Top 3 Things I Would Have Done Differently Over The Past 10 Years

               This September marked 10 years since the start of my entry into the rehab and fitness fields as a student in the Kinesiology program at the University of Waterloo. Over the past decade I’ve been blessed to graduate from 2 universities (and contribute to the curriculums of both universities & teach at one of them), get my PT license & strength coach certification, write for numerous websites & contribute to books, and meet a lot of great people along the way.

                One would look at it and say “you’ve had a successful career.” While I’m proud of my successes at a young age, especially despite some of the challenges I’ve had, I’d be lying if I said there weren’t some things I would have done differently.

When I look back 10 years to when I started my rehab/fitness journey and think of what went well & what didn't ... there are 3 things that stand out to me as "things I would have done differently."

Side note: A common regret identified by many is not spending enough time with others. I do agree with this partially – but I also believe that (to quote Stan Efferding) “you can be good at anything but you can’t be good at everything.” If you’re trying to achieve a high level of success in an endeavour; be it athletics, school, career, family, relationships; that endeavour(s) will take a greater time & effort commitment than other parts of your life. While I wish I could have spent more time with friends, particularly as a University of Waterloo student, the mature part of me realizes that I may have not gotten to where I am today.

With that in mind here are the 3 things I wish I would have done differently over the past 10 years -

1) (The big one) Done a better job of prioritizing my mental health.

This is easily my biggest regret. I’ve wrote about this in previous articles so I’m not going to beat this point up too much – and I want to write a piece on how I try to manage stresses of working with a predominantly persistent pain population.

I 100% believe that having less anxiety & depression would have likely made me more productive, healthier and likely even more successful than I was both in school and in my licensing exams. Seeing counsellors and psychotherapists was the best thing I’ve done in the last 5 years. It helped me feel & perform better … and I wouldn’t be where I am at today without it.

2) Spent more time learning about psychology & communication

This is more geared towards physio school and my first 2-3 years as a practicing physiotherapist.

So much education is focused on the sexy stuff like exercises, modalities and manual therapy techniques - particularly the latter two. But not enough time is spent on how to communicate with people (both in terms of teaching exercises/concepts and behaviour change), how to build rapport/alliance with people, and how to handle difficult conversations (particularly in healthcare).

I joke around that exercise prescription is the straightforward & easy part for most cases (athletes, people with chronic diseases are more complicated). Aspects like

·         Motivating people for health behaviour change

·         Coaching exercises

·         Teaching people about pain and pacing

·         Managing maladaptive beliefs and behaviours

·         Handling difficult conversations (i.e. dealing with difficult clients, goal setting/managing unrealistic expectations)

…are the hard parts and are often the limiting factors of the clients that I struggle with in my current job where 90% of my clientele have persistent pain and/or post concussive syndrome.

I wish I would have spent more time learning about those things - and I impress that on the students that I educate.

Resources that I recommend are…

·        For coaching exercises: anything by Nick Winkelman – a lot of his stuff can be found at ResearchGate or even just through Google

·         For behaviour change

o   The book Motivational Interviewing in Healthcare

o   BJSM has a good free course on motivational interviewing

·         For pain science education

o   Know Pain by Mike Stewart (a phenomenal course for communication in general)

o   Explain Pain

·         For handling difficult conversations

o   Difficult Conversations: How To Discuss What Matters Most

o   Crucial Conversations: Tips For Talking When Stakes Are High

o   Covalent Careers and Ignite Physio also have great resources on their sites

With Mike Stewart at his Know Pain course earlier this year

3) Hired a damn coach

In high school I tried training myself. My workouts consisted of half ROM bench presses, cheat curls, situps, leg extensions & endless running. While they helped me lose a lot of weight and improve my running & calisthenics performance – they weren’t what I needed to maximize my athleticism either for rugby (which I was training for at the time) or powerlifting. Plus whenever my deadlift got up to 225 I hurt my back and had to restart again. Until taking Stu McGill’s class in 2012 I never really learned how to strength train properly.

Using a 3x5 “Starting Strength” like style of training I made good progress for 8 months and then got hurt with patellofemoral pain and took too long to bust out of the “novice/early intermediate” training phase. Bear in mind this was when we didn’t know much about good PFPS rehab and the pain science information was just in the “infancy” stage of mainstream physiotherapy knowledge. It was also when the strength & conditioning scene really shifted from being influenced by Westside Barbell/multi-ply powerlifting to having programs geared towards raw lifting and general preparation for athletics.

I would have saved a lot of headaches and made a lot more progress earlier on had I have hired a good strength & conditioning coach, even to just sporadically audit my programming, - rather than waste time figuring it out myself.

That said, making years of mistakes did give me a lot of perspective and education which I've been able to apply to others.

Programming resources I recommend for therapists/trainers are

- The Ultimate Back: Enhancing Performance DVD and Ultimate Back Fitness & Performance by Stu McGill

- The 5/3/1 book series by Jim Wendler

- Mash Files by Mash Elite Performance

- Advances in Functional Training 2.0 by Mike Boyle

- 10/20/Life by Brian Carroll – hell even the warm up section is worth the price of the book

- Starting Strength by Mark Rippetoe

- The Juggernaut Method by Chad Wesley Smith

- The Vertical Diet and Peak Performance 3.0 by Stan Efferding

No one is perfect – and I’ve learned a lot from my mistakes that I’ve been able to apply to other professionals and students that I’ve educated. I hope this helps because that’s my article and as always – thanks for reading.

Barbells And Bone Health II: Osteoporosis

 Meme courtesy of Owned.com

Before we begin – no this isn’t Star Wars where the installments are recorded out of order. The original Barbells and Bone Health article focusing on weight training for younger adults is here https://rebel-performance.com/barbells-bone-health-review-literature-says-building-strong-bones/

                Osteoporosis is a condition that affects 1 in 4 women and 1 out of every 6-7 men. Osteoporosis is characterized by decreased bone mineral density causing an increased likelihood of fracture. 20% of men and 37% of women will die after fracturing their hip and many who suffer a fracture are likely to refracture. For people who have osteoporosis a fracture can cause a downward spiral of avoiding activity, becoming deconditioned, and then becoming more susceptible to a future fracture.

                Fortunately, a well designed exercise program can help to offset the losses in bone density that occur with age and may even allow people to slightly increase their bone density. The purpose of this article is to show you which exercises can help people with osteoporosis based on the research.

Disclaimer: As I’ve said before on the website the information here is tailored for health & fitness professionals and is not intended so much for the layperson. If you are someone with osteoporosis or significant risk factors I encourage you to work with health professionals (e.g. doctors, physical therapists, kinesiologists) whom have formal education in prescribing exercise for people with osteoporosis.  

Disclaimer 2: A lot of lay people I talk to get osteoporosis and osteoarthritis confused as they sound similar but are two different conditions. Please read here to understand the differences between the two conditions  http://www.osteoporosis.ca/osteoporosis-and-you/osteoporosis-and-osteoarthritis/

WHAT IS THE BEST EXERCISE TO HELP MY BONES?

The best exercises to help with bone density are weight training exercises and impact exercise. When a bone is loaded with more force than it’s used to, assuming it’s not so high as to cause a fracture, this starts a signalling process in the bone that causes bone building cells (osteoblasts) to lay down bone that adapts and remodels over time to get stronger.

The general guidelines for weight training for people with osteoporosis are as follows

-          Frequency: at least 2 times/week

-          Intensity/Time: 1-3 sets of 8-12 repetitions of each exercise

-          Type: 1 exercise per body part

Obviously I can’t give specifics without considering the individual, their health conditions, their general work capacity, and their goals but I hope this gives you something to start with.

 Daily balance exercise of up to 15-20 minutes per day is also recommended but obviously can be rather unfeasible due to time constraints. Balance needs to be challenged in order for it to be effective and balance exercises must be maintained as balance can decrease quickly.

Side note: I’ve found that balance exercises are sometimes the most challenging type of exercise to get people to do as some are very fearful of falling & will sometimes get more anxious during the exercise which decreases their balance & self-efficacy … and so on. With clients I find combining balance with strengthening or balance in daily activities works better than structured balance exercise. I also find, with these people, that you need to progress the exercises very slowly and also start wayyyyyyyy below their threshold – even if it looks like the exercises are fairly easy for them just to gain their trust.

The recommendations for impact exercise are…

-          For people with osteoporosis but without fractures: at least 50 moderate impacts a session (i.e. jogging, low level jumping, and hopping) are recommended and should be interspersed with walking activities. This may need to be modified for people with spinal or lower extremity pathology.

-          For people with vertebral or low trauma fractures brisk walking is recommended assuming that the individual is not at risk of falls

Again – this needs to be adjusted based on the individual. Some can tolerate this (or more) and some caan’t.

WHAT ABOUT POSTURAL EXERCISES?

The bulk of the research on postural corrective exercises (e.g. strengthening weak muscles and stretching tight muscles) doesn’t seem to be very effective in changing people’s posture, contrary to popular belief, but a small body of weaker evidence suggests that these exercises may be effective for very slightly reducing kyphosis in postmenopausal women.

Postural exercises should focus on the scapular muscles and the spinal erectors to improve endurance.

WHAT ABOUT YOGA AND SPINAL FLEXION EXERCISE?

For people at lower risk of fracture yoga doesn’t pose too many issues but for people with moderate to high risk of fracture yoga poses involving spinal flexion and/or twisting (particularly under high load, repetitively, and/or to end range) should be avoided. Biomechanics research has shown us that osteoporotic vertebrae are more likely to fracture under flexion and rotation loads. By the same token I would advise staying away from traditional core exercises such as situps, twists and leg raises as they involve similar motions.

Some lower risk people who have built up the tolerance, flexibility, coordination, and muscle tone may be able to do these in low volumes but many people would increase their likelihood of fracturing.

 Some reading this article may say “oh well they can adapt.” But the research as a whole (aside from outlier studies) shows that osteoporotic bones may slightly increase bone density, may maintain bone density, or may lose bone density at a slower rate than before. The adaptive capability of these bones is very limited.

WHAT ABOUT WALKING?

Walking and other forms of cardiovascular exercise such as cycling and swimming fail to produce significant increases in bone density in most people as those exercises don’t provide enough of a loading stimulus to stimulate bone growth. While these exercises have other physical and psychosocial benefits just walking, cycling or swimming won’t do much for improving bone density.

However, as stated above, brisk walking may (theoretically) provide an impact stimulus for people who have suffered osteoporotic fractures and may not tolerate other high impact activities.

WHAT ABOUT CALCIUM AND VITAMIN D?

Even though I’m not a doctor or a dietician I do get asked a lot about the effects of Calcium and Vitamin D on osteoporosis. A recent review has shown that calcium & vitamin D supplementation doesn’t reduce fracture risk in community dwelling older adults when compared to placebo. It may be helpful with increasing bone density but it doesn’t make as big of a dent on fracture risk as many think.

I can’t safely give specific recommendations for supplementation as I don’t know your blood profile, bone density, allergies, health conditions or what medications you’re taking. At the risk of overstepping my boundaries if you (or your clients) are interested in supplementation I strongly encourage you to talk to a registered dietician regarding it.

Osteoporosis is a condition that will continue to affect the health care system as the baby boomers age but proper exercise can help offset the natural decline in bone density with age and can also greatly improve quality of life.

As always thanks for reading

Product Review - The Ultimate Landmine Program by Meghan Callaway

               Ever since 2016 I’ve been a fan of fellow Canadian Strength Coach Meghan Callaway for her knowledge; attention to detail with exercise coaching; and authentic, no-nonsense approach to strength training nutrition as well as her authentic personality. If you follow her on social media you know she’s capable of some amazing feats of strength & coordination in some crazy exercises – some of which I’ve tried myself.

                When she asked me to review her upcoming product - The Ultimate Landmine Program I couldn’t wait to read it and review it.

 Side note: As with my review of her pullup program I am not an affiliate of Meghan and do not get any money for her products. I choose not to be an affiliate with anyone so that I can review products in an objective, unbiased fashion.

                If you’re reading this you might be wondering “what the heck is a landmine?” A landmine is a cylindrical strength training apparatus on a platform that is bolted to the floor. You can place one end of a barbell in the cylindrical portion of the apparatus – allowing you to press, pull, squat and lift the bar at various angles that are impossible to do with traditional “straight bar” movements. If you don’t have a landmine apparatus you can stick one end of the barbell in the corner of a gym or the corner of a squat rack as Meg describes.

                As you might have guessed – the program is all made up of landmine exercises. However – there is a supplement to the book which covers non-landmine exercises which can be added into the program. 

                The program consists of two progressive phases – each made up of three workouts a week that incorporate landmine variations of compound movements (i.e. squats, deadlifts, presses, rows) along with advanced core stability exercises. In Phase 2 the exercises are made more difficult by adding band resistance and/or adding extra components & movements to the exercises.

                As with the pullup program – Meghan is the most anal (I say that as a complement) person I’ve known (in-person or online) with regards to coaching proper exercise technique & ensuring proper form. In each exercise she also emphasizes total body tension and proper scapular control.

                When I reviewed the pullup program in 2017 my only hesitation was that I felt some of the exercises may not be appropriate for certain injuries (i.e. elbow, shoulder) or certain medical conditions (i.e. congenital laxity). By contrast I feel a lot more comfortable recommending this program to a general population. That said, an exercise that is appropriate for one may not be for another – and Meg would be the first to agree with it.

                The program also incorporates a lot of novel, less well known exercise variations. I must confess, coming from a powerlifting background that is highly specific and incorporates a narrow range of exercises, my training got stale – and I am looking forward to incorporating some of these exercises in my powerlifting training.

                The only critique I have is that there are common coaching cues that are repeated a lot through the book – which is what Meghan intended in order to reinforce proper form – but it does lengthen the book & the read.

                All in all I enjoyed Meg’s Landmine program and wish her all the best with her success.

When Do We Need Specific Exercises In Rehab?

                If you’ve followed the physical therapy literature over the last 5-10 years you’ll notice that more and more, the literature is challenging the longheld belief that you need to do X,Y and Z exercises to get out of pain. The ideas of “you need to activate your TVA” or “you need to get your scapula set first” are slowly (sometimes very slowly) becoming a thing of the past.

                With research like this it begs the question – do we need specific exercises in rehab? That is the topic of today’s article.

When are specific exercises needed?

Specific exercises are for specific adaptations in specific tissues and can also be influenced by your clients’ tolerances. Breaking this down by section ….

1) Specific adaptations

If your goal is to build the muscle & tendon strength necessary to withstand sprinting – doing 10 minutes of jump rope probably isn’t going to help. If your goal is to develop neuromuscular control of your knee to prevent a repeat ACL injury – doing bicep curls isn’t the best choice.

Some clients, particularly elderly and/or those with persistent pain, can be so weak and deconditioned that simple tasks like getting out of a chair can be very difficult. As much as I am all for people doing activities that they want – when you don’t have the baseline strength or mobility to do IADLS … that’s a big problem that needs to be addressed.

If your goal is to develop specific adaptations – be it strength, hypertrophy, power, endurance, mobility, and/or neuromuscular control – the exercise needs to be tailored towards that. Plain & simple.

Whether or not those adaptations are relevant to getting out of pain is up for debate as research has shown that improvements in strength, muscle timing, kinematics etc don’t always correlate with changes in clinical symptoms. I look at in terms of what the client needs from an activity demands perspective versus where they’re at.

2) Specific tissues

Over the course of the decade we’ve worked to move away from structural diagnoses – which is a much needed move for the better.

That said – some injuries, such as tendinopathies and muscle strains, do require more specific exercise to allow the area to heal, adapt & recover. Arm curls don’t do much for a hamstring strain nor does your biceps tendinopathy benefit much from calf stretches. Can general exercises help? Most definitely – but to rehabilitate the specific tissue you need specific loading.

It’s important to note that even within the category of “specific” exercises you have a large range of options to work with that can range from strengthening, mobility and neuromuscular exercise all the way to practicing the desired activity with some modifications as needed (i.e. “sprinting” with reduced speed). Again these are all based on the individual.

3) Based on your client’s specific tolerances

Sometimes, in more nociceptive presentations, people may not tolerate specific movements or postures and may tolerate others very well. In those cases, emphasizing exercises in well tolerated directions & postures is a wise decision – at least during the early stages of rehab. This is where approaches like the McGill method make a lot of sense as they take away what hurts and emphasize painfree movement & exercise.

How long painful movements are avoided, if at all, is a controversial topic that depends on numerous individual factors.

When are specific exercises not needed?

For more general pain relief where there are no major structural tissue concerns, and where there are no major physical deficits that need to be addressed, you can incorporate more general exercises and some more valued, leisurely activities such as walking, gardening, skiing, handyman work, whatever you like.

Best of both worlds

And to be honest – an ideal rehab program for most (not all) people incorporates valued activities that people enjoy & want/need to get back to as well as specific exercises to address specific physical deficits.

So there you have it – a very simple explanation of where specific and general exercises & activities fit within the scope of rehab. As always – thanks for reading.

Pain Science Education: What It Is And What It Isn't

            Over the course of this weekend two main themes filled my social media feed. The first were videos of the amazing feats of strength from the various events at the Arnold Sports Festival (side note: props to two-time Arnold Strongman Classic champ Hafthor Bjornsson as well as to powerlifting world record breakers Blaine Sumner and Stefi Cohen for their successes). The other was this study that provided a systematic review & meta-analysis on pain science education (PNE). The article showed that…

·         PNE did not significantly reduce pain or disability

·         But PNE did reduce catastrophizing and kinesiophobia

It created a lot of controversy and debate amongst therapists from different backgrounds & ideologies as well as a need for clarification as to what PNE is and isn’t – the topic of this article.

What PNE isn’t

PNE is not

1) A cure or magic bullet

As we’ve discussed above pain science education doesn’t create significant improvements in pain. This review showed a reduction in pain of 3.2/100 – less than half a point on a 0-10 pain scale.

2) A standalone intervention

Some studies have shown better effectiveness of PNE mixed with exercise versus one or the other alone. Granted this is still being studied and is still up for debate.

3) An intervention that will produce the same results in everyone

Some qualitative studies have shown that PNE can create great reductions in fear and improvements with activity in some people but can be useless or even counterproductive with others.

Side note: studies like these, plus my own experiences, are why I disagree with (well meaning but misguided) practioners who think that everyone needs PNE. As with everything else the intervention needs to be tailored to the individual.

4) The only part of biopsychosocial rehabilitation

As Jarod Hall and Sandy Hilton say “pain science should be the air you breathe” – not something you just do to people. There are many components of biopsychosocial rehab (and proper rehab in general) including

·         Simply being a good person who’s attentive, caring and is a good listener

·         Acknowledging that there are numerous contributors to the pain experience, working to address these different areas and referring out for help when needed

·         Educating people on how to get back to a lifestyle that is meaningful for them through pacing

·         Also educating people on healthy lifestyle habits

·         Experiential learning & graded exposure to activities: to me this is a great way for people to experience that hurt doesn’t equal harm and that they can likely do more than what they’re capable of

·         Getting people more physically active

·         Using positive language & self-management skills to empower the patient and build their self-efficacy

What PNE is

PNE is

1) A means to explaining the science of pain and the contributing factors behind a person’s pain

2) A means to (hopefully) decrease some of the anxiety, fear and negative beliefs surrounding pain and a means to get people more physically active & working towards the lives they want to live.

I hope this article sheds some light for you (and others) on what PNE truly is & isn’t and where it fits in the grand scheme of things. As always – thanks for reading.

Is Strength Training The Newest Fad In Sports Injury Prevention?

Image courtesy Focus Fitness

Earlier this year I watched a video on Canadian trainer Omar Isuf’s YouTube channel where he interviewed DPT and 20x world record breaking (as of the time I’m writing this) powerlifter Stefi Cohen. As a physiotherapist who competes in powerlifting Stefi is definitely someone whom I greatly idolize for her insane athletic accomplishments as well as the success she’s had getting her DPT and starting a fantastic performance gym & company with her fiancée Hayden.

            In the video Omar asked Stefi about her thoughts on strength training as a means of preventing sports injuries and Stefi discussed that it may be or may not be a fad. She also brought up the fact that we seem to shift from fad to fad with common trends (over the last 2 decades) in sports injury reduction including (but not limited to) bracing, transverse abdominnis exercises, movement screening & functional movement, workload ratio and other topics. So it raises the question – is strength training a fad in sports injury prevention?

First the term “injury prevention” is a misnomer and should be changed to sports injury reduction as we can never truly prevent injuries. There are some injuries; particularly contact injuries; that you can’t prevent no matter what – short of completely removing yourself or your athletes from the sport.

Now that that’s out of the way let’s look at the evidence ….

A 2018 systematic review and meta-analysis in the British Journal of Sports Medicine (free access link here) showed that a 10% increase in strength training volume reduced sports injury risk by 4%. It’s a heterogenous paper with many different sports & many different protocols … but it gives us something to work with.

But with this evidence comes a few caveats, one more opinion based and one more evidence based

#1: Past a certain level of strength; which is sport & athlete specific; increasing strength comes with a point of diminishing returns. The stronger you get the harder it is to get stronger; from an eating, sleeping, rehab, and recovery perspective; plus there is (in my anecdotal opinion) a higher risk of injury as you push the envelope of maximal strength. For most athletes (excluding powerlifters, Olympic lifters & strongmen); past a certain level of strength; more time could be spent improving other components of athletic performance such as speed training, conditioning, and most importantly skill work over trying to get your athletes stronger.

#2: Sports injuries are multifactorial and can be influenced by training workload (and fluctuations in workload), sleep, psychosocial factors, nutrition, genetics, previous injury, movement skill, anatomy & anthropometrics, and other factors. As such we have to take a multi-faceted approach to sports injury reduction rather than simply relying on a single cure-all. I plan to elaborate on these topics on more detail in future articles for both my site and for Mash Elite Performance.

I hope this brief article provides some food for thought on a complex and popular topic. As always – thanks for reading.

What Role Do Physiotherapists Play In Managing Psychosocial Factors?

Over the course of the decade we’ve seen a shift in physiotherapy practice guidelines from a focus solely on tissue and biomechanics to looking at biological, psychological and social factors as part of the individuals’ pain and disease experiences. While many are slow to adopt these new guidelines the shift is encouraging.

The increasing focus on psychosocial factors begs the question; especially for those of us who aren’t trained psychologists, psychotherapists, or psychiatrists; “where does the line get drawn and what’s our role in managing psychosocial factors in our patients?”

Getting something important out of the way first

Regardless of whether you’re a medical or rehab professional working with diseased and/or pained populations, or a strength coach working with high performance athletes, psychology feeds into everything you do whether it’s motivating a client for behaviour change or helping an athlete achieve peak performance. What we do does not operate in vacuums and almost always has both physiological and psychological effects.

Where our boundaries lie in managing psychosocial factors

This is going to be controversial, but I partially disagree with the opinion of some people that I’ve seen (no names mentioned) post in threads on social media that state that we should be directly managing psychosocial factors in our patients and that our scope of practice should be expanded.

The reason is … as physiotherapists we are responsible for a ton of information and skills when it comes to assessing, diagnosing and treating musculoskeletal, cardiopulmonary, neurological and systemic conditions. I’m of the belief that you can be good at anything but you can’t be good at everything (to quote Stan Efferding). I don’t know of anyone who’s great at nutrition, strength sports, orthopedic physical therapy, pediatrics and the like all at the same time. Doing 8-10 years of post-undergraduate schooling; along with tons of post graduate courses & continuing education; to excel at both physical therapy and psychology is both expensive, unhealthy and impractical in my opinion. That’s where you network with other professionals and refer out as needed.

I think we would overstep our boundaries if we

1) Diagnose mental health conditions: Just as we can’t diagnose cancer or infections or heart issues as physios (at least in Canada) we shouldn’t try to diagnose PTSD, OCD or other mental health conditions. We just need to recognize the symptoms and refer out.

2) Try to treat psychosocial factors that aren’t related to pain, injury, movement, or activity: We aren’t trained to grief counsel a mother who’s lost her kid and we aren’t trained to treat the PTSD of someone who has been sexually assaulted. That ain’t our skillset and just as we get POed when a trainer tries to be a therapist we shouldn’t try to be a psychiatrist if it’s something outside of our ballpark.

Where can we help with managing psychosocial factors?

We can help our patients with psychosocial factors by

1) Finding ways to help get them active: Exercise can help for chronic pain and for mental health conditions

Image courtesy Focus Fitness

2) Educating our patients on the importance of sleep hygiene: Given how poor sleep can be a contributor to (and result of) pain and mental health issues we’d be remised if we didn’t discuss this (and ways to improve it) with our clients.

3) Quite simply being a good person to be with: I open any (non WSIB specialty) assessment with “tell me your story.” This allows patients to say what they need to say and helps them get whatever they need to get off their chest – which can be therapeutic in and of itself. There’s a lot to be said; especially in chronic cases where a client may have been mistreated by employers, coworkers, family members and/or friends; for being the first “good guy” they talk to and by being attentive & caring.

4) Helping to decrease anxieties and unhelpful beliefs regarding pain, injury, and activity: Educating patients on the many factors involved in pain & hurt versus harm; as well as gradually increasing your client’s tolerance to both feared & desired activities (barring any medical or orthopedic contraindications); can be helpful in improving the function & well being of your clients.

5) And obviously referring out as needed

So, in a nutshell, that’s where the role of physiotherapists is in managing the psychosocial factors of patients. Not everyone’s gonna agree with me but that’s my opinion and as always – thanks for reading.

Case Study: How I Rehabbed My Own Knees

In today’s article I take you through a case study. Because of rules set by our regulatory body, The College of Physiotherapists of Ontario, I cannot give specific confidential details of any patients I have formally treated. However, I can and will share my own story of how I rehabilitated my own knees.

                Before we get started – from January 10^th to the 13^th I will be taking part in Travis Mash’s “Feats Of Strength” online meet (link here to register) to help raise money for his weightlifting team and to get back into the mindset of competing after a year long hiatus. Check out the link to compete or at least make a donation to Coach Travis Mash’s non-profit weightlifting team.

I developed patellofemoral pain a few years back during my days as a runner which carried over into the beginning of my powerlifting career. Unfortunately, this was compounded by getting some bad advice from other professionals (which I’ll elaborate on). In this piece I share my story of how I, as a powerlifter and physical therapist, returned to painfree squatting and running.  

Disclaimer: I’m a N=1. Pain can be influenced by numerous factors so as such this is strictly anecdotal. Also this is not intended to be specific medical advice for anyone else.

My rehab plan came down to the following components which form my philosophy.

1) Minimize what worsens symptoms

2) Find well tolerated movement & move … a lot

3) Address maladaptive beliefs, psychosocial factors, and general health factors

4) Eventually build up tolerance to the desired activity

Going through these step by step

1) Minimize what worsens symptoms

The McGill and McKenzie influenced therapist in me looks at what movements, postures, and loads exacerbate symptoms … and what are tolerated. For me running and deep squatting past a certain weight were what caused problems. As such I removed the running (which partly came due to my injury and partly due to me beginning powerlifting) and set all squatting weights below a weight & depth threshold that caused pain

In certain rehab situations, which I’ll write about in another article, sometimes painful exercises are supported in the literature. That said, I’m not a fan of pain during high skill strength, speed and power activities (in most situations) due to the negative effects of pain on motor control. Also, while some research supports painful exercises in PFPS I’ve found it not to work to my liking for me or my patients.

Which brings me to

2) Find well tolerated movement & move a lot

When I work with physically active clients I do my best to find painfree exercises that they can do in their own exercise routines to help with maintaining (and if possible improving) mobility & fitness and to help with not making the rehab process seem boring.

For me – I could tolerate hip dominant exercises such as good mornings, swings, deadlift variations, GHRs and leg curls. Low impact conditioning options such as the rower, sled pushes/pulls and the recumbent bike were the main tools I used to help with cardiovascular fitness and GPP. I also regularly performed the McGill Big 3 and weighted carries.

Quad/knee dominant training was more difficult as most every exercise that involved a lot of deep knee flexion initially bothered my knees. The way I beat this was through three steps.

First was through doing 20-rep sets of leg presses (with a neutral spine), leg extensions, and walking lunges. I got this idea after watching one of Stan Efferding’s videos & reading his Vertical Diet package. The leg presses & lunges were initially done with a more vertical shin angle and then were progressed to deeper levels of knee flexion as my tolerance improved. My best explanations for how these worked can be attributed to a combination of

-          Simply lighter weight & load being used

-          The novelty of the stimulus: if you’re used to doing sets of 1-5 in your training like a powerlifter doing sets of 20 rep leg presses with a 90-120 second rest between sets definitely provides a new stimulus. As a side note it can provide a good training stimulus if you’re just looking for something different.

-          Increased blood flow & post-exercise analgesia from the higher reps & volume used

-          And the other components of any treatment that can affect recovery such as patient expectations, natural recovery etc etc

Second was through very high volume warmups. I got this idea from Matt Wenning and other proponents of conjugate training but had gotten away from it recently. In my high volume warmups for leg days I would do

-          Recumbent bike for 5 minutes

-          The McGill Big 3

-          2 (and later 3) sets of 20 of leg curls and leg presses using a weight that was just heavy enough to give me a “pump” at the end of the sets

While this style of warmup added a good 8-10 minutes to my training session, and took a few weeks of adjustment from a recovery perspective, the results were well worth it. I got my heart rate up & got a good leg pump, snuck in some extra volume to help with hypertrophy & work capacity, and my knees were a lot less stiff when I began to warm up for squats with the empty bar.

Third was through building up squat tolerance (more on that below).

3) Address maladaptive beliefs, psychosocial factors & general health factors

At the time I initially developed patellofemoral pain we didn’t have the same understanding of pain science that we do now. As such I believed that all pain was due to tissue damage and I felt like “oh I have cartilage damage I’m just going to wear my knees out.” As such I initially, permanently avoided everything that hurted. While my knees became painfree with 99% of tasks the fitness wasn’t where I wanted it to be & I still couldn’t tolerate deep squatting. Once I realized the adaptive capability of my body and used a graded exposure approach to build my squat tolerance … while training what I could do to build my fitness … things took off.

In terms of psychosocial factors I had some stress and depression as I battled to get to and through physiotherapy school & the board exams. I have elaborated on these in a separate article but that’s as open as I want to be about this topic for the time being.

In terms of general health – due to the above factors (and getting sick) I ended up gaining a bunch of excess body weight. Reducing body weight through initially a IIFYM diet and later through Stan’s Vertical Diet helped a lot with sleep, knee health, and overall well being.

4) Building up tolerance to the desired activity

While I was grateful for the positive effect of all these painfree exercises – I realized that at some point I need to build myself back into squatting if I wanted to do full powerlifting meets again. I was nervous and realized that I protected myself a lot when descending in the squat as I was anticipating the pain + guarding. My squat descent was initially so slow it looked like I was in a multi-ply squat suit and had the tightest pair of briefs & knee wraps imaginable on.

Towards that end I realized that I, psychologically, needed to get out of my own head and get back to my usual “dive bomb” style of squatting – which I did initially beginning with body weight squats. Once I hit this stage – getting psychologically confident with squatting plus doing the 20 rep sets of quad dominant exercises got my knees painfree.

Then I realized it was time to add load. I squatted twice a week – once with knee sleeves & a belt and the other without equipment after deadlifting. I stuck to Prilepin’s Chart to get in volume while emphasizing proper technique. Over time I got to the stage where I could work up to a 3RM squat without pain.

As of now my strength is still not where I want it to be but it is building up fast.

Again, I’m just a N=1 but I hope this helps provide some insight into what I did to rehab my knees. If you have any questions DM me or message me at ericccbowman90@gmail.com. And as always – thanks for reading.