are not, like telomere length for aging. It is important to understand that a biomarker is correlated to the state of the body and is not a direct measure of the state of interest. They can be suggestive, but they don’t always predict actual health outcomes.

One of the most commonly misused biomarkers are any markers for inflammation. The assumption being that such markers indicate that something Bad is happening. So if eating sugar boosts the levels of some inflammatory biomarkers it must be terrible for you! But the research into actual health outcomes – death, disability etc. – doesn’t bear this out. Sure, eating too many calories leads to problems but the source of those calories doesn’t actually predict outcomes.

Conclusion

Yes it’s calories. Clearly though, understanding that is not the hard part. Behavior change is the hard part. Establishing new eating patterns and habits is the hard part. Fad diets that focus on one, or a few, components like sugar or carbs attempt to create the impression that it’s what you eat, not how much, that really matters. And it’s just not true.

* General health goals = is the phrase I’m using to mean premature death and disability/loss of function due to lifestyle modifiable diseases and risk.

“The Dirty Dozen” – Brief Response to News

(We’ll see if this becomes a regular thing for this blog)

The Environmental Working Group released its annual Dirty Dozen list again. They are a non-scientific group of scaremongers. This list of theirs epitomizes this fact. They take the publicly available USDA data on pesticide residue and then report characteristics like the number of different residues found and the amount of those residues. Then they rank grocery store produce based on these numbers.

What they never do is compare those values to the actual amounts necessary to harm a person. Because if they did, they’d look silly. For instance you’d have to eat 10 kilograms a day of strawberries just to reach the low end of minimum appreciable risk (RfD). (I got the math from here.)

The techniques used to detect pesticide residue are incredibly sensitive. Far more sensitive than necessary for human health. The tiniest amounts can be detected. But those tiny amounts need to be compared to results from toxicology studies to have any meaning.

The Environmental Working Group also asserts, without evidence, that a wider variety of pesticides on a plant is somehow intrinsically more dangerous than just one pesticide. This statement might be true – different chemicals may interact to be more dangerous than toxicology research on a single chemical indicates. But no evidence suggests that it is. And human health is carefully tracked by the CDC.

And even if more chemicals on the plant is more dangerous they fail to take into account the fact that the plant already has thousands of different chemicals inside. At at much higher concentrations than the pesticides. And those plant chemicals include substances evolved to kill other life forms to protect the plant i.e. pesticides. There is more of those pesticides than the ones applied by farmers.

In short, their list has nothing to do with known toxicology information. It is just an attempt to scare people. And CNN and other media swallowed it whole.

Putting Together the Program

Last week I posted about the basics of a strength training program – Getting Started with Strength Training. It contains the basic elements of what strength training should include. This post is about everything else that goes into putting together the program: warm-up, planning your sessions and progressing the plan.

Warm-up

Exercise should be begin with a warm-up. It’s problematic to jump straight from cold, “I just drove to the gym”, to vigorous exercise. Doing so increases the risk of injury.

What’s not necessary is stretching, in the sense of doing static positions to feel a stretch. Especially for long holds. A brief stretch, if it helps you feel more ready to move isn’t bad.

The Warm-Up is literally named. You should have a light sweat going by the time you are done. Your pulse should be above 100. But it shouldn’t be tiring or difficult either. A light jog, a few minutes on the bike, jump rope, really whatever works for you is fine.

How long this should take depends on the context. It will take longer to warm-up on a cold day outside than it does in a hot gym. A bike ride or jump rope may warm you up a bit faster than a light jog.

Building dynamic stretches into the routine is helpful but not essential. It’s a topic that will be covered later.

Cool Down

Taking some time to cool down after a workout is also helpful. Rather than jumping straight into a cold car. A short walk. Or just doing light exercises as the end or your workout etc.

Building it into the plan

I always encourage folks to build physical activity time into their routine to make it easier to get the recommended amount of activity. This ties into designing a program for yourself because if you can warm-up by walking to the gym and cool down by walking home, then it’s easier to get the workout done in a reasonable amount of time. Or jog, or bike to the gym.

Planning Each Session

Here’s a suggested break down of the exercises in the first post into a 2 day a week plan:

Day 1

Squats
Bench Press
Step-ups – use a box/step platform, not the padded bench, if you’re gym has one
Bent-over row
Planks
Side planks

Day 2

Straight leg deadlift
Pull-ups
Split squat
Overhead press
Planks
Side planks

This is intended to be a basic, easy starter plan. If you feel like it’s not enough you can message me for suggestions or watch for future posts.

Make sure to have a day in-between the workouts.

Progressing the Plan

Week 1 just use 5# weights for everything. It’s supposed to be easy, and the point is to learn the movements. Any movements you’re not sure about feel free to do without weights initially. It’s more important to get the movement right than it is to look impressive at the gym.

When you reach a point where you can do 15 reps at that weight, and feel good about the movement, for all 3 sets, then it’s time to progress. Progress slowly at first add 2.5#. At the low end of weight gyms typically have dumbbells in 2.5 pound increments or even smaller. But you may need to look for some magnetic 1.25# weights and add a pair, depends on the gym.

Once you get around 30# you should start increasing weight in 5# increments.

The progression scheme is for each exercise individually. Which means that keeping track of everything can get awkward.

Record your progress

Bring a notebook. You won’t be alone in doing so. Or use a note taking app on you phone.

Or use the Jefit app. It’s the best app for this purpose that I’ve encountered. (Hahahaha, I don’t get any money from them – just in case you were wondering)

Upping the Intensity

After a month up the intensity. Now aim for 12 reps. Obviously the same weight won’t be a challenge at fewer reps, so up the weight on everything. Not a lot for the first set. See how that first set goes and then bump it up a notch for the 2nd or 3rd set based on how that went.

I’d suggest going up in intensity level at 1 month intervals, as discussed in the last post.

When you reach a month at the 6RM level then it’s time to up your game to some more serious strength training. Which is not today’s post.

What to Expect When You Are Starting

Oh yeah, you are going to be sore. That’s normal. It may take a day, or two, to feel it. It may take a day or two to resolve. That’s all normal too. As you make this a regular routine it will become less of an issue. Pain or discomfort in your muscles is normal. But pain in the joints is not.

You may want to massage the sore muscles. That’ll help them feel less icky but it isn’t magic. You’ll still be sore.

You should take it easy on days you are sore. That means some walking, other light exercise is fine. But don’t go lifting weights.

Conclusion

Good luck, strength training is fun. More fun than a treadmill. But I may be biased.

As always, if you have any follow-up questions, feel free to ask in the comments or email.

Scap Squeezes: Lower Traps v. Upper Traps

Scap squeezes are a common exercise prescribed for patients with neck, shoulder or upper back pain. The intention is to address the patient’s forward, rounded shoulder posture. In a patient with adequate muscle length i.e. no shortening of the pec minor, the exercise will help the patient normalize posture by balancing the front and back muscles of posture.

The most common compensation that I see in patient’s doing this exercise is scapular elevation. That is they hunch their shoulders up as they pull them back. This substitutes one problem for another.

It’s understandable why this error would exist. Most of these individuals will have elevated shoulders as part of their bad posture – these two go together. In someone with hunched shoulders the upper traps are overactive, and stronger, while the lower traps, mid traps and rhomboids are constantly held in a lengthened state, which weakens them. As such, when the person fires their traps to achieve scapular retraction the uppers are stronger and therefore do more. And the shoulders hunch up.

Obviously we’d prefer a pure, smooth scapular retraction without the elevation since that elevation can contribute to shoulder problems and may be a part of the problem we are treating.

So here are some strategies for achieving that, in two different categories:1) motor control – verbal, visual and tactile cues; 2) muscle performance. As with most such things we should expect a combined approach to be more effective than any single strategy.

Motor Control

While working with a patient a while back who was there for neck pain, I said to them, “I don’t want to make you self-conscious about your posture. Wait, actually, I do. I want you do be self-conscious . . .” As we are trying to refine the movement a person makes while doing the scap squeeze exercise we are in part asking them to be more conscious about how they perform the motion. Motor learning is it’s own huge topic that I won’t delve into here, but the principles will be applied.

Watch themselves in the mirror – I pretty much always have patients do an exercise like this in the mirror. To make sure they understand what they are looking for takes a bit extra for most people. What I found is that most of my patient’s don’t have a sense of scapular depression already, so the instruction I’d give is, “I want you to hunch your shoulders up. Now I want you to move your shoulders the opposite direction.” This got folks into a scapular depression position more effectively than other strategies. The concept is they now have a visual for themselves to watch for in doing the scap squeezes in the mirror. This also helps them do the exercise effectively at home.
Tactile cue – If the mirror visual isn’t working, or a mirror isn’t available I would put my hands hovering just above their shoulders while they do the exercise and tell them to avoid touching my hands as they the retract their scapulae.

One of the things I don’t do, is tell people where to move their scapulae/shoulder blades. Unlike like their limbs most people don’t seem to have an innate understanding of their shoulder blade, as such an instruction to move it will tend to have the same poor results as an intrinsic cue, even if we might debate whether or not it is one.

Muscle Performance

The objective here is to supplement our patient’s program with exercises that will preferentially strengthen the lower traps over the upper traps. First, these exercises should not be done in an upright position – the upper traps are active in that position just for postural purposes. So these exercises are done in either a side-lying or prone position

The Exercises

Prone horizontal ABD+ER
Prone extension
Side-lying ER
Side-lying forward flexion

All the usual guidelines for the prescription of exercise for the purpose of strengthening should be followed, that is, 12RM or higher intensity. In particular the prone extension exercise will tolerate much more weight than the others in most people as the muscles involved are larger.

I recommend progressing the patient to using a bent-over position, as with common dumbbell rowing exercises, for the prone exercises. This brings more postural muscles in to play with the exercise and will be easier for them to do on their own.

I hope you found this useful. As always, let me know if you have any questions!

References:

https://theprehabguys.com/evidence-based-shoulder-exercises/

Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature. (2009). Journal of Orthopaedic & Sports Physical Therapy, 39(2), 105–117. https://doi.org/10.2519/jospt.2009.2835

Cools, A. M., Dewitte, V., Lanszweert, F., Notebaert, D., Roets, A., Soetens, B., … Witvrouw, E. E. (2007). Rehabilitation of Scapular Muscle Balance: Which Exercises to Prescribe? The American Journal of Sports Medicine, 35(10), 1744–1751. https://doi.org/10.1177/0363546507303560

Cools, A. M. J., Struyf, F., Mey, K. D., Maenhout, A., Castelein, B., & Cagnie, B. (2014). Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete. Br J Sports Med, 48(8), 692–697. https://doi.org/10.1136/bjsports-2013-092148

jospt.2009.pdf. (n.d.). Retrieved from https://www.jospt.org/doi/pdf/10.2519/jospt.2009.2835?code=jospt-site

Getting Started with Strength Training

(This is an update of a post from my old blog)

This is about getting started with strength training. For those who have little or no experience with the topic.

I firmly believe that just about everybody will benefit from strength training. It has different health benefits from cardio and flexibility training. It is part of the ACSM guidelines for physical activity for adults.

One of the big reasons is that strength training is all about functional activities. I could rename the core exercises of a typical strength training program as:

Picking up heavy things
Carrying heavy things
Carrying heavy things up and down the stairs
Pushing something
Pulling something
Keeping your spine stable

First though, we need to properly define strength training: Strength training is exercises hard enough that you can only do 12 in a row or fewer. Or, with isometric exercises, a position you can only hold for less than 45 seconds.

Otherwise what you are doing is endurance training. Which is not the same thing.

Primarily, it’s not about which exercises you do, but how heavy. Bodyweight squats are an endurance activity for most folks because they can do 15 or 20 or more. But if you did the exact same exercise while holding weights – enough weight that you could not do more than 12 – then the exercise would be strength training instead.

The basic exercises I recommend here are dumbbell exercises. This is because adjustable dumbbells are cheap, readily available and usable at home; alternately they are commonly available an just about any gym. Dumbbells also address a common cause of hesitation in new folks, the concern about the bar, in barbell exercises.

The Exercises

Squats – can also be done with the dumbbells held by the side
- Can also be done with a goblet style hold for lower weights
Split squats
Straight leg deadlifts
- Alternate option, easier to do safely – Hip thrust/bridge with weight (you can start this with dumbbells in your lap. You need to put your back up against something sturdy. I push a chair up against the wall).
Bench press – can be done on the floor, a bench isn’t necessary
Bent-over row
Shoulder/overhead press – do this standing not seated
Pull-ups (a pull-up bar can be gotten that works in almost any apartment and doesn’t require tools to install). Here‘s a primer on doing pull-ups if you can’t yet.
Planks – when you get up to 45 seconds, start adding weight. Put it on the small of your back
Side planks – when you get up to 45 seconds, start adding weight. Put it on your hip
- Start with the bent knee version if necessary

This set covers every major muscle group in the body and works them in all the major planes of motion. So it is very nearly complete.

The amount of weight you are looking for is something that will develop strength, which means higher weights and lower reps.

Start at 12-15 RM – Repetition Maximum – the number that you can do before you cannot do another with good form.

Start easy on the exercises to develop your form. In the long run good form is much more important that increasing weight quickly.

For each week pick an intensity level. Do all of your exercises at that level. Every 4 weeks you can increase the intensity level.

Intensity levels:

15 RM – learning the movement
12 RM – building endurance for the movement
10 RM – building muscle
8 RM – building muscle and strength
6 RM – building strength

I wouldn’t go higher than that without a spotter though.

Do the workout at least twice a week and each session has a rest day in-between another session. So not more than three times per week.

Aim for multiple sets of each exercise. 2-3 sets is a reasonable workout.

But if you only have time to do one of each then start there.

You need to rest between each set to get the most out of it.

12-15RM – rest 60+ sec.
8-12RM – rest 90+ sec.
6-8 RM and heavier – rest 2-4 minutes

You can shorten the rest periods if you alternate exercises between different muscle groups e.g. push/pull or upper/lower. But you’ll still need rest between sets. This sort of plan can be done on “light” days.

For strength training you should also have a “heavy” day where you don’t alternate like this, take appropriate rest periods and do fewer exercises.

Questions? Feel free to ask.

There’s a part II about Putting Together the Program.