Random Thoughts - Being Everything to Everyone and Taking Care of Yourself Personally & Professionally

Earlier this evening I (in the midst of not wanting to see the Blue Jays get decimated again) had a good thread discussion with a colleague on Facebook. Out of respect to my colleague I won’t elaborate on any specifics – but it made me think a lot about how us health & fitness professionals want to be everything to everyone.

Whether you’re a personal trainer/strength coach who works long days 5-7 days a week training clients or a rehab professional who deals with people in pain and/or with various health conditions … it’s tough either way. Those of you who are reading this are likely motivated, Type A’s who all have an intense drive to improve and help all of our clients. Those are fantastic qualities.

But at the same time we have to understand that our time, money and wallet are limited resources. Professional burnout is pretty common in both the rehab and fitness industries. As such we have to take care of ourselves and "pay ourselves first" to quote Stan “the Rhino” Efferding. 

Side note: I thank Stan Efferding for helping me get on track with better balancing my professional career and my powerlifting career. Yes the picture is faded as my phone cam was dying but I don’t care.

Some bits of advice that I’ve stuck to (and given to others) are…

1) To reference Stan again – you can be good at anything but you can’t be good at everything. Do you know anyone who’s great at orthopedic physical therapy, strength & conditioning, sprint coaching, bodybuilding, nutrition, pediatric physical therapy and ICU rehab? Me neither.

The older I get the more I stick to the areas that I’m knowledgeable in and ask experts (or refer out if needed) for the other stuff.

2) Have an idea how many hours you can work in a week and recover from. This may require trial & error.

I saw a FB thread where Jarod Hall (whom I love BTW) asked how many non-clinical hours people put in. While it’s a great question I had visions of it turning into a contest pretty quickly. Working 100 hour weeks isn’t helpful if you burn out in a month.

3) Doing the simple stuff like

- Getting 6-7+ hours of sleep a night

- Taking 1.5-2 hours 1-2x a week to prep healthy meals

- Getting some exercise most days of the week

… can all go a long way

4) Being organized is a lifesaver. When I worked as a Research Assistant at the University of Waterloo I had every hour of my day scheduled. I use Google Calendar as well as a To Do List app (en.todoist.com) that I have synced on my phone and my laptop to record tasks that need to be done & schedule them appropriately. I also found this helped me with not overcommitting myself and giving myself some down time.

I hope this provides some useful tips for you. 

What I'm doing differently in my 2nd year out of PT school - Part 1

Today, August 28^th 2017, marks 2 years since the end of my physiotherapy schooling. In that time period I’ve seen a lot of interesting cases, had a lot of interesting professional opportunities, and had some ups & downs along the way.

                In this piece I will detail what I’ve been doing differently during my last year of practice and cite some of the research behind those

1) Finding the line between not over-treating and not under-treating

                Recent research over the last few years has shown that we as health professionals can overtreat patients and actually make them worse off. The two biggest examples of this in the literature are in Whiplash Associated Disorders (WAD) and in Low Back Pain (LBP) – two conditions that often get better on their own. Some research in Australia suggests that chronic LBP can be an iatrogenic (health care induced) disorder¹ and that people with WAD who undergo a variety of treatment options are actually worse off^2,3!!

Side note: both WAD and LBP are very heterogenous populations and some clinical populations (mainly WAD) can be complicated to treat due to the variety of other injuries and psychosocial changes that can accompany their main injury.

                Finding the right level of treatment is a fine line. You don’t want to undertreat the patient and/or make them feel blown off & ignored … but you also don’t want to overtreat the patient and set them up for frailty.

                When I find someone who I think will get likely get better on their own what I do is

-          Educate them on a positive prognosis with their condition

-          Give them some form of exercise/movement that they can tolerate as well as some self-management skills

-          Minimize use of passive therapy

-          Followup as needed and let nature take its course

2) Refining my subjective and objective assessments

                One of my big gripes regarding “clinical reasoning” in the orthopedic physical therapy world is that much of it is based off of assessments that either lack reliability, validity, sensitivity and/or specificity and/or don’t correlate with pain.

                That said clinical reasoning is still important to

1 – Ensure that musculoskeletal pain is the problem, not pain secondary to a major red flag that hasn’t been addressed AND

2 – Understand which pieces of the bio, psycho, and social are important to each individual’s pain experience

                Lately I’ve tried to hack down my objective assessment and focus more on my subjective. I’ve said in previous years that, while I appreciate pain science, there initially wasn't a lot of information or guidance on how to practically apply it. However, in the last couple years some great resources have came out on patient interviewing and education through a biopsychosocial model. I encourage you check out the paper “Listening is therapy: Patient interviewing from a pain science perspective” for some practical tips on interviewing⁴. I don’t exactly follow this verbatim but it does help me a lot.

                In addition I also use the Orebro Questionnaire to screen for psychosocial factors and maladaptive beliefs that may need to be addressed.

3) Using less core exercise & more general exercise for LBP.

                A lot of research has came out over the last 5 years showing that “core-stability” exercises are no more superior to any other form of exercise for LBP⁵.

                As I said above LBP is a heterogenous condition, and in my experience some people respond better to different types of exercise than others. I’ve had a client that did and didn’t tolerate each of flexion exercises, extension exercises, core exercises, walking, and cycling. While I don’t believe there is a magical exercise for LBP I’ve had too many people tell me that “the exercises my physio gave me made me worse” to believe exercise choice (and the reasoning behind it) doesn’t matter.

                With that in mind – I have strived to use less core exercise for people with LBP (unless someone is a lifting junkie or has high occupational/sporting demands) and focus more on general exercise and importantly what the patient (where applicable) likes to do.

                Tune back in 2 weeks where I will discuss 3 more changes I’ve made in my 2^nd year out of PT school.

References

1.          Lin IB, O’Sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM. Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ Open. 2013;3(4):e002654. doi:10.1136/bmjopen-2013-002654.

2.          Skillgate E, Côté P, Cassidy JD, Boyle E, Carroll L, Holm LW. Effect of Early Intensive Care on Recovery From Whiplash-Associated Disorders: Results of a Population-Based Cohort Study. Arch Phys Med Rehabil. 2016;97(5):739-746. doi:10.1016/j.apmr.2015.12.028.

3.          Carroll LJ, Ferrari R, Cassidy JD, Côté P. Coping and recovery in whiplash-associated disorders: early use of passive coping strategies is associated with slower recovery of neck pain and pain-related disability. Clin J Pain. 2014;30(1):1-8. doi:10.1097/AJP.0b013e3182869d50.

4.          Diener I, Kargela M, Louw A. Listening is therapy: Patient interviewing from a pain science perspective. Physiother Theory Pract. 2016;32(5):356-367. doi:10.1080/09593985.2016.1194648.

5.          Smith BE, Littlewood C, May S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskelet Disord. 2014;15(1):416. doi:10.1186/1471-2474-15-416.

The most important concept I've learned in the last year and a half

Updated July 26, 2019             

                One of the most exciting parts of being a rehab & fitness professional in today’s age is there’s so much new and exciting information and research being disseminated. It makes for a very dynamic and ever-evolving career as there’s always something new to learn and implement into your work.

                One concept I’ve learned over the last year and a half has made a major impact in how I work with people with musculoskeletal pain as well as with weight training clients that I consult with.

                No the concept isn’t that of the nocebo effect and the importance of your choice of words. While it’s probably the most important concept I’ve learned, as well as the most important concept you can learn from my work, it was something I learned several years ago¹.

                The most important concept I’ve learned in the last year and a half is the concept of the baseline from Brian Carroll.

What is a baseline?

                A baseline is your starting point or what you’re currently doing in terms of

-          Training volume

-          Training frequency

-          Calorie intake

-          Supplementation

-          And any combination of the above²

Why is this concept so important?

                The importance of having a baseline is so you know what is effectively working and can make small adjustments as needed if changes need to be made. This is especially important when it comes to training volume as research has shown that huge spikes in training volume can increase an athlete’s risk of injury.

                Researcher Tim Gabbett’s work has looked a lot at the acute:chronic workload ratio and how it applies to athletes. Basically…

-          The acute workload is what you’ve been doing this week (ie running 25 miles)

-          The chronic workload is the average of what you’ve been doing over the previous 3 weeks (ie running an average of 20 miles per week over the last 3 weeks)

The acute workload is divided by the chronic workload to create the ratio. In the above example

the ratio would be 25/20 or 1.25. Research in a variety of sports has shown that once the ratio gets to 1.5 or greater the risk of injury rises considerably^3–6.

                As a side note this is why I get a bit grumpy when I hear people say “you need a high volume and/or high frequency training program” to lifters or athletes that are just getting their feet wet and haven’t built up much work capacity.

I used to think that lower training loads were the way to protect everyone. I was wrong. Now I think building people’s ability to better tolerate their training loads is a better idea. I also use the term “training load error” instead of “overuse injury.” Props to Bang Fitness owner Geoff Girvitz for teaching me that.

Knowing the above information you can see why its important to know what you’re doing right now so that you can make proper adjustments to your workload without considerably increasing your injury risk.

How can I apply it to my athletes or patients?

                Some clients may not have the desired work capacity to perform their desired activity – be it throwing 100 pitches, running a 5k, or doing a lot of weight training.

               Having an idea of what your client is capable of, and then slowly increasing their workload by about 10-25% per week (bear in mind that some clients tolerate workload increases better than others) is a way that you can build up a client’s training volume and work capacity while reducing (you can never fully eliminate) the risk of injury^3–6.

Some updates to this article based on recent research…

A recent editorial criticized the acute-chronic workload ratio for being flawed as it combined unpublished data as well as different measures from different sports to form the ratio. It is important to acknowledge this – but it doesn’t change the general idea and theme of increasing activity levels slowly and making sure your clients’ current fitness and work capacity matches the demand of the desired activity⁷.

And again – sports injury prevention is a complex, multifactorial topic. No matter what we do – we can’t 100% prevent injuries, we can only reduce them. And no one single measure can fully predict who will and won’t get sports injuries. 

I’m very grateful to Brian for all he’s done for me and his concept of a baseline has been the most influential concept in my career over the last year and a half.

References

1.          Petersen GL, Finnerup NB, Colloca L, et al. The magnitude of nocebo effects in pain: A meta-analysis. Pain. 2014;155(8):1426-1434. doi:10.1016/j.pain.2014.04.016.

2.          Carroll B. 10/20/Life Second Edition: The Professional’s Guide to Building Strength Has Gotten Even Bigger and Better: Brian Carroll: 9781542659291: Amazon.com: Books. Power Rack Strength ; 2017. https://www.amazon.com/10-20-Life-Second-Professionals/dp/1542659299. Accessed August 6, 2017.

3.          Gabbett TJ. The training—injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med. 2016;50(5):273-280. doi:10.1136/bjsports-2015-095788.

4.          Gabbett TJ, Hulin BT, Blanch P, Whiteley R. High training workloads alone do not cause sports injuries: how you get there is the real issue. Br J Sports Med. 2016;50(8):444-445. doi:10.1136/bjsports-2015-095567.

5.          Gabbett TJ, Kennelly S, Sheehan J, et al. If overuse injury is a “training load error”, should undertraining be viewed the same way? Br J Sports Med. 2016;50(17):1017-1018. doi:10.1136/bjsports-2016-096308.

6.          Bourdon PC, Cardinale M, Murray A, et al. Monitoring Athlete Training Loads: Consensus Statement. Int J Sports Physiol Perform. 2017;12(Suppl 2):S2-161-S2-170. doi:10.1123/IJSPP.2017-0208.

7.          Impellizzeri FM, Woodcock S, McCall A, et al. The acute-chronic workload ratio-injury figure and its 'sweet spot' are flawed. SportRxiv. 

3 applications of Interval Training for health

                Before I get started I want to congratulate all the great athletes competing at the Fergus Highland Games this past weekend. It was a real pleasure to watch a great group of athletes compete and see some national records get broken.

But now to the point of this article….

Since the turn of the century interval training, specifically high intensity interval training (HIIT) has become a popular mode of exercise particularly in the fat loss industry as research (and anecdotes) have shown HIIT to be far more time efficient for fat loss than steady state cardio.

While HIIT training for fat loss is the most commonly known application of interval training for improved health in this article I will go over 3 other methods of interval training that can be used to improve the health of certain populations you may work with.

1) Interval Training for Cardiovascular Disease prevention

A 2012 review showed that HIIT training was shown to improve various cardiovascular health indicators such as

-          HDL-cholesterol

-          Blood pressure

-          Improved insulin sensitivity

-          Improved cardiovascular fitness and

-          Fasting plasma glucose¹

More importantly these results were obtained in a fraction of the time spent doing steady state cardio.

Side note: If you are someone new to the gym I don’t recommend using HIIT training right away, particularly if you are obese, sedentary, or have any health issues. Every exercise program needs to be fit to the individual to maximize results while minimizing risk of harm.  

2) Interval Training for people with COPD

Now many of you reading this are thinking “you must be crazy recommending interval training for people with COPD.” If I was recommending HIIT training then you may be right but interval training can take many forms.

In COPD populations interval training has been shown to produce equal improvements in cardiorespiratory fitness in comparison to steady state, continuous cardio but interval training has been associated with fewer reported incidences of dyspnea (shortness of breath), respiratory muscle discomfort, and peripheral muscle discomfort.

Evidence based guidelines suggest using interval training methods of 20-30s of exercise coupled with 30-40s of rest to a total of 15 minutes and progressing from there. The guidelines suggest that the exercise intervals should be performed at a 4-6 RPE on a 10 point scale².

Anecdote alert: As someone who’s worked in ICU and in homecare during my physiotherapy school placements I’ve found that some people with COPD don’t always tolerate these volumes and intensities and I have started people at far lower volumes/intensities than those in the literature.

3) Interval Training to improve walking tolerance in Low Back Pain (LBP)  

Another anecdote alert!!!

I credit world renowned back researcher Stuart McGill for teaching me the technique of interval walking^3,4. Interval walking is (in my anecdotal experience) helpful for people with LBP who have decreased walking tolerance and want to return to walking. The goal is to have the individual walk in short sessions that don’t increase their pain, rest for a bit, and repeat through the day. Over time the duration of the walking intervals should increase in most cases.

For a couple of examples ….

If you have a client who has pain walking for 20 minutes but needs to walk 30 minutes you can have them walk for 15 minutes; rest by leaning against a tree, wall, or bench; than have them walk for another 15 minutes.

If you have a client who an only walk 20 steps before their pain increases they should walk in bursts of 15 steps and do these frequently throughout the day.

I hope this article gives you some out of the box ways to apply different methods of interval training to the people you may be working with.

References

1.          Kessler HS, Sisson SB, Short KR. The Potential for High-Intensity Interval Training to Reduce Cardiometabolic Disease Risk. Sport Med. 2012;42(6):489-509. doi:10.2165/11630910-000000000-00000.

2.          Gloeckl R, Marinov B, Pitta F. Practical recommendations for exercise training in patients with COPD. Eur Respir Rev. 2013;22(128):178-186. doi:10.1183/09059180.00000513.

3.          McGill S. The Ultimate Back: Enhancing Performance.; 2009. http://www.backfitpro.com/dvd.php. Accessed July 21, 2017.

4.          McGill S. Back Mechanic: The Step-by-Step McGill Method to Fix Back Pain. BackFitPro Inc; 2015. http://www.backfitpro.com/Back-Mechanic-Fix-Your-Back-Pain.php. Accessed July 21, 2017.

Product Review: Charlie Weingroff's T=R 3

                I just finished watching Charlie Weingroff’s DVD T=R3 (Training=Rehab) last week. Charlie is a Physical Therapist and Strength and Conditioning Coach who works for Drive 495, Nike and Canada Basketball. He is also an elite powerlifter.

                In 2012 when I started to “look outside of the box” with regards to my schooling & education Charlie was one of the first people that I was recommended to by my friends from the University of Waterloo Strength & Conditioning Club. I started following Charlie’s work then, bought his first DVD in 2013 and have continued to follow him ever since. I have a lot of respect for him and have learned a lot from him in regards to rehab & training. Regardless of whether or not you agree with him you can’t deny the influence he’s had on the fields.

Some of the great takeaways from the DVD were

1) I loved Charlie’s opening analogy of a snowglobe – representing a performance team (ie doctor, PT, strength coach, psychologist etc). The person at the top of the snowglobe – be it an owner, manager, or consultant has a broader view of the operation as a whole and how everything interconnects. Yet the individuals at the bottom of the snowglobe – the doctor, the PT, the strength coach etc have a better view of each of their own respective areas.

2) One of the things I’ve always loved about Charlie’s work is how he preaches networking and working together with other individuals to fill other pieces of the puzzle. In his 4 windows of success (which he’s talked about in other interviews and presentations): Equipment, Technical & Tactical, Biological Power, and Movement he goes over how everyone from the guy designing a golf club, to a skill coach, to a strength coach to a PT can make a difference in health & performance.

3) Going in hand with #2 Charlie discusses 4 main components to his evaluation

- Movement: can the joints get into the right positions

- Output: what you are physically capable of on your best day

- Readiness: what you are today compared to your best

- Sensory systems

4) During the DVD Charlie also went over a lot of great info on motor skill acquisition, learning and coaching. A lot of it referenced Nick Winkelman’s brilliant work. I’m not going to steal their thunder – go read Nick’s research (a lot of it is on Research Gate) and buy the DVD.

5) In the past Charlie and I had differing views on the FMS. In this DVD Charlie said that the FMS is not an injury predictor but it still can be used to see if joints are “nice” and can get into the desired positions – and I totally agree with both points and that perspective.

One concept he discussed is the idea of having your own movement screen (if you don’t believe in FMS) that also looks at active vs passive movements, eliminates joints and changes positions. For instance – if someone can get to 110 degrees hip flexion on their back but can’t bodyweight squat deep is that a mobility problem or a skill problem?

6) The biggest thing I’ve liked about Weingroff’s work – and what I’ve carried into my practice … is the idea of being able to give people an effective training stimulus while dealing with injuries and/or mobility limitations. This DVD does a greater job of expanding on that.

7) One component of Charlie’s DVD that I feel a lot of my colleagues who are into pain science would appreciate is the concept of incorporating low-load movement variability into a warmup. While I still am more cautious of certain movement patterns when they’re under high load situations and/or are symptomatic in people …. we should be able to move our spine around a little bit without fear of our back blowing up.

Following in this thread Charlie makes a great point that there’s no such thing as a bad movement or bad exercise unless you categorize what it’s for and the cost/benefit ratio involved.

8) In the DVD Charlie goes into great detail on the differences between concurrent training (using examples from Mike Boyle Strength & Conditioning and Westside Barbell) and block training as far as their advantages, disadvantages and how to properly apply them. Having had a superficial knowledge of block training I found this section interesting and full of information.

Side note: Do not make the same mistake I did and try to rush through the DVD set in a few days. Take your time.

9) One of the great points Charlie makes is the concept of “lowest system load” in training. While this may seem contradictory to what’s said above some exercises do carry a higher risk/benefit ratio than others.

While I see some people on the internet harping about why certain strength coaches do/don’t do certain exercises we have to remember that strength coaches are the ones who are responsible for keeping their athletes fit & healthy. Strength coaches are liable if an injury happens in the weight room. In that situation I don’t know about you but the biomechanics guy in me believes in exercises with the best risk/benefit ratio which again depends on the goal.

10) To finish off the DVD set (before bonus content) Charlie does a full subjective and objective assessment using the SFMA on one of the attendees. The section of this that stood out to me was the idea of making sure there isn’t something orthopedic or medical going on that’s contributing to a person’s pain. While this may seem common sense to us in the rehab world I have heard very scary stories of personal trainers who tried to “treat” their clients pain when they had serious medical issues going on that never got looked at until it was too late.

                Anyways my review has gone on long enough and I don’t want to steal Charlie’s thunder. All in all I quite enjoyed the DVD and would recommend it for anyone in rehab or S&C.

                Tune in next Monday for next week’s article “3 out of the box applications of Interval Training for health.”