My 2018 In Review: Top Things I Learned + My Top 5 Most Viewed Articles Of 2018

2018, especially its Fall, was an exciting time for me. I’m grateful for all the people who I’ve met and talked to over the past year through working at Altum Health, SWIS, taking the Canadian Powerlifting Union Coaching Certification, guest lecturing at UW and becoming a writer for Mash Elite Performance. Thank you all.

Through all the excitements and highlights of 2018 I’ve learned quite a few things, some of which the hard way, that I’d like to share in the final article of 2018.

Side note: This does not include anything that I learned at SWIS 2018 as that would basically involve regurgitating another article that I have written here.

1) You may not always get all of your patients’ psychosocial factors on Day 1

In my career I’ve worked hard to gain a complete understanding of my patients’ psychosocial factors through subjective history, questionnairres such as the Orebro Questionnaire and just good interviewing skills.

I’ve had a few experiences this past year with patients where patients didn’t open up about various psychosocial issues, stressors or traumatic events until a few weeks (or even a few months) into therapy.

When you think about it – it seems like common sense. You wouldn’t tell a random dude on the street your most personal secrets on the first day … so as such I (and you) need to not assume that we’ve detected all of a patients’ psychosocial factors on Day 1.

This shows the importance of

-          Taking your time

-          Listening to the patient’s story

-          Validating their story

-          And just being an overall good person to build that rapport with your patients

2) Core exercises & core stiffness may not be a bad thing (at least for a short time period) in certain people with LBP

With some of the research that’s came out showing that core exercises are equal to (or maybe slightly better than) general exercise for LBP – many practitioners wonder why we even bother with them.

However in some LBP cases, to paraphrase a quote from Greg Lehman, people may be aggravated by specific movements/postures/or loads in a more “nociceptive” manner. These are the cases most people refer to when using terms like “flexion intolerant,” “extension intolerant,” and others. While we know back pain can’t be attributed to just mechanical factors – sometimes a person’s movement or posture can make a big difference on their individual symptom presentation.

In these populations I do believe there is a place for McGill-esque core exercises, if anything else, to teach them the control required to move in a way that doesn’t aggravate the problem. This is where approaches like McGill and McKenzie make a ton of sense – you move and exercise in a way that doesn’t exacerbate the symptoms long term.

 That said

-          You don’t want to have people avoid movements forever and/or walk like Tin Man from The Wizard Of Oz

-          For some people other factors (i.e. stress, poor sleep, fear of movement) may be bigger drivers of your clients’ sensitivity. In those situations I care less about “core stiffening” and more about managing these other issues.

3) You’re never gonna please everyone

Having worked at a couple different clinics, and having talked to many different clinic owners, I’ve learned that … you’re never gonna please everyone whether its patients or other physios.

Some want more manual therapy … some want less. Some want more exercise … some want less. Some want more education … others want less talking more doing. Some want more modalities … some want less.

At the end of the day you can’t please everyone. That said – it is important to ask patients (and clinic owners if you’re searching for a job) what their expectations are.

Therapy shouldn’t be a dictatorship but there has to be some give and take on both ends.

While I’m not a huge modality guy – if doing 5 minutes of ultrasound gets a patient to do everything I need them to do – I’ll take that tradeoff. That said if a patient doesn’t want to follow any of my recommendations outside of the clinic and just wants me to “fix” them – then we have problems and have some work to do.

I’m also more OK now with just letting the occasional patient go rather than feeling like I have to excessively bend over backwards to please everyone when I know it’s not in their best interest.

4) Don’t be intimidated by fibromyalgia & chronic pain diagnoses

This came partly through my last job at Impact Physiotherapy & Performance but was more solidified through my current job at Altum Health in Cambridge, Ontario, Canada. Approximately 80% or more of my caseload is people with persistent pain.

I, like most physios at some point, got intimidated by these more complex and more irritable cases & was more cautious with them. While you have to be careful to not flare them up – quite often many people, even those with chronic pain, are capable of more than we realize and a process of starting super slow and building up gradually can (in my experience) provide great benefits for fitness, mobility & health.

That said, as I said above, there are some patients that will be flared up regardless of how gentle you proceed with things. Again these people likely need more help in other areas (i.e. psychosocial factors, sleep management) to help with decreasing pain.

5) How great vacations are … when you actually take them

2018 was the first year out of physio school where I took all of my vacation days. Some of these were spent with family & friends and some were spent travelling across Ontario. As much as I enjoy working hard it’s great to take some restorative time and to catch up with friends – something that gets neglected in the pursuit of selfish goals.

 6) Sometimes you just gotta say “no” and set boundaries

Having a lot of great professional opportunities can be both a blessing and a curse. It’s a blessing in the sense that people value your work & your opinion – plus some of these come with financial benefit. But it can also be a curse as it’s very easy to get overloaded & overburdened.

Over the course of this year I’ve had to, for the sake of my own mental sanity & energy levels, say no to some big opportunities with some big names in the field. As someone who wants to help as many people as possible – that hurt. But it was something I had to do to take care of myself first.

Below is a list of my five most viewed articles of 2018 on this site….

5 – Barriers To Exercise In People With Chronic Health Conditions

4 – How I Assess & Treat People With Low Back Pain: Parts 1 and 2

3 – My Journey With A Learning Disability, Anxiety and Depression: Finding Strength & Confidence – I wrote this article in honour of #bellletstalkday and had no idea how well it would be received. Thank you.

2 – The McGill Method: Common Misconceptions – Co-authored with Dr. Stuart McGill

1 – An Evidence & Experience Based Critique Of The McKenzie Method (MDT)

I wish you all a Merry Christmas and a fun, safe and happy holiday season with friends & family. Thanks for reading and I will see you in 2019!!!

Do I Need A Strength & Conditioning Certification As A Physiotherapist And If So Which One Should I Take?

                Over the last couple weeks I’ve gotten several messages in my Messenger inbox and I’ve also seen several social media posts discussing whether or not physiotherapists should get involved in strength training clients and discussing which certifications to get. The past decade has seen a huge increase in “hybrid” physiotherapists & strength coaches and while it’s great to see people that can take clients from in pain to high performance it begs the question – do all physiotherapists need S&C certifications and if so what route to take?

                The answer is, to quote my friend and mentor Stuart McGill, “it depends.” It depends on…

1) The demographic you want to work with

This is the biggest decision-maker. If you work in pediatrics – good luck getting them into strength training. If you work in ICU, or acute care in general, spending a lot of money on a strength & conditioning certification probably won’t offer the same return on investment as courses & education more tailored to that setting. Same goes for pelvic health physiotherapy.

When it comes to neuro rehab it’s a grayer area as it depends on how well functioning your clients are. If many of your clients have at least Grade 3/5 muscle strength than hell yes it’s worthwhile to know this stuff. If many of your clients tend to be more flaccid and lack that strength than learning more neuro-rehab specific techniques is likely a better use of your time & effort. As Stan Efferding said “you can be good at anything but you can’t be good at everything.”

If you work in orthopedics in a more general population setting I don’t believe a S&C certification is essential although it can be helpful if you have athletes and/or lifting junkies come through the door on occasion. That said I do believe a basic knowledge of exercise prescription is essential for all physios in any setting.

The biggest populations where having a personal training or strength coaching certification can be helpful are

- When working with chronic disease populations such as osteoarthritis, osteoporosis, cancer, diabetes, heart disease and/or lung disease due to the number of safety precautions and rules that you have to be aware of.

At UW KINNection 2018 where many Kinesiology students get their first experience making exercise programs for people with chronic diseases.

- The big one … if you work in a clinic with athletes and/or people who love weight training. This is self-explanatory as you need to, to do your job effectively, have the knowledge to transition those clients from pain & potentially very remedial levels of exercise to being able to do high performance movements such as lifting, sprinting, jumping, and potentially throwing based on their activities.

This may seem like common sense but, as strength coach Trevor Cottrell said, a lot of physios don’t know strength training and athletics & spend more time strengthening their clients’ glute med than they do physically preparing them to withstand the demands of athletic + strength training endeavours. It’s as big of an injustice to underload and underprepare someone and put them through “rehab purgatory” just prior to returning them to sport as it is to overload them.

Under Trevor Cottrell's coaching earlier this year at the Intro To Olympic Lifting course at The Vault Barbell Club

2) If you need it for a job

Some clinics, particularly sport rehab clinics or clinics in a gym, will require you or recommend you have a strength coaching or personal training certification.

So now to the second part of the article … which certification should I take?

Option #1: I work with elderly and/or diseased populations

In that case the best certifications are the CSEP (in Canada) or ACSM (in the US) Exercise Physiologist certifications. I do believe you should spend a fair amount of time working with those populations, under the direction of someone highly qualified, before working with that population on your own as there is great potential to help people but also great potential for harm if things are done incorrectly.

The GLAD (GoodLife with osteoArthritis in Denmark) courses done worldwide are fantastic for understanding lower body exercise prescription, not just for osteoarthritis, but in general.

BoneFit, done by Osteoporosis Canada in Canada, is quite useful as well.

Option #2: I work with athletes and/or weight training clients

CSCS is the most popular one that people go with. That said there are a couple holes that CSCS, in my opinion, leaves uncovered which are

-          Understanding how to coach, program and progress speed movements (I.e. sprinting & jumping): I recommend Joe DeFranco, Lee Taft, and Nick Winkelman’s work as resources for speed training as this is essential for returning team sport athletes to sport after certain injuries (i.e. ACL tear, hamstring strain)

-          Understanding how to coach and modify the powerlifts for clients: I did the Canadian Powerlifting Union Coaching Certification this year and found it insanely valuable. It was probably the best training related certification I’ve done specifically on the powerlifts.

At the CPU Coaching Certification earlier this year at The Vault Barbell Club

As with Option 2 – you still need to, in my opinion, spend time working with these populations under the supervision of a qualified coach before working with these populations on your own. That’s why, despite my certification, I don’t call myself a powerlifting coach.

Bonus: Who are good people to learn from?

People that I recommend other physios learn from in regards to strength training are

Physiotherapists: Scotty Butcher, Charlie Weingroff, Stefi Cohen, John Rusin, Dani LaMartina (Overcash), Christina Prevett (Nowak), Michael Mash, Zach Long … and myself.

Strength Coaches: Nick Winkelman, Brian Carroll, Chris Duffin, Travis Mash, Meghan Callaway, Mike Boyle, Eric Cressey, Mike Robertson.

I hope this article provided some useful advice and guidance and I hope you will share it with other physiotherapists & physiotherapy students who may have the same question. As always – thanks for reading.

My Experience At SWIS 2018 And The Top Things I Learned

               

On October 26^th I travelled down the 401 to Mississauga for SWIS (Society of Weight-Training Injury Specialists) 2018. The weekend was the highlight of my year and exceeded all expectations. Hell – I’m still coming down from the energy high of the symposium a week later. So bear with me while I try to explain my experiences from the weekend.

                In a previous Facebook post SWIS organizer Ken Kinakin encouraged people to come to SWIS in person rather than just buy the video package. Don’t get me wrong, the presentations were great, but the interpersonal interaction with many great rehab & fitness professionals from around the world was even greater.

                I came to SWIS with a list of people in my head that I wanted to meet (and get my picture taken with). I thought to myself “I’ll probably be lucky to get a few seconds here & there with them” but I ended up running into all of them fairly frequently in the hallway, restaurant, bar and lobby. I met Ken & Sheri Whetham, caught up with Stan Efferding, met Dani LaMartina (Overcash) and met Scotty Butcher within the span of just over an hour.

                Some of the highlights (god there were so many) from these interactions included

1)      Hanging out with fellow PTs, lifters, and strength training junkies – EliteFTS writer & 2^nd ranked powerlifter in the world in her weight class Dani LaMartina and University of Saskatchewan professor & Strength Rebels founder Scotty Butcher.

2)      Getting into a conversation (and picture) with Stan Efferding, Brian Carroll, and Stu McGill – easily 3 of the biggest influences on my training.

3)      Ducking out after the Rehab Panel’s presentation on Saturday afternoon & being invited for a whiskey by Jim Wendler. If you’d have told me I’d have spent the evening of my 28^th birthday talking about everything under the sun with Wendler I wouldn’t have believed you.

4)      A good hour or so of chit chat with Dani and John Rusin – two of the most influential PTs in the world of strength training today.

5)      Spending a good chunk of Sunday afternoon with my good friend & mentor Stuart McGill, Brian & Ria Carroll, Dani LaMartina, and Paul Oneid.

6)      And meeting Bill Kazmaier (whom I’ve watched on TV since being a little kid) and Eddy Coan – that’s pretty self-explanatory

The presentations that I went to (and the top point I learned from each) were…

Stan Efferding - The Vertical Diet: Meal prepping and organized diets like Weight Watchers & Jenny Craig are actually more effective for weight loss than advice provided by a dietician or doctor.

Bill Kazmaier & Ed Coan - Powerlifting Workshop: Both lifters emphasized how they trained in a “powerbuilding” style in the off-season further away from meets using more general movements and a focus on volume. This is a contrast to the popular high-volume, high specificity, and high-frequency style of training used by many drugfree lifters yet it seems (so far, anecdotally) that the former style of  training is more conducive to longevity.

Chris Duffin & Brandon Senn – Back Training For The Strength Athlete: Their presentation was not so much on stereotypical back muscle training (i.e. chins, rows, face pulls, shrugs) as it was on training the back to withstand high training volumes of axially loading exercises. Brandon emphasized that you can progress training volume very slowly – a couple reps or a set at a time over a period of weeks to months to allow for progress while minimizing injury risk. This is in line with Tim Gabbett’s work on acute/chronic workload ratios & injury risk in athletes.

Bill Kazmaier, Ed Coan, Jim Wendler, Matt Wenning, Ken Whetham, Brian Carroll, J.L. Holdsworth – Powerlifting Panel: The biggest point they emphasized to me was putting the ego in park, not rushing things, and progressing slowly. This is a tough thing to do as we are a delayed gratification society … and admittedly it was a tough thing to do for me as I had i) achieved a lot of professional success at a young age and ii) always felt like I needed to be a better lifter for fear that I would be seen as a “fraud” by the strength training community.

Brian Carroll & Stu McGill – Gift Of Injury: Now being a student of Stu’s and having worked off of Brian’s training philosophy for 3 years I am quite familiar with their work already. The biggest thing I’ve learned from them over the years, and told them, was their focus on purposeful repetitions and maximal full body tightness & intensity. This is the kind of technique that you can only execute for a rep or 2 ‘cause it’s so exhausting.

J.L. Holdsworth – Grip Strength Training: J.L. broke down grip strength training to a level that I had never thought of before. To me grip training was always doing lots of deadlifts, carries, shrugs, chins and rows with challenging weights. J.L. described 7 different types of grip strength and the ways to train each of them. He also discussed how, contrary to popular belief, long duration holds (i.e. farmer’s walks) may be counterproductive for grip strength training and would build more endurance than strength.  

Rehab Panel: How funny and outrageous Dr. Eric Serrano is. No but seriously the top thing I learned from this presentation was the value of scapular upward rotation & protraction work for athletes who train the bench press in a competitive manner (i.e. lats tight, scapulae retracted & depressed). The problem is – people think that chins or rows are antagonistic to bench press but they really (assuming you bench for strength) involve the same scapular movements. The presenters described a neat variation of the scap pushup that involved more scapular upward rotation and t-spine movement to, in theory, involve the serratus anterior more and train those movement qualities that get neglected in bench pressing powerlifters.

Jim Wendler – High School Strength Training: Wendler’s known worldwide for his ability to simplify strength training through his 5/3/1 books and this was no different. The two top things that Wendler discussed were the concepts of letting young athletes become leaders and the idea of giving them a high GPP base through running, jumping jacks, bodyweight movements and the like. I wish I would have done this kind of training earlier in my lifting career.

John Rusin - Performance Recovery Systems: In Rusin’s recovery system he discussed a difference between foam rolling for warming up to work out (i.e. hard, short, fast) and the idea of foam rolling for recovery (i.e. slow paced, over broad muscle groups, relaxed). Admittedly I did treat foam rolling as a “fuck it – let’s get this over with” kind of project but now I will focus more on foam rolling in the latter manner to get the maximum benefit.

 I ended up helping Stu & Brian with some stuff Sunday afternoon and as such didn’t get to the last couple presentations. I have a good 15 hours (or more) of video to watch from presentations I didn’t even attend.

My only regret from the weekend was not getting to know more about the less “famous” (if that’s the right word) presenters. I wanted to meet the heavy hitters like Kaz, Coan, Carroll, Wenning, Rusin, Wendler etc. and as such didn’t investigate the backgrounds of many of the other presenters.

As an example - at the dinner table on Saturday I was surrounded by Wendler on one side and by medical doctor & 2 time European Union powerlifting champ Dr. Fionnula McHale on the other side. Fionnula was visited by many people, almost to the point where we couldn’t talk much. She struck me as a very beautiful, outgoing, physically fit woman who I had; to my own chagrin; assumed was a bodybuilder or figure competitor. I had no idea; until Kaz told me the next morning; that she had overcame a lot of mental demons to present here and that she was such a successful athlete, doctor & person. I had no idea how amazing of a person I had sitting behind me. I use this as an example, and as advice to future attendees to do your homework and read more into the stories & credentials of all the presenters … not just the #1 attractions.

Another piece of advice I have from SWIS, and in contrast to above was something I did right, is to take the time to meet local fitness & rehab professionals closer to your area. When you have people coming from as far as Singapore & Hong Kong it’s easy to neglect connections with the people near you. Take the time to do so.

With the man behind the magic - Ken Kinakin

Well – this article is nearing 1500 words and as such it’s time to wrap it up. Thank you Ken Kinakin, and all the amazing people mentioned above, for an amazing weekend. I look forward to the next SWIS symposium. As always – thanks for reading.

The Future Of Evidence Based Rehab And Training

        Hello all. First of all I want to say thank you for all your support over 2017 and 2018. It's been an amazing and fun ride & you have no idea how grateful I am for everything.
        Secondly - I know I've been MIA lately as I've recently switched jobs and moved to a new city. Needless to say it's been an exciting fall. In addition to the delays involved with starting a new job and moving ... I have also been working on a revamp to the style and content of my site.

Content focus –

As I have switched jobs from Impact Physiotherapy and Performance to UHN Altum Health Cambridge my clinical focus has changed. I deal more with complex injuries to the shoulder, lower extremity, and entire spinal column as well as with concussions. 

Sports-related therapy is a very small focus of what I do now so it will get a smaller emphasis on the website. My “rehab to performance” based material will still be more prevalent on Mash Elite Performance.

My involvement with geriatrics and chronic diseases, aside from OA and osteoporosis/osteopenia, is pretty much nil.

Concussion therapy is very difficult to describe via a 500-1000 word article and is probably best left to the experts who teach concussion therapy courses such as the Shift, R2P and my old physio school instructor Shannon McGuire.

  

Now you may be wondering “what does that leave for my site.” Well my content will focus on

-          Persistent Pain: exercise strategies and general concepts around persistent pain

-          Communication based themes such as explaining various concepts (i.e. pain science education, exercise coaching) and subjective interviewing

-          Tips for schooling and early practice (now that I’m through that phase of my career)

-          Specifics (i.e. risk factors, special tests) on specific conditions such as

o   Shoulders: rotator cuff strains & tendinopathies, shoulder dislocations

o   Knees: ACL/MCL tears, patellar dislocations, meniscus tears, OA

o   Spinal: WAD, Osteoporosis, I’ve already got a series on low back pain

-          As well as some exercise tips & tricks that I use. I’m hoping to get more tech savvy and put more video content out.

Frequency –

As I posted on FB recently a goal of mine is to cut-back a bit on writing, curriculum work, and even lifting time to give me more time for both my patients and myself. As such I am not holding myself to a set frequency of articles. You may see one every few months or a few in a month depending on my creative juices and what comes through.

If you have any comments, suggestions or anything you'd like covered send me a DM or message me via my email bigericbowman@gmail.com. As always - thanks for reading. 

If You Want To Stay Fit And Painfree Don't Ever Do This Exercise!!!!

       As a physiotherapist who also works and lives in the fitness industry I’ve seen many people who have hurt themselves performing various exercises or activities. Over time – a few common exercises stand out in my head as problematic for many of the people I work with. In this article I tell you what exercises you must absolutely avoid to stay fit and painfree.

…..Alright, but seriously, now that the clickbait is out of the way it’s time to get to the true purpose of this article. A recent couple of stories have been making rounds over the past few weeks as they recommend modifying or eliminating specific exercises for people over 50.

                Although my involvement with the middle aged & elderly has decreased as a result of my recent change of jobs I still spend a fair amount of time with those populations through my current job and through my involvement with the University of Waterloo. While the above pieces are a bit overboard and can border on fear-mongering – it’s important to understand that some exercises may not be good fits for certain people. Instead of saying an exercise is bad or good a better way to do things is to look at an exercise through the questions I pose below

Question 1: What is the goal of the individual?

This will vary based on the setting you work with (rehab vs fitness) and the specific population you work with. The goals determine the acceptable risk/reward ratio of the exercise.

For instance – a heavy deadlift with chains on each end of the bar may be an appropriate exercise for someone competing in strength sports but can be overkill for someone who’s interested in other goals such as pain relief, fat loss, hypertrophy or improved athleticism. Another exercise that has less joint load may be a better choice for them.

Running is a big example of this as it does have a higher injury rate compared to other activities, even strength sports. If you enjoy running; are healthy; and manage training load, recovery, nutrition, sleep, psychosocial factors etc well it’s probably a fine activity for you. But if you’re 100 lbs overweight and have a variety of medical & orthopedic issues there are better options to improve your fitness.

Basically, to make a long story short, does the exercise fit within the goals of the individual and work towards those goals.

Question 2: Can the exercise be done properly?

Research and anecdotes have shown that there are lots of different ways to perform an exercise properly. But there does, in my opinion, need to be standards for technique when it comes to higher load movements such as the powerlifts & the Olympic lifts. I’m not gonna lose sleep if someone forgets to “grip the floor” with their toes in a front squat but if they’re excessively falling forward and their legs look like that of a baby giraffe then it may not be an appropriate choice for them.

Side note: before saying an exercise can’t be done properly and making your client do a million corrective exercises – try showing them what you’re looking for in terms of technique, coaching & cueing them, and also experimenting with different grips & stances & bar positions. If they still can’t do it properly despite all that then, in an SFMAish sort of fashion, break things down to look at mobility and control of individual joints to see what is lacking and modify training as deemed appropriate by giving your client exercises that can be done properly.

Bottom line: if an exercise, despite proper coaching and cueing, can’t be done to an acceptable standard find another option to achieve the goal.

Question 3: Does the exercise aggravate any medical issues?

In general, for fitness training, exercise should be painfree. If an exercise causes issues modifications should be given to make training painfree.

Some exercises just don’t sit well with certain people. Tricep extensions/skullcrushers/JM presses etc; regardless of technique, order in the workout, rotation of exercises, or volume progression; just irritate my elbows so as such I stick to pushdowns and tricep dominant pressing movements (i.e. dips, close grip bench press).

The only exception I make in training, as I talked about with Travis Mash, is when an athlete is peaking for a major competition that means a lot to them. In that case “the juice may be worth the squeeze” to quote Brian Carroll.

In rehab, for the most part, exercises should be painfree where possible – but I also believe some people (i.e. chronic pain, post-surgical, central sensitization) may not be able to do anything painfree. Exercising patients into pain is a complex and difficult topic which I plan to write about in more detail in a future article.  I would say if you’re not someone who’s well versed (from a research knowledge, professional training & licensing, and experience perspective) in exercise for those populations you need to refer out to someone who is. If you need help contact me via Facebook.

If an exercise doesn’t have an appropriate risk/benefit ratio based on the goals of the person don’t force it if it’s painful.

Question 4: Is the exercise being programmed & progressed appropriately?

Sometimes an exercise is good but can be programmed inappropriately. Take for instance people that go from squatting 1x/week to doing a “Squat Everyday.” Neither of those are bad programs but there needs to be a proper progression that allows for recovery & building work capacity. In a previous article I discussed Tim Gabbett’s research provided some general ideas on progressing activity volume that I find useful for competitive athletes, weekend warriors, and even people with persistent pain.

I hope this article provides some useful algorithms for you to determine whether or not an exercise is good for you or your clients. As always – thanks for reading. 

Strength And Conditioning For The Regular Person - How Much Is Enough? How Much Is Too Much?

                

                Earlier this summer my friend and fellow PT and strength training junkie Scotty Butcher tagged me in a brilliant presentation for Ignite Physio where he discussed the value of strength training post rehabilitation to transition from PPLOF (piss poor level of function) to OLOF (optimal level of function).

                As someone who’s a physio, strength coach and powerlifter and has seen, worked with, and/or learned from people who have squatted over a grand to people who can barely out of their own chair it got me thinking. For the regular person who’s not a competitive athlete and just wants to look good, feel good, and be healthy … how much strength is enough? How much cardiovascular fitness is enough? At what point does trying to improve those areas become detrimental to health and cross-over into high performance athletics? That is the topic of today’s article.

Disclaimer: Since many studies on strength use grip strength as a primary measure (which is linked to mortality) I will discuss this topic from a philosophical and opinion based perspective than with specific data as most people, outside of a physio clinic or performance centre, can’t measure their grip strength on a whim. Same goes for cardiovascular fitness.

I’m going to look at this topic from two perspectives

Perspective #1: We should just let people do the activities they want and live their life that way

There’s a lot to be said for this especially given the rates of obesity and inactivity in the developed world. A common saying is “the best form of activity is the one you’ll do and stick to.”

From a compliance perspective – yes it’s important that people enjoy the activities that they are doing. Not everyone enjoys running or slugging weights around as much as you do. It is what it is. As much as people like to knock CrossFit – it’s helped excite a bunch of people to get physically active.

My only concerns with this perspective are two fold

Concern 1 – In some regions, especially here in Canada where it seems to be either cold and snowy or stinking hot all year, many activities that people enjoy (i.e. certain sports, walking, gardening) just don’t get done. What good is an activity if you’re not doing it most of the year?

 Concern 2 – Are these activities enough to build both strength, cardiovascular fitness, lean body mass, and bone density to a point that

-          People can take part in more strenuous activities without any major issues

-          These attributes are built enough and maintained enough to the point where they won’t sink to a harmful level with age and

-          Supply a reserve of ability for after the activity is done

Explaining these points in more detail, and again using Canadian examples, look at the person who just walks and does things around the house … and then has a heartattack during the first major snowfall of the winter while shovelling snow. Those activities that the person took part in did not prepare them enough for the demands of a more physically demanding (yet essential) task nor did it give them a reserve of ability for afterwards as it was a beyond “max effort” task.

In addition – some research have questioned where low intensity activities such as walking can provide enough of a stimulus to maintain health, especially through the aging process.

As such, while it’s important that people pick activities they enjoy, there needs to be enough of a stimulus to promote health and to enable more strenuous essential activities to be done while still maintaining a reserve of physical functioning afterwards.

Perspective #2: We should turn all our physical therapy or personal training clients into powerlifters, endurance athletes or functional fitness freaks

As my friend Nick Tumminello said (paraphrased) we do tend to train our clients based on our specific biases – whether it’s cardio, bodybuilding, powerlifting, kettlebells, crossfit or the like.

While all of these activities, when programmed properly, can have great benefits on physical function my concerns are twofold.

First of all … these activities carry a higher health risk than just training for general health.

 My friend Stan Efferding has said “if you want to be healthy don’t compete.” While strength sports such as bodybuilding, powerlifting, strongman, and crossfit do have an injury rate comparable to (or slightly less than) those of non-contact sports an injury rate ranging from 1 every 10 years to over 1 per year is a lot for someone who’s not pursuing highly competitive athletics. In addition there are the other health risks involved from carrying  too much bodyweight; which includes too much fat and too much muscle; which include OA, insulin sensitivity, high blood pressure, and sleep apnea.

Endurance sports, while widely considered to be healthier than strength sports, actually have a much higher rate of injury. In a recent paper recreational runners are less likely to develop knee OA than the sedentary population – however competitive runners are more likely to develop knee OA. In addition – the relationship between cardiovascular fitness and health is not 100% linear. High performance endurance athletes can have higher mortality and adaptations of the heart that can predispose them to further issues.

 Secondly … training like a high-level athlete can become very burdensome from a time, effort and money perspective. Many high-level athletes train, eat, sleep and recover like it’s their job. Eating 6 meals a day, being in bed by 10 every night, and training 8-10+ hours a week doesn’t seem like the lifestyle most people want to live when their goal is just to be healthy.

As such – training like a competitive athlete isn’t the answer either.

Well what is the answer?

It’s tough to give specifics without understanding a person’s goals, general health, and demands of their life.

A good general guideline for what I consider to be “sufficient” strength and cardiovascular fitness is for people to ….

1)      Be able to do physically demanding activities such as factory and farm work, help move furniture, and be able to play some sports with coworkers/kids … without these tasks being a “max effort” or causing such fatigue or muscle soreness that they can’t be performed consistently.

2)      Have appropriate levels of bone density and lean body mass

…all throughout the lifespan. Some may argue with me – but that’s my standard.

For most people who are healthy and already eat & train well – 2-3 days a week of some well designed strength training & a bit of HIIT training – as well as some leisure walks or bike rides a week should have the desired effect without being burdensome or counterproductive to health.

I hope this article provided some useful food for thought on making the distinction between optimal health and optimal athletic performance. As always – thanks for reading.

The Biggest Step I Had To Take To Be A Rehab & Fitness Educator

First of all – I want to say thank you to everyone who has supported my site over its first year of existence. I really appreciate all the feedback, likes, shares and other benefits you have given me. Thank you.

I sometimes get asked how I’ve gotten into the role that I have – writing for two sites, having contributed to two books and having contributed to multiple university courses. Also, given the amount of outdated & questionable material out there in health & fitness, I’m sometimes asked how I stay sane and keep a level, positive attitude. This article, which I feel is an appropriate “1 year anniversary” article, delves into that….

Back in 2013, as I was preparing for physio school application interviews, Stu McGill was gracious enough to take some time out of his insane schedule to let me work with him. When I asked him about some of the schools he told me that some of them do teach a lot of outdated materials.

Alo and behold - during my first term of PT school I was getting taught, what I knew was outdated, information and was angry, bitter, frustrated, and depressed about it. Sometimes I felt like I took my anger out on my fellow classmates which, along with my lack of taking care of my physical and mental health, sits as my biggest regret from PT school. This is why I’ve always appreciated when someone sends me a message or posts a comment complimenting me for having a positive, balanced attitude as I wasn’t always that way and have tried to work in that direction. Due to these issues I almost quit PT school more than once along the way and have known many people who have struggled through similar journies.

Side note: so many people comment on my successes but they don’t see the hardships, failures, or low points along the way. Such is true with a lot of people’s stories on social media.

Those frustrations, to be honest, were the biggest spark for me to want to make change in the educational system for both rehab & fitness professionals.

In 2014, during a casual phone call, my old professor and great friend Lora Giangregorio asked me if I would help her design a course on exercise for people with chronic health conditions for the University of Waterloo KInesiology program - to which I said hell yes. I’ve been involved with UW ever since.

In 2014/15 I got asked by Brian Carroll, James Cerbie, and Alexander Cortes to write for PowerRack Strength, Rebel Performance, and EliteFTS respectively. For a 24 year old, still in grad school, the opportunity to write for those high level sites was nothing short of amazing.

Fast forward a couple years – I got asked to be part of a review panel for Western University, contributed to two books, started my own website, and am currently a writer for Mash Elite Performance.

Even though I’ve had the opportunity to reach people from Alaska to Australia … I felt something was missing in my work and my attitude up until a few months ago. The event that tipped that off was the passing of my former physio school instructor Deb Lucy. Deb was one of the main masterminds behind the way the Western University physiotherapy program runs today. She always had a lot of energy and cared a lot about her students. When you’re in the same classes Monday-Friday with the same 50 or so people for months on end … you become a family.

 That made me realize – it was time for me to let go of the anger and bitterness that I harboured towards the education system. It wasn’t helping me and, if anything, it was bringing me down and negatively affecting my relationships with colleagues.

I’m not saying that every piece of material out there in rehab or fitness is peachy or perfect. Far from it. What I do believe though is this - "If you change the way you look at things, the things you look at change" to quote Wayne Dyerr.

When I first learned about pain science & the biopsychosocial model in 2014, near the end of first year physio school, it really shook me and made me question a lot of things I thought I knew. It created some cognitive dissonance and it took me a while to rewire my thought pattern.

That, and the desire to be diplomatic in order to get my knowledge across, are the two main reasons I try to be patient with other professionals who I educate & deal with. I operate under the premise that most professionals mean well and want to help patients – and that belief change is tough especially when you’ve emotionally invested yourself into your methods & the results you get with your clients.

As such – my attitude has shifted. We still have a long way to go and a lot of work to do in improving rehab & fitness education for professionals & students. But I look at the positives – we have a lot of great rehab & fitness professionals who care a lot and want to learn and get better and we have great opportunities and educational methods through schooling, courses, and social media to get the information out there. We can’t change the world – but we can make a little part of the world, a little bit better.

Thank you for your support for the past year, and as always, thanks for reading.

What I'm Doing Differently In My Third Year Out Of Physiotherapy School - Part 1

           

On a rainy summer day by Elborn College - the building where I spent the bulk of my two years in physiotherapy school.

August 28, 2018 marks the 3^rd anniversary of my last day of physiotherapy school. This time last year I wrote a series where I discussed several changes I’ve made in my own practice. In this article I will share some of the things I’ve been doing differently since that time period.

1) Doing more neck strengthening instead of stretching

The traditional, stereotypical PT approach to neck pain rehab consists of a lot of stretching, soft tissue work, and needling of the upper traps, levator scapulae, scalenes and/or SCM muscles. For whatever reason, and maybe it’s just me, this approach never worked well for me or my clients with neck pain and just left a lot of people feeling sore.

By contrast – I’ve gotten much more out of isometric neck exercises (sets of 7-10 second holds within a tolerable level of force) and dynamic shoulder strengthening exercises such as front/side/rear raises, rows, shrugs and shoulder presses (based on the patient’s activity tolerance and physical capabilities). This approach is (in my opinion) better tolerated by my clients.

Side note: this isn’t to say I don’t do any stretching or soft tissue work in people with neck pain as I do see an anecdotal benefit in certain populations (ie radiculopathies) but many people I work with tend to  not enjoy being stretched and are limited more by pain before their neck movements even encounter resistance.

 Image courtesy Focus Fitness

2) Doing less more often in people with persistent pain

Working with persistent pain can be a challenge in terms of exercise prescription as it may be entirely possible that every movement/activity hurts and they can be easy to flare up. It leaves us in a bit of a conundrum as we want to be able to improve/maintain our clients mobility & fitness but we also don’t want to flare them up.

A solution I found came from a podcast I listened to with Greg Lehman last year where he suggested “doing less more often” with people with fibromyalgia and other chronic pain conditions. For example – I would prescribe a set of 3-10 of 1-2 exercises (depending on the client’s goals, limitations, level of irritability, and whether they are having a “good” or “bad” day) to be done repeatedly through the day.

I found this approach helped my clients immensely with maintaining (or even improving) mobility & fitness while minimizing the chances of flaring up.

3) Referring out (or at least backing off) if I’m not the right person to treat someone’s pain

This may seem like common sense physio. If someone has

-          Red Flags: ie tumor, infection, cauda equina syndrome and/or

-          Major orthopedic issues requiring surgery: ie fracture; dislocation; progressive neurological deficit; ligament/meniscus tear creating locking, instability, and/or giving out;

…. Then you need to refer out

I’m not talking about those in particular. I’m talking about cases where, quite frankly, physio just may not be the most valuable use of a client’s time and resources even in the absence of the above issues.

I’ve seen a fair amount of clients this past year with significant levels of pain and disability that were linked to significant psychosocial factors such as job stresses or even deaths/family illnesses. These clients would even tell me that as their stressors went up, so did their pain. After a couple of these cases I realized that, while physio can still have a benefit for maintaining/improving mobility & physical function, that the drivers of their pain were likely beyond my skillset and required counselling or psychotherapy to deal with these issues.

Over the past year I’ve also had patients referred to me for conditions that were clearly medical in nature – such as polymyalgia rheumatica. Again, while we can help with mobility in function, most of the treatment for conditions like PMR is medical in nature.

I’ve ranted before about how I don’t like personal trainers & strength coaches trying to be half-assed PTs but at the same time I don’t believe a rehab professional should try to be a half-ass psychiatrist or doctor. That’s where we need to realize our limitations and refer out to other professionals.

Side note: this isn’t to say that I completely stopped treating them – but we both came to a consensus that other resources were needed.

4) Bubble diagrams for pain science

Quite often I find patients want to know “what causes this?” That’s a great gateway to get into some pain science education. But instead of bombarding people with a bunch of neuroscience – I take the time to do a bubble diagram (similar to Peter O’Sullivan) to show all the different factors that can be involved with a patient’s pain including (where applicable)…

-          Tissue changes

-          Too much (or too little) activity

-          General health factors (i.e. body weight, smoking, poor sleep)

-          Psychosocial factors and maladaptive behaviours

This is a great way to get some practical, applicable information about pain out to the patient without bombarding them with info.

5) Giving patients exercise set/rep ranges

This follows in from Point #3 – I like the idea of giving patients set/rep ranges for exercises so they can adjust if they’re having a good day or bad day. I find this useful for people with persistent pain (or any fluctuating pain) and/or for “borderline” cases where you’re not 100% confident about how far you can push them.

That’s the end of Part 1 of this article. Tune back in a few weeks where I discuss four more changes I’ve made.