Monday 16 April 2018

The Most Underrated Tool In Your Rehab & Fitness Arsenal – The Short, Frequent, Daily Walk

Updated May 21, 2018

Photo courtesy Focus Fitness

                Before we get started I just want to say thank you and props to Jacob Lucs, Jordan Foley and Mark Giffin for an amazing weekend at the Canadian Powerlifting Union Coaching Workshop & Seminar at The Vault Barbell Club in Guelph two weekends ago.

In May of last year I got to meet former pro-bodybuilder & world record powerlifter Stan “the Rhino” Efferding. In addition to numerous other knowledge bombs in lifting & business – one of the big concepts he drew my attention to, through his presentation & videos, was the concept of the “10 minute walk.” In this article I discuss the concept of the 10 minute walk & the science behind. I also take the concept a step further to discuss how short, frequent, daily walks can be applied for various diseased, pained and healthy populations.

The 10 minute walk … and how it originated

The concept of the 10 minute walk started with research that was done in Australia on people with Type 2 Diabetes. Research showed that a 10 minute walk after each meal (3 times/day) was more effective than a single 30 minute daily walk for improving insulin sensitivity & glucose levels. An earlier study also showed that a 10 minute walk  times a day improved blood pressure more than single daily 30 minute walk. And an informal experiment that came out this year showed that doing 3-10 minute walks a day at a brisk pace resulted in more moderate to vigorous physical activity than doing the traditional 10,000 steps a day.

At this event, and in Stan’s later videos, he’s discussed how he’s used these 10 minute walks with his clients (including Hafthor Bjornsson and Brian Shaw) in combination with either a calorie deficit or surplus for weight loss or muscle gain goals, respectively. Stan recommends doing these walks 2-4 times a day after a meal.

 The benefits of walking have been well studied and include
-          Improved cardiovascular & metabolic health
-          Improved sleep
-          Improved mental health

Short, frequent walks also have many benefits compared to single walks such as
-          Ease of fitting into a busy schedule
-          Less monotony
-          More frequent activity & shorter sitting durations

Side note: sitting is not the new smoking like many would have you believe but, for most people, less sitting & more movement is overall better for health.

So as you can see 10 minute walks are definitely a great idea if you can do them but….

I work with clinical populations. They’ll never be able to tolerate three 10 minute walks daily!!

Some populations – be it due to deconditioning or pain may not be able to do these sessions. This doesn’t mean however that they can’t reap the benefits of short, frequent daily walks – just that the sessions have to be modified.

Some clinical populations that may not be ideal for these are
-          People who are contradicted for exercise due to cardiovascular or metabolic reasons. I recommend you look up the ACSM & CSEP guidelines for a full list of these contraindications.
-          People with weight bearing restrictions or limitations post fracture, dislocation, or surgery
-          People who have balance issues and are at high falls risk

Two populations that I use short, frequently, daily walks with a lot are

1) People with respiratory diseases

2) People with low back pain and/or lower limb pain

3) I also use these with people in cardiac rehab … but a discussion of cardiac rehab is outside of the scope of a quick 500-1000 word blog.

Getting back to those populations I mentioned earlier

1) People with respiratory diseases – I’m a big fan of interval training for people with COPD, asthma, and other conditions as its less monotonous and allows for more recovery & less shortness of breath. In these populations I’ll have clients walk for anywhere from between 15-60s at a 4-8/10 RPE (sometimes less than that), rest for 45-120s, and repeat for 8-30 minute long sessions. As with people with musculoskeletal pain, I like to increase the number of intervals before decreasing rest periods.

2) People with low back or lower limb musculoskeletal pain (i.e. OA)

Some research has shown interestingly enough that walking can be just as effective as core stability training for people with back pain. The trick is to have it dosed in a way that doesn’t increase long term symptoms.

For walking duration – I like to have these people stop just before their pain would increase. The frequency of walks is inversely proportional to the duration of walking that is tolerated. If someone has pain after 20 steps of walking I will have them walk for 15 step intervals as frequently as every couple hours through the day. If someone’s pain increases after 30 minutes of walking I may only have them walk twice daily for 20 minutes at a time. This technique was taught to me by professor Stuart McGill in his books Back Mechanic & Gift of Injury with Brian Carroll.

Sometimes; for people who are morbidly obese and are limited due to mobility limitations, balance issues, or musculoskeletal pain; I prefer replacing the walks with stationary bike rides – a tactic Stan has used with some of his larger clients. 

I hope this article shows why short, frequent walks are an underrated tool in the fitness arsenal as well as how to apply them to clinical populations that you may work with. As always - thanks for reading. 

Saturday 14 April 2018

Random thoughts March 2018 - Exercise For Chronic Pain, Importance Of Context In LBP, When Making Sense Of Imaging Findings Doesn't Work, Squats & Deadlifts for Reps vs Singles, and more

Sometimes exercise and even physio aren't the best options for people with pain

One of the hardest things I had to learn in my career is that exercise, and sometimes even physio as a whole, is not a cure or even the best option for everyone with pain.

Yes, for many (not all) musculoskeletal pain conditions exercise is well supported and for many (not all) conditions can be the most effective treatment. And I still 100% stand by the fact that I believe every patient (short of medical contradictions or being super irritable (see below)) should do some form of exercise or movement activity.

Sometimes exercise (I include movement therapies in here) need to be combined with more psychosocially and behaviourally oriented therapies to help address patients' fears & negative beliefs about movement, activity, pain, injury and the body.

That said - sometimes the key drivers' of a patients' pain are things that may not be addressable (or addressable to a small degree) by exercise. I've had it occasionally where the main drivers of patients' pain were issues outside of (what I consider) a physiotherapists scope of practice such as life/family/relationship stress, poor sleep, financial issues or PTSD. If these outside drivers are what's contributing to the issue, and a patient's pain is so highly irritable that I can't do much of anything without flaring them up, than I have no problem referring them to other professionals who can help with the above issues.

Props to Lars Avemarie and Greg Lehman for helping my hard-headed personality see this.

Continuing Education Tips

Some Saturday morning continuing education thoughts

1) The more I go with continuing education, the more I find "less is more." I used to try for an hour a day - as that was what a lot of top people in my field who I looked up to did.

Over time I did find it very hard from a time and energy perspective to get that in. In addition I also found it very tough to do an hour a day of continuing education & retain it all.

As such I do anywhere from 1.5-8 hours of continuing education a week. The lower numbers are when I'm busy with family stuff and/or running a fat loss or meet peaking phase when my time is shorter and my energy levels are lower. The higher numbers are more during a hypertrophy/work capacity/or basic strength phase, doing a weekend course, and/or when I'm not busy with family stuff - there my time & energy are greater. I found these hours worked better for retention of material.

2) If you're on the road a lot like I am and/or don't have the energy or desire to sit down & read a lot of research podcasts are a wonderful thing. Podcasts that have handouts or note packages are ideal as you can listen to them when on the road/cooking/cleaning etc and don't have to worry about taking notes.

3) As my old Western prof Dave Walton said "in school you'll learn what'll treat 70-80% of your patients." When it comes to continuing education - a podcast you listen to, course you do, or article you read may only help 0.5-2% of your clientele ... but when you start putting those 0.5-2% together it adds up A LOT.

Importance of context in LBP

Long post ... reflecting on a podcast interview I listened to with Craig Liebenson yesterday.

One thing that gets lost a lot is the context of the message
As he said there is a definite disconnect between the pain science and RCT literature on low back pain ... and the real world clinical work. The tough thing about LBP research is that
1) Most people with LBP do get better naturally without any treatment and
2) It is such a broad, heterogenous population. Taking the high numbers - if you figure 90% of people get back pain and 90% of back pain cases are "non-specific" (ie not nerve roots or red flags) than that's 81% of the population. Two people with back pain can be vastly different in terms of the bio-psycho-social factors that can be contributing to their pain.

Last fall I was listening to a podcast with Peter O'Sullivan and Karen Litzy at the same time I was reading Gift Of Injury by Stuart McGill and Brian Carroll.

I get asked a lot about Gift of Injury and was going to write a formal review for my website on the book but chose not to as Stu was concerned it would be a conflict of interest on my part. All in all, I really loved the book and my only wish was that it had a bit more on psychosocial factors & LBP. But at the end of the day; in the context of Brian's legit symptomatic injuries, his psychosocial & general health profile, and his top level powerlifting goals; I agree 100% with the approach that he and McGill took and use a similar approach with lifters & gym rats that I work with.

Some would say that O'Sullivan's approach may be a total 180 to McGill but as Pete even said "I don't work with powerlifters." For people who's back pain is not due to a symptomatic injury, aren't pushing their back to the limit through high end activities, and are fearful of bending and movement .... I don't necessarily see a problem with teaching them that some spinal movement is OK and shouldn't be feared. While I am a fan of "spine sparing" in people who's LBP is related to an injury ... and in certain clinical populations (ie osteoporosis, bone cancer) or athletes who require spinal stiffness (ie powerlifters) ... I'd like to think we can move our backs as needed without feeling like they're going to blow out on us.

I'm a big fan of both men and even their approaches may be vastly different a lot can be learned from both if you appreciate the contexts behind her message ... something that gets lost a lot in internet info and in social media.

Not fixing what’s not broken in a consultation

Tip I learned from Stuart McGill

When I consult with someone who trains regularly, be it in a physical therapy role or as a separate fitness consult for a painfree client, I try not to change too much of what they're doing. If they're getting results and are happy with their current program why "fix what's not broken."

What I will do is tweak any technique or any programming issues that may increase the clients' risk of injuries, impact recovery, or impair performance.

I find this helps me better connect with clients too as I'm not "overhauling" their program - rather I'm tweaking it.

When making sense of false positive imaging findings doesn’t work

Communication tip I've learned ...

Sometimes when I try to explain the false positive findings on MRIs, X-Rays etc the message goes in 1 ear & out the other. Sometimes patients are so dead-set that that's what's causing their pain that those explanations won't change them.

In those situations I like to take a different route which can involve
1) Emphasizing all the different factors involved with pain
2) Describing how tissues can heal, remodel and adapt to load
3) Showing patients what they can do to help them feel confident about their body

Just a tip I've found useful for anyone who feels the same way I do

Squatting/deadlifting for reps vs singles – which is safer

Squatting/deadlifting for reps vs singles - which is safer? It's a debatable topic but the answer isn't as black & white as you may think.

- Advantages of doing higher reps
i) Greater hypertrophy stimulus: this is self-explanatory
ii) Less joint and CNS load: I've met and talked to some older lifters and former powerlifters who's bodies (anecdotally) tolerate repetition training a lot better than heavy training

- Advantages of doing singles
i) Big one - less potential for form degradation: Some lifters, especially fast twitch ones such as a Brian Carroll, can't maintain form for any more than 1-3 repetitions. Quite often I see people (especially in the deadlift) who have 1-2 good looking reps and the rest look like shit. I can count on my one hand the number of people who I've seen that can do deadlifts for sets of 8+ with what I consider "acceptable" form.
ii) Greater neural stimulus & higher neural specificity

The answer as to "which is better" has to be made on an individual basis based on the person's injury history, fitness levels, and goals.

Also I quite often hear of injured weight training clients being automatically told by their doctor/physio/chiro to "use less weight and do more reps" without further investigating why an injury occurred
- Maybe it's a workload issue and they're doing too much too soon?
- Maybe it's a technique issue?
- Maybe there are major psychosocial factors going on that are making the body more sensitive?
- Maybe there are sleep issues going on? Given the amount of strength athletes who have sleep apnea & other sleep issues this shouldn't be forgotten about but often is.

I hope this provides some food for thought on a grey and debatable area.

Commonalities between rehab & performance training

When you think about it, and I just had this realization after reading a colleague's post on Facebook, a lot of the key things I look for in successful rehab & in performance training overlap by quite a bit.
Simple key concepts such as
1) Carrying a positive mindset about yourself and your ability to achieve your goal
2) Getting proper, consistent, high quality sleep
3) Managing stressors (both physical and psychological) well
4) Appropriately progressing your workload to build fitness & function while minimizing injury risk
... all apply to both rehab & performance training

Exercise for chronic pain – is there a place?

I'm seeing a lot of interesting threads lately on the topic of exercise for chronic pain.

Nothing wrong with exercise for chronic pain as long as its programmed appropriately. In my own experience a lot of people I work with who have chronic pain have major mobility limitations and are concerned about further decline as they age. I'm a big believer of giving people with chronic pain some exercise with the purpose of maintaining or improving mobility & fitness.

The problem is when articles (and therapists - I was guilty of this too) think that exercise by itself is a cure for the complex, multifactorial problem that is pain and fail to address the other factors such as psychological factors; maladaptive beliefs; sociological factors/environments; poor general health issues such as obesity, poor sleep & smoking; and other issues that may be significant drivers' of an individual's pain.

Exercise has a place in rehab for persistent pain but it should be part of a multidimensional and multidisciplinary game plan to address the complex, multifactorial issue that is pain.

Can we really 100% assess psychosocial factors on Day 1?

One thing I’ve noticed in my career is that sometimes patients won’t open up to you about psychosocial factors (or other things in their life) until a few weeks into therapy. This is human nature to some degree as we, as Nick Tumminello noted in a recent video, have barriers with new people on what we do & don’t share.

What this means from a practical rehab standpoint is
1) Do the best you can to be a good person, build rapport with your patient and listen to their story.
2) You may not be able to obtain 100% of all the patients’ psychosocial factors & details on Day 1.

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