Monday 25 September 2017

Barbells and Bone Health Version 2.0

People lift weights for varying reasons. Some want a big bench press, some want big biceps, and some just want to “look good naked” for that special someone. But I’ll bet ya that nobody in the gym thinks about how lifting weights affects their bones.   

Osteoporosis is a common condition that occurs when we break down more bone than we build up. This causes our bones to become thinner, weaker, and more fragile. Osteoporosis is often called "the silent thief" as many people don't know they have it until they fracture. While a fracture may not seem like much to you or I, for an elderly individual, the consequences of a fracture are dire and can include anxiety, depression, pain (1), and death (2).

But thankfully, lifting weights can help to prevent these from happening. When we load our bones we provide a strain that causes bone cells to be stimulated. This leads to osteoclasts (bone absorbing cells) reabsorbing bones just like how PacMan eats pacdots.

Afterwards osteoblasts (bone building cells) differentiate and lay down new, stronger bone which is like new, softer cement which hardens over time (3).

Disclaimer: This article is tailored more towards younger adults. I will write a similar article in the future that is directed more towards working with middle-aged and elderly individuals.

What kind of training program do I need to do to strengthen my bones?

Linear and undulating periodization are the two programming styles that have been studied and shown to increase bone formation and bone mineral density (BMD) (4-6).

*Side note: Before I get any hate messages in the comments - this isn’t to say that the other great training methods out there (e.g. 10/20/Life, Juggernaut, 5/3/1, Westside, Cube etc.) can’t strengthen your bones, it’s just that they’ve never been studied in this regard.

Linear periodization is a method of training where you gradually increase the weight and decrease the repetitions over a period of weeks and "peak" for an athletic event. Note that it only applies to your main or “opening” exercise in a workout such as a squat or deadlift variation for the lower body or a bench or military press variation for the upper body. There are many ways to cycle and train assistance work, but that’s beyond the scope of this article. Below is an example of a 17 week linear periodization model.

Percentage of One Rep Max
Rest between sets
3 minutes
3 minutes
3-5 minutes
5-7 minutes

In contrast to linear periodization, undulating periodization uses a repetition scheme that is varied from workout to workout. Here's an example of an undulating periodization model which can be applied to almost all exercises in a workout:  

3 x 12
3 x 8
3 x 4
3 x 8
3 x 4
3 x 12
3 x 4
3 x 12
3 x 8

For more about undulating periodization check out this link

Both periodization styles have similar effects on BMD in women (7) and have approximately the same effectiveness in improving maximal strength in beginner to novice trainees (8-12).

Progressive overload in a training program is critical for improving bone growth. Low intensity training doesn’t have the same effect on improving BMD (6, 11, 13). A 5 or 10 lb dumbbell is appropriate for someone new to the gym, but past that it’s only appropriate for prehab, as a doorstop, or as a paper weight. It’s not gonna improve your bone health.

Do men’s and women’s bones respond the same way to lifting?

College, adult, and middle aged men have all shown increases in their lumbar spine and hip BMD through lifting weights (5, 11, 14).

By contrast, premenopausal women respond more variably to lifting. Some studies show no effect of weight training on BMD (7, 15-17) while others (including a review) show a positive effect of lifting on hip BMD and bone formation (6, 18). Weight training (4), even explosive weight training (19), has been consistently shown to maintain or increase BMD in postmenopausal women (13) – a population at high risk of osteoporosis.

In my biased opinion, when you look at the effect of lifting on overall health, women can’t go wrong with lifting some weights. Your body will thank you for it in the long run.

Strength sports and bone health

Several studies have shown that Olympic weightlifters and powerlifters have a much higher BMD than people who are untrained or train at a lower intensity (11, 20-23). Competing as a high level strength athlete comes with its own health risks (24) but focusing on getting stronger can help your bones, your muscle mass, your athleticism, and your performance (wink).

In the strength and conditioning world you'll be hard pressed to find a strength coach that doesn't recommend a squat variation. But how do squats relate with bone health?

Some research hypothesizes that ground reaction force and rate of force development are linked with bone development (25). When you push into the ground, the ground sends an equal and opposite force into you, that's what a ground reaction force is. Rate of force development refers to the speed at which you can apply force.

A 2012 study in the Journal of Strength and Conditioning Research showed that in comparison to traditional squats and powerlifting squats, box squats have slightly lower ground reaction force but conversely have three to four times the rate of force development (26). This suggests that box squats may be a better choice of squat variations for bone development assuming you’re not a competitive strength athlete who has to do back squats in your sport.

What about plyometrics and bone health?

The relationship between jumping and BMD hasn’t been thoroughly researched in young adults. Several recent studies have shown a positive relationship between hip BMD, maximal vertical jump height (27), and maximal broad jump length (28). Low-repetition jump training has been shown to increase BMD in female college athletes (29) and higher-repetition jump training has been shown to increase lumbar spine and hip BMD in pre-menopausal women (30,31). Elite jumpers have been shown to have a higher BMD than matched controls (32).

Assuming you have no injury history and can land properly, adding in a few sets of jumps (e.g. 2-5 sets of 1-3 reps) once a week before a full body or a lower body workout can be a great way to improve your athleticism & explosiveness. As an added bonus jumps help to improve muscle power, something we lose with age.

Osteoporosis is a common condition that will change the face of the health care system as we age. But doing some periodized weight training & jumps can improve your physique, improve your athleticism, and keep your bones healthy for the long haul.

Practical takeaways

·         Both linear and undulating periodization programs have been shown to improve bone mineral density in young adults
·         To maximize your bone development in a training program, progressive overload must occur while maintaining good form
·         Assuming you can do them correctly and pain free, adding in a few sets of box squats and jumps into your training program may help to increase your BMD and keep your bones healthy for the long term


1.       Gold DT. The clinical impact of vertebral fractures: quality of life in women with osteoporosis. Bone. 1996 Mar;18(3 Suppl):185S-189S.
2.       Tajeu GS, Delzell E, Smith W, Arora T, Curtis JR, Saag KG, Morrisey MA, Yun H, Kilgore ML. Death, debility, and destitution following hip fracture. J Gerontol A Biol Sci Med Sci. 2014 Mar;69(3):346-353. doi: 10.1093/gerona/glt105. Epub 2013 Jul 19.
3.       Galli C, Passeri G, Macaluso GM. Osteocytes and WNT: the mechanical control of bone formation. J Dent Res. 2010 Apr;89(4):331-343.
4.       Lester ME, Urso ML, Evans RK, Pierce JR, Spiering BA, Maresh CM, Hatfield DL, Kraemer WJ, Nindl BC. Influence of exercise mode and osteogenic index on bone biomarker responses during short-term physical training. Bone. 2009 Oct;45(4):768-776. doi: 10.1016/j.bone.2009.06.001.
5.       Almstedt HC, Canepa JA, Ramirez DA, Shoepe TC. Changes in bone mineral density in response to 24 weeks of resistance training in college-age men and women. J Strength Cond Res. 2011 Apr;25(4):1098-103. doi: 10.1519/JSC.0b013e3181d09e9d.
6.       Martyn-St James M, Carroll S. Progressive high-intensity resistance training and bone mineral density changes among premenopausal women: evidence of discordant site-specific skeletal effects. Sports Med. 2006;36(8):683-704.
7.       Vanni AC, Meyer F, da Veiga AD, Zanardo VP.  Comparison of the effects of two resistance training regimens on muscular and bone responses in premenopausal women. Osteoporos Int. 2010 Sep;21(9):1537-1544. doi: 10.1007/s00198-009-1139-z.
8.       Miranda F, Simão R, Rhea M, Bunker D, Prestes J, Leite RD, Miranda H, de Salles BF, Novaes J. Effects of linear vs. daily undulatory periodized resistance training on maximal and submaximal strength gains. J Strength Cond Res. 2011 Jul;25(7):1824-1830. doi: 10.1519/JSC.0b013e3181e7ff75.
9.       Prestes J, Frollini AB, de Lima C, Donatto FF, Foschini D, de Cássia Marqueti R, Figueira A Jr, Fleck SJ. Comparison between linear and daily undulating periodized resistance training to increase strength. J Strength Cond Res. 2009 Dec;23(9):2437-2442. doi: 10.1519/JSC.0b013e3181c03548.
10.   Rhea MR, Ball SD, Phillips WT, Burkett LN. A comparison of linear and daily undulating periodized programs with equated volume and intensity for strength. J Strength Cond Res. 2002 May;16(2):250-255.
11.   Tsuzuku S, Shimokata H, Ikegami Y, Yabe K, Wasnich RD. Effects of high versus low-intensity resistance training on bone mineral density in young males. Calcif Tissue Int. 2001 Jun;68(6):342-347.
12.   Harries SK, Lubans DR, Callister R.Systematic Review and Meta-Analysis of Linear and Undulating Periodized Resistance Training Programs on Muscular Strength. J Strength Cond Res. 2014 Sep 29.
13.   Bonaiuti D, Shea B, Iovine R, Negrini S, Robinson V, Kemper HC, Wells G, Tugwell P, Cranney A. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database Syst Rev. 2002;(3):CD000333.
14.   Bolam KA, van Uffelen JG, Taaffe DR. The effect of physical exercise on bone density in middle-aged and older men: a systematic review. Osteoporos Int. 2013 Nov;24(11):2749-2762. doi: 10.1007/s00198-013-2346-1. Epub 2013 Apr 4.
15.   Warren M, Petit MA, Hannan PJ, Schmitz KH. Strength training effects on bone mineral content and density in premenopausal women. Med Sci Sports Exerc. 2008 Jul;40(7):1282-1288. doi: 10.1249/MSS.0b013e31816bce8a.
16.   Singh JA, Schmitz KH, Petit MA. Effect of resistance exercise on bone mineral density in premenopausal women. Joint Bone Spine. 2009 May;76(3):273-280. doi: 10.1016/j.jbspin.2008.07.016.
17.   Chilibeck PD, Calder A, Sale DG, Webber CE. Twenty weeks of weight training increases lean tissue mass but not bone mineral mass or density in healthy, active young women. Can J Physiol Pharmacol. 1996 Oct;74(10):1180-1185.
18.   Lohman T, Going S, Pamenter R, Hall M, Boyden T, Houtkooper L, Ritenbaugh C, Bare L, Hill A, Aickin M. Effects of resistance training on regional and total bone mineral density in premenopausal women: a randomized prospective study. J Bone Miner Res. 1995 Jul;10(7):1015-1024.
19.   Stengel SV, Kemmler W, Pintag R, Beeskow C, Weineck J, Lauber D, Kalender WA, Engelke K. Power training is more effective than strength training for maintaining bone mineral density in postmenopausal women. J Appl Physiol (1985). 2005 Jul;99(1):181-188.
20.   Conroy BP, Kraemer WJ, Maresh CM, Fleck SJ, Stone MH, Fry AC, Miller PD, Dalsky GP. Bone mineral density in elite junior Olympic weightlifters. Med Sci Sports Exerc. 1993 Oct;25(10):1103-1109.
21.   Suominen H. Muscle training for bone strength. Aging Clin Exp Res. 2006 Apr;18(2):85-93.
22.   Tsuzuku S, Ikegami Y, Yabe K. Effects of high-intensity resistance training on bone mineral density in young male powerlifters. Calcif Tissue Int. 1998 Oct;63(4):283-286.
23.   Walters PH, Jezequel JJ, Grove MB. Case study: Bone mineral density of two elite senior female powerlifters. J Strength Cond Res. 2012 Mar;26(3):867-872. doi: 10.1519/JSC.0b013e31822c71c0.
24.   Siewe J, Rudat J, Röllinghoff M, Schlegel UJ, Eysel P, Michael JW. Injuries and overuse syndromes in powerlifting. Int J Sports Med. 2011 Sep;32(9):703-711. doi: 10.1055/s-0031-1277207.
25.   Ebben WP, Garceau LR, Wurm BJ, Suchomel TJ, Duran K, Petushek EJ. The optimal back squat load for potential osteogenesis. J Strength Cond Res. 2012 May;26(5):1232-1237. doi: 10.1519/JSC.0b013e3182305321.
26.   Swinton PA, Lloyd R, Keogh JW, Agouris I, Stewart AD. A biomechanical comparison of the traditional squat, powerlifting squat, and box squat. J Strength Cond Res. 2012 Jul;26(7):1805-1816. doi: 10.1519/JSC.0b013e3182577067.
27.   Zakhem E, El Hage R, Bassil S, Moussa E, Zunquin G, Theunynck D. Standing long jump performance is a positive determinant of bone mineral density in young adult women. J Clin Densitom. 2013 Apr-Jun;16(2):129-130. doi: 10.1016/j.jocd.2013.02.015.
28.   El Hage R, Zakhem E, Zunquin G, Theunynck D, Moussa E, Maalouf G. Performances in Vertical Jump and Horizontal Jump Tests Are Positive Determinants of Hip Bone Mineral Density in a Group of Young Adult Men. J Clin Densitom. 2013 Apr 23. pii: S1094-6950(13)00053-X. doi: 10.1016/j.jocd.2013.03.016.
29.   Kato T, Terashima T, Yamashita T, Hatanaka Y, Honda A, Umemura Y. Effect of low-repetition jump training on bone mineral density in young women. J Appl Physiol (1985). 2006 Mar;100(3):839-843.
30.   Zhao R, Zhao M, Zhang L. Efficiency of jumping exercise in improving bone mineral density among premenopausal women: a meta-analysis. Sports Med. 2014 Oct;44(10):1393-1402. doi: 10.1007/s40279-014-0220-8.
31.   Tucker LA, Strong JE, LeCheminant JD, Bailey BW. Effect of two jumping programs on hip bone mineral density in premenopausal women: a randomized controlled trial. Am J Health Promot. 2015 Jan-Feb;29(3):158-164. doi: 10.4278/ajhp.130430-QUAN-200.

32.   Trabelsi H, Elloumi M, Mrad M, Aouichaoui C, Chortane SG, Cheour I, Tabka Z. Jumping improves lower limbs bone mass and lean mass in elite jumpers. J Sports Med Phys Fitness. 2016 Dec;56(12):1494-1502. Epub 2016 Jan 14.

Monday 18 September 2017

Low Back Pain: What Are We Doing Wrong and What Can We Do Better?

            Low back pain (LBP) is one of the largest causes of disability worldwide. Approximately 80-90% of people have LBP at some point in their lives. For most people with LBP the prognosis is good as the vast majority get better on their own and don’t need to seek treatment. However, despite an increase in research and treatment options, the rate of chronic LBP has alarmingly increased as of late1.
            I initially wanted to call this article “Low Back Pain: What Are We Doing Wrong” but I decided to reframe it and try to provide some positive advice & alternatives to what is commonly done in healthcare. The purpose of this article is not to come up with a panacea for LBP as none exists but rather to show some areas that we as healthcare professionals (myself included) can improve on to reduce the impact of LBP on society.

Disclaimer: As outlined in this article my website is tailored towards professionals and is not intended to be medical advice for patients or lay people.

Disclaimer 2: As with some of my previous articles, to keep it short & not bog it down in references, this will not and should not be considered a systematic lit review.

So where are we going wrong with back pain?

1) Overimaging

One of the major issues in the LBP epidemic is the overuse of imaging technologies such as X-Rays and MRI scans.

Well won’t they show what’s wrong with my back?

The problem is that many PAINFREE people have degenerative disc disease, disc herniations and facet joint arthritis (among other things). As such it’s very difficult to rely on imaging as the sole method of diagnosis due to the higher number of false positives (i.e. positive findings in people WITHOUT back pain).

This table below came from a 2014 review done on PAINFREE people and shows that “abnormal” imaging findings are quite common in painfree people2.

Now imaging does have a time in a place in certain situations such as
-          Suspected cancer, fracture, infection, cauda equina syndrome or inflammatory disease
-          Worsening neurological deficit (i.e. loss of sensation, reflexes and/or strength in an area innervated by a specific nerve root) that isn’t improving with treatment

However, back pain in and of itself is not an indication for an MRI and research shows that people who get unwarranted imaging actually do worse in the long term3. As such it’s appropriate to save medical imaging for the few times its indicated.

2) Lack of understanding of pain science & the biopsychosocial model

Many people think that pain is solely due to an injury or something wrong. In reality that’s not the case. Research has shown that only 10-20% of back pain cases are attributable to a specific diagnosis such a fracture, symptomatic disc herniation or other cause4. I often hear of people that were diagnosed as having a “pinched nerve” or “arthritis” or “degenerative disc disease” yet these diagnoses don’t match the symptomatic presentation that the patient has.

Side note: just because your clients’ back pain doesn’t fit into a specific pathoanatomical diagnosis doesn’t mean you can’t develop a specific treatment plan based on their presentation, general health, psychosocial factors, and goals.

Yet pain in reality is a product of the nervous system which can be caused by a variety of factors. Pain isn’t a sole 1:1 result of injury and can be influenced by biological, psychological and sociological factors5 and as such should be viewed as a complex, multifactorial experience.

3) Overpathologizing

Some may disagree with me, but I do believe that biomechanics are still important in pain & injury. The problem that I have is that many patients are diagnosed with “pseudobiomechanical” faults that either
-          Can’t be reliably assessed and/or
-          Don’t correlate well with pain6–9

In some cases of back pain biomechanics can be relevant10–12 – but too often we tend to assume that “pseudobiomechanical” faults are the root causes of back pain without doing a proper, thorough assessment of the individual such as the McGill Method and/or the McKenzie method.

The other issue is the impact of what clinicians say to people with back pain. Nocebo, the opposite of placebo, can have very powerful and negative effects on people’s pain13. If a patient is told that they’re a complete dysfunctional mess and should be in pain than they probably will be. Read this paper if you don’t believe me14. Using positive language is critical to helping your clients believe in themselves and their backs.  

4) Overuse of surgeries

Some back surgeries such as discectomies (disc removal) have very high rates of complications15 and spinal fusion surgeries have been shown to be no better than placebo surgery16. Following with points 1 & 2 many, unfortunately uneducated, people feel that by “cutting out” the cause of the pain than symptoms will reside but as stated above many of these findings are common in painfree populations & may not be clinically relevant. Going through surgery and failing can, in my opinion, create a nocebo effect and a sense of hopelessness in the patient.

Surgeries, as with imaging, have a time and a place – mostly for the same reasons. As such surgeries should only be performed when indicated.  

I hope this gives you, the reader, some ideas as to how you can improve your own practice.

As always I’m interested to hear your thoughts.


1.           Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating Chronic Back Pain: Time to Back Off? J Am Board Fam Med. 2009;22(1):62-68. doi:10.3122/jabfm.2009.01.080102.
2.           Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173.
3.           Darlow B, Forster BB, O’Sullivan K, O’Sullivan P. It is time to stop causing harm with inappropriate imaging for low back pain. Br J Sports Med. 2017;51(5):414-415. doi:10.1136/bjsports-2016-096741.
4.           O’Sullivan P. Diagnosis and classification of chronic low back pain disorders: Maladaptive movement and motor control impairments as underlying mechanism. Man Ther. 2005;10(4):242-255. doi:10.1016/j.math.2005.07.001.
5.           Edwards RR, Dworkin RH, Sullivan MD, Turk DC, Wasan AD. The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain. J Pain. 2016;17(9):T70-T92. doi:10.1016/j.jpain.2016.01.001.
6.           Huijbregts PA. Spinal Motion Palpation: A Review of Reliability Studies. J Man Manip Ther. 2002;10(1):24-39. doi:10.1179/106698102792209585.
7.           Cooperstein R, Hickey M. The reliability of palpating the posterior superior iliac spine: a systematic review. J Can Chiropr Assoc. 2016;60(1):36-46. Accessed July 21, 2017.
8.           Tüzün C, Yorulmaz I, Cindaş A, Vatan S. Low back pain and posture. Clin Rheumatol. 1999;18(4):308-312. Accessed July 8, 2017.
9.           Lederman E. The fall of the postural-structural-biomechanical model in manual and physical therapies: Exemplified by lower back pain. J Bodyw Mov Ther. 2011;15(2):131-138. doi:10.1016/j.jbmt.2011.01.011.
10.         Rannisto S, Okuloff A, Uitti J, et al. Leg-length discrepancy is associated with low back pain among those who must stand while working. BMC Musculoskelet Disord. 2015;16(1):110. doi:10.1186/s12891-015-0571-9.
11.         McGill SM. Low Back Disorders: The Scientific Foundation for Prevention and Rehabilitation. Champaign, IL: Human Kinetics; 2002.
12.         Brinjikji W, Diehn FE, Jarvik JG, et al. MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol. 2015;36(12):2394-2399. doi:10.3174/ajnr.A4498.
13.         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.
14.         Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med. 2013;11(6):527-534. doi:10.1370/afm.1518.
15.         Shriver MF, Xie JJ, Tye EY, et al. Lumbar microdiscectomy complication rates: a systematic review and meta-analysis. Neurosurg Focus. 2015;39(4):E6. doi:10.3171/2015.7.FOCUS15281.

16.         Mannion AF, Brox J-I, Fairbank JC. Consensus at last! Long-term results of all randomized controlled trials show that fusion is no better than non-operative care in improving pain and disability in chronic low back pain. Spine J. 2016;16(5):588-590. doi:10.1016/j.spinee.2015.12.001.

How I've Adapted The McKenzie Method Over The Years

If someone were to ask me “what are the biggest influences on your therapy philosophy” they would be (in no particular order) ·  ...