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Resistance Exercise: The What, Why, and How to Get ...
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All right, it's three o'clock, so let's get started. Welcome. Hello. My name is Raghav Sharma. I'm a fourth-year resident at the Medical College of Wisconsin, and I have the distinct honor and pleasure of kind of sharing some of our joint passions in a resistance exercise. I also want to thank you all for being here. It's 3 p.m. on a beautiful Saturday afternoon in San Diego. Hopefully, we can provide something of value so that you're not double-thinking about why you're here and not outside. So today's agenda, hopefully, like I said, will be worthwhile. We have some of the basic mechanisms, trends, benefits of resistance training. We're talking about a lot of the barriers in demonstrating safety, what resistance training looks like in case presentations. And a lot of you were probably in that lifestyle medicine session, the plenary session by Dr. Frady's right before this. She talked a lot about exercise and how important it is. When it does come to exercise, a lot of times when our patients do ask us about it, we have hiccups, and sometimes you don't know exactly what to say to them, how to counsel them. And we've noticed that's especially true for resistance exercise. So hopefully, this presentation can bring a little bit of clarity to that. We have no disclosures. A little bit about me, I've been a personal coach and trainer for quite a while. I do compete in both endurance sports, so we're not just resistance training people here. We both think both are important. We have Dr. Delbert here, who is the current fellow at the Hospital for Special Surgery, has also competed numerous times in strength things. We have Dr. Kirshner, who is an attending physiatrist at the Hospital for Special Surgery, and Dr. Luo. We're going to get this started with the basics. Thanks, man. Good afternoon. So, first, we'll talk about muscular hypertrophy. So, muscle hypertrophy essentially occurs when protein synthesis is greater than protein breakdown. But how does this happen? So, first, there's some form of an overload stimulus, aka resistance training, and this causes a disturbance in myofibers and extracellular matrix. This sets forth a chain of events, which include satellite cell activation. These cells are normally quiet at baseline, but when activated, they'll actually contribute their nuclei to damaged muscle fibers. This increases the capacity to make new contractile proteins. You also get an increase in multiple anabolic signaling pathways. The names are listed. I won't go through them. And the end result is an increase in the size and the amount of both actin and myosin, and the number of sarcomeres that are arranged in parallel. This leads to a greater myofibril cross-sectional area and, ultimately, a greater size of the muscle belly. Cellular strength is both a combination of changes at the muscular level and neural adaptations. So, at the muscle level, the primary adaptation is muscle hypertrophy, which I just mentioned. But there's also a concept known as the panation angle. So, strength training can actually increase the panation angle. In the image on the right side of the screen, you can see that the larger muscle has an increased panation angle. This is basically extra obliquity. So, the larger muscle, with that increased panation, is going to actually have decreased force generated per fiber. But because of the angulation, you're able to actually stack more sarcomeres in parallel, so the net effect is a greater overall force produced by the muscle. There's also neural adaptations. So when I was a personal trainer, one of my favorite things would be to train with somebody who had never touched a weight before because, in the first four to eight weeks of training, they would get way, way stronger than their baseline, and it was always so fun for them. And the reason for this is that they were becoming more efficient at using the muscle that they already had. They were able to recruit more of those available fibers. It's not until about three to five weeks into training that hypertrophy starts to become a bigger part. And there's also EMG studies, pretty sophisticated ones, to back this up. So, one study that showed that after 14 weeks of resistance training, there's essentially decreased neuromuscular inhibition and increased EMG activity in the quadriceps muscles in untrained athletes. But what about the role of dietary protein? So a lot of patients are going to ask you, hey, I'm weightlifting now, how much protein should I be taking in? The answer is complicated, and it really depends on who's being asked and what the population being discussed is. So the recommended daily allowance of protein set forth by the World Health Organization is approximately 0.8 grams per kilogram. But they made this recommendation based on basically young males, so it may not be generalizable to the population at large. Now the European Society for Clinical Health and Nutrition, they say, well, for elderly patients, they actually have anabolic resistance, so they need more protein. So for a quote-unquote healthy elderly patient, we're talking about up to 1.2 grams per kilogram. But if someone's at risk for malnutrition, they have a neuromuscular wasting disease, cancer, you want them to have up to 1.5 grams per kilogram. But not all risk of malnutrition is created equally, so there's also renal considerations. There's a lot of talk about, well, won't high-protein diet be bad for my kidney? The answer is that it also depends. So one systematic review showed that an intake of greater than 1.5 grams per kilogram actually did not have any adverse effect on GFR in healthy young adults. The Nurses' Health Study is actually a pretty impressive study that looked at over 1,600 females over the course of 11 years. And their goal was to determine whether a high-protein diet over that 11-year period was detrimental to GFR in women who had a normal GFR at baseline versus women who had a mildly decreased GFR. And what they found was that if you had a normal GFR at baseline, a high-protein diet after 11 years had no effect on your GFR. But if you had a mild hit to your kidneys at baseline, so mild CKD, then over the course of 11 years, the GFR actually dipped considerably. And the National Kidney Foundation, they give recommendations on all types of patients with CKD. So for more advanced CKD, stages 3 through 5, you definitely want to limit protein if someone's not on dialysis. So no more than 0.6 grams per kilogram. But interestingly, if somebody is on dialysis, they now have a machine filtering their blood for them. So they can get the urea waste products out of their blood. And you now want them to be back on a high-protein diet in order to prevent protein wasting. And if we're talking about athletes specifically for performance purposes, supplementation of protein does improve 1 rep max. It does improve fat-free mass in resistance-trained athletes. But there's a ceiling effect. So beyond 1.6 grams per kilogram, we're probably not able to utilize that extra protein for additional gains. So I would counsel athletes not to go beyond 1.6 grams per kilogram if they're healthy. This is a slide that I'll just kind of leave for you to look at at home, if you please. But essentially, the take-home point is that when it comes to sarcopenia and muscle wasting, the primary driver is generally age-related changes. So for our elderly patients, we definitely want to encourage a high-protein diet. And for patients in general, we want to be able to intervene where we can in this chart. So for example, counseling them better on nutrition, encouraging physical activity so they're not having disuse atrophy. And now in terms of physical activity guidelines, the physical activity guidelines for Americans and the World Health Organization both put forth generally the same statement that says for aerobics, you want somebody to have between 150 to 300 minutes of moderate intensity activity per week. And if it's intense training, a little bit less, between 75 and 150 minutes. But they also recommend that you should be doing at least two weight training sessions per week, targeting most of the major muscle groups in the body. Interestingly, it wasn't added into the guidelines until 2008 in the US. So I think that there's still a little bit of a time lapse in terms of physicians counseling more so on resistance training. I think a lot of doctors are probably more likely to drive home the aerobics point in general and maybe less so resistance training. In terms of activity, unfortunately, about 80% of Americans are not getting enough. So 80% don't meet the guidelines that I just talked about. And the risk factors include a poor self-rated health, older adults, women, lower socioeconomic status, and current smoking status. So be on the lookout for those risk factors if you are counseling somebody on exercise. And in terms of resistance training itself, some studies actually report that less than 10% of people are meeting those two plus days of resistance training per week. And this is compared to about 50% that meet the aerobic activity guidelines. So there's obviously a discrepancy between the two. And there's a large gap that we can catch up on and help to drive that as physicians. All right, everybody. Thanks so much. So I'm going to be talking about the benefits of resistance training. And it's not just looking good in a swimsuit. But it's going to have good effects on body composition, bone health, cardiovascular health, metabolic health, mental health, frailty, and then general overall morbidity and mortality. So all things very relevant to us as physiatrists and to our patient population. So as far as body composition, adequately dosed resistance training can increase both fat-free mass and it decreases overall body fat relative to visceral fat. So this is really important because overall fat-free mass is a prognostic indicator for overall frailty and just well-being overall. If you look at lifespan and things like that, fat-free mass is a good predictor of that. And it also helps improve energy and increases appetite. So if you have more fat-free mass, you're going to want to eat more to maintain that muscle mass. For patients that are in the hospital, they're frail, in an inpatient unit, they've had surgery, they're deconditioned, they need even more muscle mass and more protein, as Dr. Delva was saying. So it really can help sort of feed itself on. You exercise more, you eat more. It helps with nutrition, your overall well-being. Bone health is really important. This is something we see a lot in our offices. The time to lay down the bone is when you're younger, and this graph sort of shows we're laying down bone actively until around 30, and after that, there's sort of a slow decline. There's a more precipitous decline when folks reach menopause, and this is more relevant in women, but it's certainly relevant for men as well. Certain populations are going to be higher risk for bone loss. People with a lower BMI, Caucasian, Asian background. So keep those risk factors in mind. We always are trying to encourage our patients to load. A lot of people say, well, just walk around. That's going to be enough. That's going to load the bone. But unfortunately, walking isn't enough to load the bone. If you're going to walk, you should wear a weighted backpack, which a lot of patients either don't want to do or can't tolerate, or if they also have back pain, probably not the best idea. So these are some of the different ways we can load the bone, but resistance training is really the best way to do that. It can prevent bone loss. It can increase your peak bone mass. So not just for older individuals, but for our younger patients, our teenage, our adolescent athletes, our kids that go to school with our kids, teach them to do resistance training early on, because it's like building up money in the bank. Later, you can only withdraw, you can't deposit. So when you're younger, in your adolescent years, this is when you really want to build up that bone mass through resistance training. Aerobics is not going to do it, and walking by itself certainly isn't going to do it either. So there was a Korean study where they specifically had folks do resistance training, and they found that their peak bone mass was higher, and there was less bone loss later. So fighting osteoporosis fractures, resistance training not only combats osteoporosis directly, but it affects the other factors that can lead to fracture. So if you do strength training, you have stronger hip abductors, you'll be more stable, you're less likely to fall. If you have more fat-free muscle mass, if you actually fall, you'll have something else to cushion you. It's not just bone, skin, and subcutaneous adipose tissue. It can help with balance. There are other neuromuscular control factors that Dr. Delbert alluded to beyond just the strength gains. You have more neuromuscular control when you do resistance training, that reduces the risk of falls. So I always tell my patients, when you exercise, there should be four components to it. An aerobic component, strength training, balance, and then flexibility. How many patients have you seen in the office, oh, I exercise, I walk. What else do you do? That's it. What are your issues? What are your goals? How do you get up those stairs? Well, maybe we should be doing some squats, lunges, things like that, to get those leg muscles stronger. How about cardiovascular health? It seems like a no-brainer that your heart's going to get better with resistance training. And in many ways, resistance training can be as equal or even superior to aerobic training. So resistance training can reduce total cholesterol, LDL, triglycerides, waist circumference. It increases the good cholesterol, the HDL. It reduces both systolic and diastolic blood pressure. It improves peak VO2 and six-minute walk tests for those with heart failure who can't tolerate aerobic exercise. A lot of patients say, well, I'm too sick, I can't exercise. You can start with light resistance training and work your way up. If you do it at a fast enough clip, you're going to get some aerobic benefit from the resistance training, too. So you can sort of do a two-for-one by doing the strength training and also get an aerobic benefit. And at the end of the day, the combined effect of resistance training and aerobic exercise is much better than just resistance training or the aerobic exercise alone. Resistance training helps metabolically, helps our insulin sensitivity, helps reduce our glucose. It helps improve the upregulation of the GLUT4 receptor, which helps glucose absorption and glucose tolerance. So it lowers people's insulin resistance. I'm sure you've all seen people, type 2 diabetics, they get on a resistance training program, they lose a little weight, now they no longer have to take oral hypoglycemics or insulin. And this effect is even more improved when you combine the resistance training with the aerobic activity. How about mental health benefits? I'm sure a lot of us like to exercise. We feel good after. It helps clear our mind. So there are good studies that show that anxiety, depression can be reduced in folks who do resistance training specifically. So whether or not people have preexisting mental illness, it can reduce anxiety, reduces symptoms in young adults with diagnosed anxiety disorder, and compared to aerobic exercise, it's more effective. It can also help with depression. So resistance training significantly reduces depressive symptoms in adults and adolescents regardless of their background health and baseline health, or regardless of the amount of resistance training. Just getting them to do anything is better than nothing, and it will improve their mental health. To get kids outside, away from the screens, hopefully outdoor exercise in a place like San Diego. It's hard not to. It's going to be great for their body, for their mind, their mental health as well. So resistance training alone has a similar effectiveness to aerobic exercise or mixed exercise. There's some studies that show it's equal to oral SSRIs as well. Well, how about pain management? A lot of us are dealing with folks who are in pain. Well, it hurts too much, doc. I can't exercise. Well, how about we flip that around? Maybe we start exercising. Your pain is going to be reduced. Or patients exercise, and they realize, well, my pain doesn't really change. So why not exercise? So there are good studies showing that it can decrease pain intensity in chronic, nonspecific low back pain. It reduces pain, stiffness, and improves physical function in those with knee arthritis. And that's not just from the effect of you have a stronger VMO, therefore, your quad is stabilizing. You have less knee pain. There's other factors beyond that as well. It reduces pain, fatigue, and the number of tender points, increases functional capacity, and increases the quality of life in patients with fibromyalgia. So a lot of us were taught, oh, fibromyalgia, you need to get good sleep, do aerobic exercise. But strength training should really be a hallmark of the treatment for fibromyalgia as well. So how about overall frailty? This is really a big problem. We're doing a great job of extending lives, treating heart disease, cancer. And now we have older, frailer patients that are going to develop orthopedic issues. They're going to slip, fall. I remember when I was taught in residency, 50% of people who fracture their hip don't leave the hospital. So we really want to prevent and minimize frailty in our older individuals. So as per the Academy of Family Practice, frailty typically presents in the geriatric population with age-associated declines in physiologic reserve and vulnerability to both internal and external stressors. So we can evaluate this through gait speed, by weight, grip strength, physical exhaustion. And you can grade people into non-frail, pre-frail, or frail. Inactive adults lose between 3% to 8% of their muscle mass per decade, with the most rapid loss occurring between 50 and 80. So we know naturally folks develop sarcopenia. And you see these sort of bumps during menopause. And some people would say manopause, where there are drops in testosterone when you're in your 40s and 50s. And that's where you see a precipitous decline that continues to decline as we get older. So we really want to get ahead of this, get ahead of the sarcopenia, sort of build up that reserve of muscle so that as we naturally lose that muscle, we have a reserve for it. So resistance training in the elderly improves muscle size and strength. When you look at a chair stand test, the time up and go, gait speed test, and six-minute test. So overall morbidity mortality really is decreased. It's not just we're looking at lab values, your cholesterol is better, your glucose is better. Do you actually live longer, a better quality of life? Yes. So any amount of resistance training reduces all cause mortality by 15%. And there's a nonlinear relationship with maximal risk reduction of 27% with 60 minutes per week. So that's much less than the physical activity guidelines that Dr. Delbert mentioned. It's hard to really motivate people, and Dr. Sharma's going to talk about that next. But every little bit, anywhere you can get them started and just build up on that. Don't make it this onerous thing. I show and all of us show patients how to do exercise in the office right then and there. Don't wait to go to PT. It's going to take six weeks, and you have to call and schedule an appointment. And my car broke down. I can't make it. You know, we want to teach people exercise they can do in their living room, you know, while they're on the couch, at the commercial break, in between watching TV, stuff you can do without any specific weights or other equipment. So there's a 15-year cohort study using the National Health Interview Study. And they found that older adults adhering to the recommended resistance training guidelines had a 46% lower odds of all cause mortality compared to those who didn't. There's another cohort study looking at similar data with about 500,000 participants, and they found that those who were adherent to both parts of the ACSM guidelines had a 40% reduction in all cause mortality. Aerobic only was 29%, and RT only was 11%. So combined, that's where you get that 40% benefit. So here's sort of a summary table with all that, and we'll take questions later. Thank you. All right, so we're going to talk about some of the barriers to participation. I want to thank Dr. Delbo and Kirshner for that first part. Little bit drier, but incredibly important to kind of set the stage for why we need to get our patients to engage in resistance training. So there are several barriers and the CDC lists several to kind of just exercise in general. I'm not going to say them all, but there's a whole host of things. We've all said these things ourselves. We've heard our patients say these, but there's a lot of these and it's very dependent on the population that we treat and we know this based on kind of the things that we hear day to day. So when you look at resistance training specific barriers, this is a really busy slide. I'm just going to kind of sum it up. The biggest things generally seem to be a lack of time, being more interested in other things, seasonal reasons, like they want to maybe participate more in a specific sport during that season and whatnot, but then you start breaking it down into some of the other subgroups. For older folks, there's some interesting reasons and one is thinking that it will increase the risk of having heart attack, whereas we just heard Dr. Kirshner talk about that's actually the opposite. For females, unfortunately, there's still a plethora of gender-based stigmas, discouragement, negative comments, things like that, that unfortunately we're still fighting. When we go to like the prescription of resistance training, we think of our physical therapist as kind of the the know-alls of resistance training and these are the people that are going to solve this problem. Unfortunately, that doesn't seem to be the case either and then when it comes to us physicians, there is a lot of ambiguity around exercise prescription because is there a raise of hands for how many people got taught exercise prescription in med school or anywhere? Probably no one, so that's exactly, there's an ambiguity. We don't really know how to talk about it. However, there's still a ton of gaps that aren't really in the literature. Obviously, it's very difficult to do this. It's difficult to get these very niche subgroups and kind of talk about what limits you from engaging in resistance exercise. One of those things, unfortunately, is dogma and we've heard a lot about the various risks and things about resistance training, so there are kind of a lot of narratives and things that we might have heard. Things like squatting puts a lot of load on your knees, so you shouldn't do it. Dead lifting is terrible for your back. You're gonna injure yourself, end up in the hospital. It's not when, it's if, or sorry, it's not if, it's when you're gonna injure yourself and all these different things that we've probably all heard one time or another, either being a patient or unfortunately sometimes maybe you've said it if we didn't know any better. Like I said, we often use these phrases. We just don't know, so we're gonna take a page out of their book right here. I'm sure all of you recognize who these two are and we're going to kind of go through some of these myths and things that I think are incredibly important for us as physicians to kind of talk about and be able to address when our patients bring these up. So the first thing is I'm going to get hurt. Resistance training is often perceived as risky. We think of these huge beefed up lifters that like blow out their knees, throw out their backs, all these different kinds of things. However, when you start looking at the actual literature for it, the incidence of injury in resistance training is actually 0.31 and 0.05 per 1,000 hours for men and women respectively. If you do the math, break this out per the resistance training guidelines, that actually gets to one injury per 28 years for males and one injury for 192 years for females. And that's, like I said, assuming the ACSM guidelines. And that's two hours per week, which probably, like we said, you don't need two hours, only 60 minutes. Most injuries that are actually seen from resistance training are just being kind of dumb, for lack of a better term, and dropping weights, unsafe practices, stuff like that in the gym, which are obviously not safe. When we compare this to sport, we think of several sports as much safer than resistance training. And we have running, basketball, and golf here. I want to highlight golf here, which we think of as a very safe sport because it's the one that we play into as we age. As we get older, you can play it throughout. And there's actually 8.5 injuries per 1,000 hours of competition and 3.3 per 1,000 in training. And if you remember the numbers here, that's a lot different. So golf is more injurious than resistance training. And then tennis here was a standout. There are a lot of injuries in tennis. So these are just some of the comparisons to sport. Another one is, I'm going to hurt my back. And this is something that we have probably all heard. Unfortunately, sometimes some of us probably have said it. And it's actually for a good reason. There's the majority of injuries, which, like I said, is a very small portion of injuries, are actually from resistance training in the lower back. And the deadlift and the squat are the most commonly associated exercises with this. But like with anything, the people who exercise more, who train more, who compete in like athletics related with this are the ones who are getting more injured. And more training hours leads to more injury. But then when you look at the literature for powerlifters, who are theoretically doing the most weights, there's actually no huge like catastrophic back injuries in the literature reflected from this. And then also when we look at like kind of these mechanistic studies about discs and whatnot, about like deadlifting in a flex position, those studies are done in kind of stiffer backs in anatomic populations and nothing's really been done dynamically while someone's deadlifting. Like people who are deadlifting a thousand pounds out there, the back is dynamic and things adjust and it's not reflected in the literature that lumbar flexion contributes to specifically back pain. This is actually a really interesting study. There was 154 individuals and they all had disc herniations and pain. And when you ask them where this came from, 67% had no clue where they got this pain or where they injured their disc. 26% were from like daily activities, like maybe vacuuming, sweeping, doing things like that. And only 6.5% were from heavy lifting. So usually when we think about it though, and we have a weightlifter that comes in, we're thinking, oh obviously he injured his back from that. No, it could just be from going up the stairs, bending over to pick up like clean up your dog's toys, something like that. The knees. This is also one that I think is getting better from what I've heard. And it sounds like a lot of people think that loading the knees, like squatting and stuff, is going to injure your knees and increase the rate of degeneration in people with things like arthritis. And this is a common area for injuries in powerlifters, but a lot of these things are more like tendinitis, strains, cramps, and things like that, which are usually poorly dosed training, which we'll talk about, Dr. Luo will talk about in a little bit. And as Dr. Kirshner talked about, it's actually the opposite, where people with knee osteoarthritis benefit from resistance training in function, in pain, and kind of a lot of different things. And then going again back to the mechanistic kind of portion or notion of this, there's no literature to reflect that squatting in a knee valgus position, kind of with your knees in like that, actually contributes to the risk of injury. And sometimes it's actually an advantageous position is what we're finding out in the literature now. There's another one where people think that they're too old to benefit. And you'll hear this, you have your classic elderly patient that comes into the clinic that you're kind of talking about this, and then you mention you should probably start resistance training, and they say, oh, I'm too old, and or I have too many pre-morbid conditions. And this was actually another really, really interesting study called the Liftmore trial, and it had 101 women, and they were all aged above 60, and they all had osteoporosis. And if you look at the study, some of them actually had previous osteoporotic fractures, like compression fractures, and it had them do five sets of squats and deadlifts at 85% of their one rep maximum, which if anyone in here is lifting, you know that's quite a lot of effort to put into that, especially for something like squats and deadlifts. And they did this for a period of time, and in over 2,600 sessions, there was only one adverse event, and that was essentially a mild low back strain, and they got back to exercising, got back into the trial pretty quickly. And in both groups, it improved bone mass and physical function, or sorry, the exercise group improved bone mass and physical function substantially. So obviously it's the contrary, where also when you're older, you can also benefit pretty significantly, and I think Dr. Luo will also talk about that in a little bit. There's also a notion that it takes too much time, and we think of these people who exercise all the time are quote-unquote health nuts that are always in the gym, but when you come down to it and what's actually effective for health, a training frequency of three sessions per week, two to three sets per exercise, seven to nine repetitions per set, was the most effective for muscular hypertrophy and strength. And if you kind of do the math for that, come all the way down, if you pick four to five exercises, like once again Dr. Luo will talk about in the next section, it can come down to only 15 to 20 minutes per week, and that's for maximum muscular hypertrophy and strength. And obviously any amount is beneficial, as Dr. Kirshner was talking about as well, but 15 to 20 minutes per week is technically all you would really need there. And there's newer concepts such as exercise snacking out there recently, which is kind of you do a little bit of exercise, go back to whatever it is you were doing, then you can come back to it. And this can get really easy if you have just like little weights lying around that you can like do some squats with or things like that. It's too hard to learn, and we think of this as once again our seasoned lifters who are going in there doing these complex exercises, they look like they're having a tough time doing them, and skill is an often reported barrier to engaging resistance training. And oftentimes this comes to thinking about proper form, and we're thinking about making sure that you do everything with the exact, perfect, strict form, otherwise you're going to injure yourself. However, if you look at the quote-unquote sport with the most irregular form, which is CrossFit, because the goal is kind of just to get the, no shade to CrossFit, sorry, no shade to CrossFit, it's just you're trying to complete the objective. So if you are comparing it to that, there's the same injury risk with more strict form requirements, like powerlifting. In powerlifting you get judged on very strict criteria of completing the lift, and it's the same injury risk as CrossFit, which is really interesting. And then also free weights and machines kind of do the same thing in promoting strength and hypertrophy, and machines are much more accessible. You can also quote-unquote train dumb, is what I like to call it, which is very stupid. Put on a heavy backpack, hold jugs of water, go up the stairs with those, things like that, and it's pretty easy to engage in. You don't have to worry about those very complex exercises that you might people see people doing on Instagram as you're scrolling through reels or whatnot. What's the answer for this? Dosing. Dosing is everything, and the best way to prevent injuries is training dose, and this is kind of like Goldilocks. If you do too little and you kind of try to advance and do too much too quickly, you're going to injure yourself. And if you're doing too much and you're not ready for it, you're probably going to injure yourself. So you want to kind of make sure that you're at a moderate dose of resistance training that reduces the risk of injuries and pain in athletes, which is what the research is finding. And the way I like to think about it is not that you are kind of training to reach another milestone, but you are building resilience through movement. And the more you train, the more resilient you become to more movement, and kind of the cascade goes on and on, and that feeds into the ideas of frailty and whatnot throughout the lifespan. And this is kind of, as us physicians, you don't become an attending physician and kind of go through all the stresses of that. You build up throughout the way and you build your tolerance. Obviously we know the trans-theoretical model of change. We've all seen this at some point in counseling patients. It's important to recognize where they are in this stage, and you're not going to kind of hammer home all these points if they're not even thinking about it. So you kind of want to make sure that you're catching them at the right time, and if they don't want to talk about it, fine. There's a whole lot else we can talk about as physicians. That's the reason they're coming to see us, not just for us to tell them, go exercise. And that feeds into the point of not being paternalistic. We are not supposed to just be like, do exercise, because everyone kind of knows that to some extent, and no one being like told what to do. So we're, don't just tell them to go exercise. Don't use body weight centered language, which is unfortunately what a lot of people attach exercise to. There's a whole host of benefits, and I don't know if you remember from when Dr. Kirshen was talking about, we really didn't talk that much about body weight. We talked about a whole host of other benefits. So don't just attach it to body weight. Don't tell them that it's easy. We don't know the barriers and restrictions that patients have to approaching resistance exercise, so something that you think is easy might not be as much for them. And then don't tell them that it must be done quote-unquote right. We just talked about a whole host of things that we would think of as right, that are not necessarily true, and we went through myth-busting them. And also avoid the nocebo effect, which is essentially telling them that something might cause a risk of injury, when in reality it wouldn't, because then they're thinking about that, and then they're not going to participate in it. So like I said, our spoken word carries a significant impact. We are physicians. Our patients kind of, they're coming and paying to see us, and this is why they value our word. So we should suggest a general home exercise program that includes resistance training, provide reassurance for continuing resistance training if someone is doing that, and kind of talking about all the different things that might be helping erase barriers. We should dispel myths, kind of like some of the ones that we just talked about regarding the safety, and once again avoiding the nocebo effect, which the definition is up there, but we want to make sure that we don't nocebo our patients into not participating in resistance training. So now Dr. Liu is going to talk about what does resistance training actually look like. All right, so basically with resistance training, it generally involves the contraction of skeletal muscles against external resistance, any kind of resistance really, and usually we think about people just moving around, but honestly you can even get stronger doing isometrics, and so in the top right corner I've included a little meme from my favorite movie, or one of my favorite movies with the Joker, but essentially you see this person in the top right corner really doing like kind of a deadlift that's still, but this rack, you know, the barbell is fixed and it's not moving anywhere, and yet you can actually change how much effort you're putting on to actually maximize your effort, so you're modulating effort there, but for the general population we don't have access to that particular setup, so we use things like body weight or partial body weight conferred by bands, cables, and straps, or even another human, and that's possible, but for the most part the most convenient thing is a sort of incrementally loadable and adjustable kind of form of resistance, and we find that in the use of machines and also free weights. When it comes to sports, there are many kinds of strength sports out there, you know, I think it was mentioned before, powerlifting, there's also Olympic weightlifting, strongman bodybuilding, there's also CrossFit, each one has a different goal, right, and so you have in powerlifting, you're basically expressing maximum strength, however slow, and that's in contrast to Olympic weightlifting where you're doing strength in the context of power and sort of technique, and strongman, there are also some individual events, we're just trying to be functional within the confines of those things, but regardless of what you're passionate about, and most people I know aren't really passionate about these things, especially not my patients, really though when it comes to athletes or former athletes, most people who either have a history of competition, they understand this idea of off-season and in-season, so when you want to talk to your patient about that, really, and really try to connect with them and relate to them, one thing that works for me is, hey, like, you know, did you ever enjoy sports either recreationally now or in the past, and usually, you know, once you get a yes, then you explore that further, and then I use that to kind of talk to them about off-season versus in- season, building a foundation of strength, size, and conditioning, and then, you know, moving forward to more in-season training, those sport-specific goals, so really identifying like a connection point with your patients is important, and I think most people who have a history of competition or competitive sports, once they sort of have that gear and you sort of like have them focus on that, they're able to sort of better detach from their usual lives and just, you know, reinvigorate themselves. When it comes to our patients that we see who are hurt, I mean, is this the endgame, right? So as physiatrists in the musculoskeletal world, we oftentimes see patients when they are in a tremendous amount of pain, and so we give them a focused physical therapy prescription so they can go ahead and get physical therapy for their specific diagnosis, and if we're lucky and the PT is good and they don't just put a hot pack on their backs, they graduate physical therapy with a specific home exercise program, and for many patients that you talk to, that's really the endgame, that's really what, like, you know, I did my PT and now I'm better, but then they go home and they come back to your office two, three months later and they're not better and they're worse because they fell off, right? So we want to try to have, you know, talk to our patients really about focusing on the later goals of physical therapy and not just doing more range of motion stuff, stretching, or doing isolated muscle groups, but really focusing more on movement efficiency, pain-free movement, and then loading it, and then really returning to your preferred activities and ADLs. So as they evolve, and hopefully as they kind of get stronger and more mobile, can we really move the goalposts here and talk to our patients about readjusting what they want to do out of their lives to really demand more of themselves and ask more of themselves. So in so doing, you know, the way I see it is from going to physical therapy to home exercise, that's great, you're going from reactive to proactive, but maybe the last step is becoming iterative and having them sort of explore this very important activity that will no longer, you know, I'm sorry, not longer, but will also add healthspan to their lifespan. So when it comes to exercise selection, right, you know, today we're really going to talk about more about foundational movement patterns that you see a lot of times in the gym, but also in your day-to-day lives. Things like the squat, the hip hinge, the pull, the push, and the carry. I purposely included pictures here of commonplace activities and not really sporting stuff because you guys already do that, and so do your patients, and so as I say to a lot of my patients, this is inevitable, right? It's not optional, and so because of that, if we really want to mimic this the most, we need to focus on multi-joint exercises, closed kinetic chain, and evolving full body as much as possible. So starting off with the squat, generally, you know, this involves flexion of the hips, the knees, and ankles to perform a sitting type of motion. You know, I gave just some variations of it, and there's a dozen ways to do it with different kinds of barbells and weights, and you can get all fancy with it, but in general, you can start with nothing, right? And you could just progress from there, and so the primary muscles targeted are the glutes and the quads, but depending on how you do it and how, why your, you know, thighs are together, how externally rotated your femurs are, you may be activating other muscles too, typically the adductors and the hamstrings, but if you're loading the squat, and so you're not just doing a belt squat or something that's unloaded from the waist down, if you're loading yourself with a barbell or something overhead, you're using a lot more muscle mass in your upper extremities and upper body as well. So I did include a link to a YouTube channel slash video that Dr. Sharma really created back in the day when he was coaching, so you can see him at his prime, and he talked you through all the squats and variations. Thank you for that resource. Coming up next is the hip hinge. You know, for us gym goers, we typically see this in a form of some kind of deadlift, either with a barbell or a trap bar, but you know, you can also use a kettlebell, you know, really the hip hinge maneuver is super important. You have to learn how to bend at the hip to avoid excessive lumbar flexion or extension depending on, you know, where your spine is at. So hip extension from a fixed position, and sometimes this involves a little bit of knee flexion or extension, other times it does not. The primary muscles targeted for this exercise are the glutes and quads and the hamstrings, but also, as you can see, the traps, the lats, the core, really the whole body. So I've also attached a video there for your perusal later on. Next, you have to pull. Pretty self-explanatory. You're pulling something towards yourself, generally without too much hip or knee range of motion. There's lots of ways to do it. You know, primary muscles targeted are the trapezius, the rhomboids, and lat dorsi. Specifically with our patients who are spending most of their days sitting at a desk, we tend to really emphasize and talk to them about either doing a row or seated row because some of the muscles that we're targeting here are the ones that fatigue the most easily throughout the workday. Another good pearl is if you're going to perform it with free weights like a barbell or dumbbells, additional muscles are required to stabilize yourself. And then for most gym goers, everyone knows the push. Everyone knows about bench pressing and uppers. And obviously, one of the inside jokes amongst gym goers, these are the aesthetic muscles. But basically, there's different angles you can do. Incline, standing, upright, military press, decline. You can also do with a barbell, kettlebell, anything you want to do, or unweighted with a push-up. You're targeting your pectorals, your deltoids, your triceps. With this in particular, things like grip width and type grip that you use, and kind of how you perform it with or without leg drive. So using your lower extremities to brace yourself, it can affect how much effort you put forth and how much weight you lift. But also, it can affect how much you can target these upper extremity musculature. And lastly, the carry. Generally, this involves walking for a distance or time while holding weight. It can be performed unilaterally, bilaterally. When performed unilaterally, it's called the suitcase carry, for obvious reasons. Bilaterally, it's more of a farmer's walk. You can also hold the weight overhead, and that's a waiter's carry. Or you can do a bear hug with either a medicine ball or an Atlas stone, which is not really commercially available in most places. But everyone has a suitcase to hug, or a child, a growing child. So primary muscles targeted, your traps, your fingers, and wrist flexors and extensors, and also your lower extremities and your core. All right, so moving on to training-related parameters. On the left-hand side of the screen are the basic parameters. Everyone's heard of the reps, and the sets, and the load, and volume. Generally, load is the weight and resistance you use. The total volume is you're really multiplying sets times reps times load. And also things like frequency and rest interval. These are pretty self-explanatory. Other parameters that people can target to sort of, I guess, pay attention more to their training that has been the subject of more and more research recently in the last few decades are things like RPE or RIR. So RPE stands for rate of perceived exertion. RIR stands for reps in reserve. They're different metrics, but they're kind of correlated. In both cases, athletes use that to gauge how far from failure they are. So if you're performing an exercise at a specific weight, and you feel like you want to stop when you're about three reps in reserve, that's different than if you feel like you have 10 more left in you. It's a way to help you auto-regulate, or help you select how much you're capable of on any given day. So the thing about the exercise prescriptions that we give patients, too, is that they're too prescriptive. So a lot of times, you would hear patients say, well, I was trying to do the program, and then all of a sudden, I tweaked it, because on that given day or in that given moment, they may not be sleeping well. They're fatigued, or they were sick or recovering from COVID. So their actual capacity for that day has changed. And because of that, you have to sort of auto-regulate on almost like a session-by-session basis. And these terms, if you sort of Google it, read about it, they've been sort of used more and more in the strength training world to kind of help patients manage. Things like intensity should also be factored. So intensity is the percentage of your one rep maximum that you can lift for any particular lift. And so if you're doing something at like 50% of your one rep maximum, clearly, it's going to be easier than the weight at 80%. So you can probably do more volume that way. So these are some things to think about. Also, velocity. Some athletes train, they have velocity trackers now. So they believe that if you start slowing down in your rep, that means that you're accumulating fatigue. And so that's also been kind of used by athletes and a lot of people who are not athletes to sort of gauge how tired am I on any given day. So these are some fun facts to get some buy-in from your patients and improve adherence. So a lot of patients, they feel as we age, we don't recover as quickly, or we're more frail, more prone to injury. That is true to a certain extent if you're comparing extremes. But really, in the past, we've had multiple studies showing that 65 to 75-year-olds, they recover a little bit slower, or they're not able to get as much progress done, or as many gains as 50-year-olds, and vice versa with 85-year-olds. But recently, I think that there was this one study I'm citing. What they did was they increased volume. And they actually found that by having the 85-year-olds do four or five sets, the end result was that they actually benefited just as much from resistance training as 65 and 75-year-olds. Additionally, this idea of, if I want to get stronger, I need to actually lift more weight, that's also been shown to not be quite as true as we think. It turns out that if you actually pick a lighter load and you do it for more repetitions, and as that becomes easier, you just increase the number of repetitions, your total strength progress and gains actually can be relatively similar. So I was talking to Dr. Delbert about this yesterday, and he brought up a good idea about using this as a currency exchange. What I can get with a lighter load but more reps, I can exchange for maybe attempting a heavier load with fewer reps. There's also this really cool idea of vertical strength transfer. So if you have resistance-trained individuals who really train their lower bodies, this can actually be shown to be improving upper body strength adaptations as well due to a host of neurophysiologic and endocrine responses. So another way of putting it is, don't skip leg day. And then now, more and more, we have multiple studies showing that you can have similar strength gains that you can achieve despite training further from failure. So do you really need to max out to really get all the benefits? And the answer is no. And lastly, what happens when life gets busy and you have prolonged layoffs due to sickness, illness? It turns out that one year of structured strength training can really provide lasting benefits for multiple years, even if you really don't train and even if your muscle mass decreases. So when it comes to programming, things like volume, things like load, and intensity, these are all things that can be prioritized for your individual goals. Probably not at the same time. You could probably do one or two at the same time in any given program. There's lots of great starting points out there, lots of great prescriptions. Here I included an infographic from BJSM from this year. It's hot off the press. But really, though, it almost doesn't matter what you do. What matters is that you do. So here in the BJSM, they recommend multiple sets, multiple reps per set. But what's good about this one is that it gives you a range. And so the whole idea of being flexible and not being too prescriptive is really key here, because once someone feels that they can't do it, that they fail, then they kind of give up. But generally, we want to have a program that is diverse, focusing on all the maneuvers and movements that we discussed before. And when it comes to the number of reps and load, given what I just told you in the last slide, you will get benefit from really a variety. But I think most people should aim to at least, if you're untrained, you should aim to start off at a lower total load and maybe be able to do more repetitions. And then once your base improves, then maybe go higher. Because with any particular exercise, if you go heavy enough, then technique becomes an issue. And then that's when you may have maybe a greater risk of injury. But ideally, we would want to attempt to tell our patients to really do a little bit of both. Why? Because let's say someone's used to carrying 20 pounds. All of a sudden, they go away for a month and they go to the airport. Now they're lifting 50 pounds for their suitcase. So the idea of being able to tolerate loads and bring up your baseline is super important. When it comes to number of sets, you want to do at least one set. So a recent systematic review, meta-analysis of only six studies, but they looked at over 200, but only six qualified. They found that a single working set of 6 to 12 reps at about 70% to 85% of one rep max significantly increased your strength in the squat and the bench press when performed two to three times a week. When it comes to frequency, you need to do it at least once a week. The study that I found, basically, found that if after a period of about 12 weeks for this particular study of training twice a week, if you just continue just once a week, you maintain pretty much everything. If you drop down to once every two weeks of training at the same exact program, same exact level, you retain about 90% or 85% of your total progress. Unfortunately, the study ended at three months. So anything after 12 weeks, they made sure to say, you know, we're not responsible for. So in terms of, oh, this is my last slide. So adapting for injury, right? And this is super important because your patients will get very, very discouraged. How can we find a tolerable entry point? Most people end up just stopping altogether, right? And they just avoid the movement because they blame it on the movement. Generally, we have, we gave you lots of options here. The number one thing, as Dr. Sharma mentioned, load and volume, just decrease it. You know, maybe you went crazy that one day. If you just, you know, if you're able to do it with half the weight and pain-free, then you really have no reason to really worry too much. Also too, though, you know, in terms of flare-ups of different musculoskeletal disorders, maybe restricting your range of motion to within tolerable limits is key. You can also play around with speed of movement. So things like, you know, introducing pauses or doing the movement slower or a tempo. So three counts down, three counts up. You know, usually that draws the patient's attention to two things. Number one, where in the movement am I sort of sticking? Am I experiencing the most pain? Can I troubleshoot this? And number two, they usually sort of realize aberrancies in their, you know, in their technique and efficiency or inefficiencies that they can address with other exercises. So definitely the speed and slowing things down literally can be very helpful. When it comes to changing mechanics, right? So in some of the movements that we discussed before, you know, I talked about grip strength and, I mean, grip width and where you place yourself. But it turns out that, you know, for upper extremity exercises like bench press and pressing, you know, changing the type of grip that you use, how wide your hands are together when you do the movement. It can make a difference because it can target different muscles and it can probably load the joints a little differently. When it comes to your lower extremities, things like stance width, how wide your feet are together for any movement, whether or not your feet are turned in or out. You can adjust these things and play with them to figure out whether or not it's just something that you can work around by changing just a slight, slight, slight things. When it comes to changing exercises, if you really can't tolerate any of the above, maybe consider, you know, an alternative, at least for the time being. If you truly are married to this one thing, you can periodically sort of go back and revisit it, but otherwise, you know, maybe be okay for the time being of an alternative. And of course, the use of supportive equipment, you know, does nothing wrong with it. If it helps you get through your training relatively comfortably, then that is more important than not. So anyways, we have a couple of cases to really sort of tie everything together for you guys. Thank you, sir. All right, so for our first case, I'm just gonna kind of briefly summarize, then we can get into the actual exercise prescription piece. So this first case is somebody that you're going to see 10,000 times in your life if you're in musculoskeletal medicine. So this is a 68-year-old woman. This particular patient had a history of osteoporosis. She comes in with left knee pain. Her history and physical exam are spot on for knee osteoarthritis. You get some x-rays, it confirms it. So she has medial joint space narrowing. There's varus angulation of the knee. You could see on the right, she has patellofemoral joint space narrowing. So you decide to treat her by referring her to a nutritionist for weight loss. This is something that she was very up for. We prescribed meloxicam as needed. And then, of course, physical therapy. However, this particular patient lived in a more rural area in New York. So she wasn't able to get an appointment for about eight weeks. So she says, well, hey doc, what can I do in the meantime? So I'm gonna go over three exercises that you could teach patients in the office in probably under five minutes. I know that very frequently, maybe we're running behind. However, you could take two to three minutes counseling on these exercises, and at least that can give them kind of a jumpstart before they go into their actual physical therapy sessions. This way, the therapist can actually do more advanced things with them on day one, maybe. So one would be seated leg extensions. Very low level, but customizable. So you have somebody sit at the edge of a chair, literally extend their knee. To make it harder for some people, hold it for a longer period of time where ankle weights do a greater number of reps or sets. The next is probably the most functional movement I can think of, but a sit to stand, aka a box squat. So in terms of progression, of course, increasing reps or sets. But you can have somebody hold a weight across their chest if they don't have access to weights. They could hold a water gallon across their chest. You could have them sit on a lower chair or a lower box. But you do wanna be careful, because for a patient that has more tibiofemoral joint compartment narrowing or osteoarthritis, those deeper squats can put a higher load on those particular compartments. For elderly patients, I think the important thing is that you're just getting them to do the movement. So if you watch them do a sit to stand on a normal day, it's probably not gonna be a beautiful picture. But you could have the patient scoot to the front of the seat and kind of get their center of gravity over their midfoot, and that can help to increase their ability to stand from a seated position. You could also have weaker patients use something like an arm rest or really sturdy furniture in front of them that they could hold on and brace off of. And some discomfort may be expected. So if someone's coming into your office and they have eight out of 10 knee pain, and you prescribe exercise to them, they're probably not gonna be pain-free when they're doing the exercise. So in general, I'd like to use like a day or so of recovery time as my gauge. So if somebody is still banged up after a day or two, you probably did a little bit too much with them and you might wanna pull back. But otherwise, it's okay to exercise with a tiny bit of pain. Over time, we're hoping that that decreases. And the last exercise is simply a step up or even just using plain old stairs. So you wanna obviously make sure that the patient has good enough balance to perform the exercise safely. If patients do have good balance, you could have them practice skipping stairs on the way up. Of course, if they have poor balance, they could practice by using the handrails. And interestingly, step ups are actually shown to activate the glutes more than squats and more than hip thrusts. So at this follow-up appointment, our patient's 60% better. She's no longer using meloxicam. She's doing seated leg extensions now with five to 10 pound ankle weights. And she's able to do a sit to stand from a deeper seated position without pain. And she was even able to add a 15 pound dumbbell across her chest with that exercise. And we decided to kind of keep the same course because she's now doing a lot better. And at six months, she had 10% further improvement in her pain. She's sitting to standing with a heavier dumbbell. And at that point, she opted to pursue visco supplementation just to get some additional pain relief. So in terms of some take-homes and positioning pearls, one thing I wanna highlight is that the excess knee flexion, aka deep squats, it can increase forces across the tibiofemoral joints. So if somebody has medial joint space narrowing only, for example, then you might not wanna have them do very deep squats or they can squat the tolerance. If they could do a deep squat with no pain, then great. But otherwise, if it's painful, you probably wanna take a step back. A wider stance in general is gonna activate the hips a lot more. A wider stance is also gonna put slightly greater strain on the tibiofemoral joints. Conversely, a narrow stance is gonna hit the quads a little bit harder and it'll put more stress on the patellofemoral joint space. So I've seen a bunch of cases throughout fellowship of patients that have just isolated patellofemoral OA. So for those patients, you're not gonna wanna have them do a narrow stance squat for the most part. And then in terms of foot position, so if you have somebody try to squat with their feet completely parallel to one another like this, it's often very hard for them to hit proper depth. You need to have very good ankle mobility. So for a lot of patients, I'll counsel them to angle their toes out slightly, no more than 30 degrees for sure, but something as subtle as 10 degrees can allow them to sit a lot deeper into a squat and squat a lot more functionally. But with greater outward rotation of the feet also comes greater medial joint space forces. So you can basically customize how you teach somebody to squat based on where their OA is and where their pain is. And a take-home point is that the technique does not need to be perfect. It's more important that you're doing something, even if it doesn't look textbook. This basically says a lot of what I just said, just in a little bit of deeper detail. So it's something that you can take a look at later if you like. And with that, we'll move on. All right, so I'm gonna talk about a real case, real patient I had. This was a 20-year-old. I initially saw him as a high school athlete, and then he went to college. So he's a football lineman, a big, strong guy. And he's had intermittent chronic axial low back pain for a while now, since I've known him for a couple years. His back tends to lock up when he's typically lifting while he's doing squats or immediately after, and then it lasts for a couple days. And then it's hard for him to practice, to play, and he can't really do much with his team. He has dull, annoying, achy pain. Sometimes he feels some pressure in the back of his legs, occasional radiation down to the right thigh. There's no bowel or bladder change. He doesn't notice any overt, gross weakness. He's tried the usual, tonilibuprofen. He's had some formal physical therapy, but hasn't really had much benefit with it. He hasn't had any injections. The major things on exam, there's no scoliosis. He has a relatively normal alignment, although he has a forward head posture. He has a little bit of decreased hip range of motion. And you notice that he's got tight Achilles and tight hip flexors. So his modified Thomas test is positive, and he has some limited ankle dorsiflexion. He has a little bit of hip abductor weakness in sidelying, more so than you'd expect from a big, strong football player. I wouldn't expect him to be able to push his leg down, but I was able to. And then on special testing, a lot of us like to watch the patients do these maneuvers in the office. So if he says, doc, it hurts when I squat, the first thing I say is, show me how you do a squat. So I have him do a single leg squat to see, is there excessive knee valgus? Does he have hip abductor weakness? I look at his double leg squat. What's the position of his toes, his ankles? I don't prime the patient. They say, well, how would you like me to do it? That's the point. I just want to see how he does it naturally. And then we can cue him based on that. So he had a relatively narrow stance and he had excessive knee flexion, sorry, excessive lumbar flexion when he was doing the maneuver. So that makes sense. Well, you get down to the bottom of the squat, you have limited hip and ankle flexion. Therefore, your lumbar spine is gonna flex. Some people call that the butt wink. So at the very bottom of the squat, there's this small lumbar flexion moment and that can really put a lot of stress on the disc. So this is what his x-rays look like. You can see he has some osteophytes at L4-5, a little bit of disc space nearing. So what's our diagnosis? He has discogenic low back pain, maybe some radiculitis, but mainly discogenic axillary low back pain, where there's an annular tear, herniated disc. We're gonna treat it the same way. So as far as our treatment, what are our goals? Well, all the issues he had on physical exam, we wanna mitigate. So decreased hip range of motion, we wanna improve that. Hip flexors are tight, we want to stretch them. Ankle limited dorsi flexion, we want to work on improved mobility of the ankle and specifically working on Achilles stretching. We want to work on hip abductor strengthening and then we want to introduce him to the MDT or the McKenzie method of physical therapy. So it's a mechanical diagnosis and treatment. He's already told you what his exacerbating factors are. He doesn't respond to flexion. I didn't mention on physical exam he only flexed about, you know, 25% of expected. He has relatively full extension. So he has no pain and in fact it relieves his pain to go into extension. So with the McKenzie method you're trying to figure out what direction does the patient want to go in, teach him exercises to go into that direction. So it's like doc, my back locks up, I can't really move, you know, arch back ten times, oh now I feel better, now I can move a little more. So that's going to work quicker than taking a pill or doing an injection, waiting a couple of weeks for that to kick in, if that's even going to help. And a lot of it, you know, is really self-management which is great. Those classic prone press-up exercises, those extension maneuvers, those are some of the McKenzie maneuvers. McKenzie doesn't always mean extension though. In this case this patient responds to extension but not all patients do. So we wanted him to continue training, not just to completely shut it down, just like an injured worker. There's other things, you know, light duty, he could still work but maybe not the exact job role. So we want him to tolerate load as much as possible. So we want to reintroduce things like squats but only with body weight with really good form. Go to the point where there, you know, you have the tolerable range of motion. You're not going too deep in the squat where you're then going to have that excessive lumbar flexion. We want to limit the range of motion of these compound movements to reduce his pain. We may want to substitute some accessory exercises or some other ancillary exercises. Maybe work on tempo work, some speed drills, agility. So he still feels like he's doing athletic type maneuvers. A lot of injured athletes, they don't want to just do rehab. They want to do more sport specific activities. So the earlier you can integrate the sport specific activities into the rehab, the better. Then it becomes part of training and it's fun. It's not just, I'm on the shelf while my team is actually playing sports. So yeah, we start with bodyweight squats. Then we did some goblet squats and then front squats and then back squats. And a lot of that's just increasing the range of motion and the loads that he's going to have to deal with. So some of the modifications we did, in his case, you can see here this is the butt wink that some people describe where at the bottom of that squat he's got excessive lumbar flexion. So in his case, we actually had him widen his stance and point his toes out a bit. And we did a scour. So as I'm assessing his hips, a lot of athletic football player linemen, you assume they're gonna have some degree of FAI or femoroacetabular impingement. And that may vary and the hip is spherical. So in this patient's case, if you put him into a straight hip flexion, he had very limited motion, lots of pain. But when you brought him out into 45 degrees, he had a lot of motion. He could do a very deep squat. So I can assess that when the patient's supine on the table and then I can translate that to when he's up and vertical and being loaded. You know, make sure you're having your patient stand and loaded while you're examining them. If you just have them sitting on the table or laying down, you're not really gonna get a full assessment of how they're doing. We want to put them through the ringer of functional movements. And not just athletes. My little ladies, I have them getting up, getting down. Show me how you walk up the stairs. Show me how to bend up to, you know, pick up something off the floor, tie your shoes. Because these are really the functional movements that, you know, where having good form is gonna help them throughout the day to minimize any injury. So you can see, you know, we have him a little bit wider. As Dr. Liu mentioned, by having the feet pointed outward, you don't want to go quite to 45 degrees, but ideally about, you know, 10 to 30 degrees. It lets you get a little deeper. It starts to activate your adductors a little bit more. So you can tolerate a little bit more load and you're sharing the load amongst other muscles as well. And it allows the heels to get down a little more. So it helps to accommodate some of his Achilles tightness and that limited ankle dorsiflexion. So this is a wall test and this is a way that you can assess ankle dorsiflexion. I just do it on manual exam, but basically you have the patient kneel and you have them kneel, lean forward like that, and the foot shouldn't come off the floor. So if it does, you know, it tells you that they're tight. You know, some people would put a heel, put a lift or a block under the heel to accommodate that tight Achilles. I would argue you don't want to propagate those bad maladaptive patterns, that you want to work on getting the range of motion back. All right. So at eight week follow-up, the intensity of his back pain has gotten a lot better. His leg pain is now centralized, so that's one of the hallmarks of the MDT method is trying to reduce the radicular symptoms, get the pain to centralize to the back, and then eventually it goes away. He has improved ankle dorsiflexion range of motion. He has a negative wall test. His hip abductors were still relatively weak, but they're getting better. He's progressed from bodyweight squats to now using goblets and a light front squat. You know, we saved him and the insurance company a couple thousand dollars. We did need to get an MRI. We made a good clinical diagnosis. There was no red flags, so you know, he was happy. He wasn't pushing for the MRI. He may be trying out for the big leagues, and they'll review his medical records, and we don't want to see anything on that MRI that may prevent him from being a high draft pick. So now we have new goals. We reintroduced back squats with lighter weight to start, incorporate some more advanced core exercises. Now he's doing standing presses, farmer's walks, suitcase carries, so now more dynamic loading. He's loading and he's moving, but trying to maintain his stability as he's doing that. He's using a trap bar for deadlifts, and that creates lower lumbar and hip flexion moments under less load compared to a straight bar. So overall, you know, as Dr. Delber mentioned too, the body is resilient. Patients often need to prove to themselves what they can do, and then they can progress. You know, there's fear, anxiety, they're hurting, there's pain inhibition of function, there's that memory, well the last time I did a squat I hurt my back. I don't want to do it again, but you have to prove to them how resilient they are and can be. This is a great range of motion exercise working on segmental lumbar range of motion. So you know, think about the positioning they're doing not only in sporting activity, but their everyday life. A lot of us don't assume the best postures and positions, whether we're just going around daily life, where we're sitting at our desk, or other factors. You want to, you know, focus on the importance of tolerating exercise at a variety of weights, reps, sets, positions. We really have to empower patients, help coach them along, find their weak points, find how we can motivate them. You know, don't fat shame or weight shame, but flip this into what can't you do that you want to do, how can we help you get there. Thank you. So by show of hands, how many people in here don't do musculoskeletal or sports medicine or pain? Anyone here with neurorehab? Okay, yes, two. Okay, good, great. So I chose this case because I work often with patients who have a neurorehab diagnosis. So obviously, this entire time we're talking, a lot of times these, some of these movement patterns are not applicable to your patients, and that's why I chose one of my patients here at Kesler Institute. So this is a 44-year-old female with a past medical history of incomplete paraplegia with chronic hip and subacute low back pain. So I had been following her since 2020. You know, she had incomplete paraplegia for at least 15 years before I met her, but basically when she first came to me, it was really just some innocent lateral hip pain on the right, you know, trochanteric pain syndrome, probably glial tendinopathy. We rehabbed her pretty aggressively with all the aforementioned things that we talked about today, PT, HEP. She did require a couple of injections, but really it was just like one a year or if that. As time went on, you know, she, her capacity really did increase a lot. But she did continue to have episodic flare-ups, mostly because the incomplete paraplegia affected her left leg more than her right. So she was very intentional with loading the right leg on a daily basis more. Since the beginning of this year, she developed a more gradual onset, worsening axial low back pain, as well as worsening spasms or spasticity in the legs, affecting her gait, balance, and home exercises even. So all the exercises that used to quote-unquote activate the, you know, glutes and things that she enjoyed and she was good at, she became incrementally less good at. And, you know, really it was due to the spasticity. And she also had multiple falls. So on exam, hip exam before was negative for any intra-articular pathology. It was negative again. She was still tender at the right side. You know, the Thomas test was very positive bilaterally, but I showed you the right side, the more effective side, on the picture on the right. The way that you see her stand right now is how, is as much extension she's able to achieve without a lot of axial back pain. So her lumbar spine, she was a very hyperlordotic. She had a very significant anterior pelvic tilt, pain with extension, and improvement with flexion. But because she had this hip flex contracture, she wasn't really able to flex her lumbar spine very much at all to begin with. So that was notable because that was the reason why she had a pain even with sitting. And that's, you know, for those of you who do spine and you think that that's not facet, but in this case it kind of was. So here the manual muscle testing is, you know, she's basically grossly weak at the hips, you know, okay at the knees, but generally the hips are the problem here as well as her low back. So when it comes to spasticity, right, so she had a modified Asher scale of 1 plus on the right and 2 on the left with her ankle plantar flexors, and her adductors were a little tight as well, 1 plus bilaterally. Her gait, as you see here, when I record the video and I got the stills and pictures, this is the best she looked when she was ambulating, all right. So as you can see, going from left to right, the significant scissoring that you sort of see, and also too, you can also see her with showing like a compensated Trendelenburg gait on the right, but part of that's because, you know, she has learned to really load the right side, right hip, right adductors as a result of being weaker generally on the left. And so because of, you know, these imbalances she was a, she's been forced to use her cane pretty much the majority of her day, you know, ambulating more than like 20 yards requires a cane. Also too, you know, I tried to get her to do sit-to-stands and squats throughout the entirety of the past few years, but since 2024, she wasn't able to do it without feeling unstable because of the knee valgus, all right, and also too a little bit of right hip pain. So when it comes to patients with disabilities, you know, how do we game plan, you know, how do we adapt everything we talked about today to them? So you want to assess baseline capacity and recognize how they are different. So if they have range of motion deficits, is it really joint, is it capsule, is it soft tissue, is the weakness just pain limited or is it really real neurologic weakness? You know, and this we see a lot, you know, is it a contracture or is it spasticity? Because, you know, that changes your management. One you can, you can address with toxin injections, the other one you can't. And also if they have concomitant, you know, joint disease, how do you factor that in? So things, you know, these are some of the options that we went, played around with over the last three years, eliminating gravity, reducing her load, you know, we focused, we went back to the basics. So instead of doing these multi-joint movements, we actually started with open chain exercises, single joints. I had her do, you know, assist herself, you know, using, using her unaffected limbs, you know, in the bottom right corner, you see her trying to just do some isometric, you know, sort of like a hip, hip flexion. But, you know, because of the weakness, she would have to support herself, but that's how she does it at home, you know. Also too, she has found a lot of success working with a Pilates reformer and a personal trainer to help her aggressively reach the end range of motion for all her joints, especially at the hips throughout this time. When it comes to patients with weakness, you know, with the two major kinds of muscles in our bodies, the, the tonic postural muscles versus the more dynamic phasic muscles, the postural muscles are the ones that are more aerobic, and they're more responsible for your posture, and they have more endurance. So we had her do a lot of isometric exercises, and we adapted different core exercises over time to just have her just hold it in a modified position. I also, of course, reached out to my colleagues, and she received toxin injections to the adductors, gastrocs, and soleus, and here she is in the office, maybe about six weeks after those injections, and this one, I made sure to include the pictures at her worst. So this is her least stable position when she was ambulating. As you can see, it's just a, it's a little bit different, you know. Here, you can see how off-kilter she is. Here, she's not even using a cane. She was able to walk for longer, and she had a little bit of improvement in back pain as well, so we were happy to see that. Also, too, I didn't have the foresight to record her squat when she was actually the most affected, but this is her squat afterwards. As you can see, she's able to, you know, really maintain a little bit, you know, of just like a, you know, knee alignment without too much valgus, but also, too, you can still see it from the side view, you know, she still has a lumbar lordosis, but she had less pain, I think because the hip flexors were a little bit, a little bit better off, so she also had less hip pain. So, so this was a case really about, you know, a patient with, with certain things about her, her capacity that can't be changed, but still you sort of work within your means. And lastly, this is a thought because we're running out of time soon, but, you know, what happens to patients who really can't resist? So we're talking about resistance training. What if they can't resist? And so, luckily for us, you know, we have other options like blood flow restriction. I know it's a hot take. I know that it's, you know, the evidence is contentious and that we recently had a panel yesterday about this, but, you know, just give it a thought, think about it, you know. It's a great way to, to work with lighter loads when it comes to, you know, the actual mechanisms of how it works to increase strength, endurance, and size, muscular size. We don't fully understand it yet, but we do know that there's enough evidence that does work that for us to, you know, to make it an option for some patients, it might be a good conversation to have. It's not altogether that expensive because you can sort of do it on your own with an elastic band at home, although you do want to be supervised when you do it. Some considerations. The research may be promising to some degree, but significant heterogeneity exists with the protocols, so take everything with a grain of salt. You know, most studies have also been done on young and healthy individuals and not the particular patient I'm talking about today. You also want to supervise your patients and make sure that, you know, that, you know, from a vascular standpoint, they're cleared. And even though it's not suitable for all patient populations, you know, I think on a patient-by-patient basis that every injury is different and everyone's goal is different, so maybe we can individualize this as a potential option. Anyways, at this point with the time we have left, we'd like to open up the floor for any questions. Thank you. So if you have any questions, you can come up to these mics, but I do have one here. This question asks, what simple home resistant training equipment would you recommend for a patient to buy to improve adherence? As somebody who has spent a lot of money on this stuff, I can tell you that you shouldn't do what I did. Basically, since COVID, there's been a plethora of different home exercise options, but I personally tell patients what, you know, first of all, show me what you can do with body weight. Once you have that, then we can move forward with what. Recently, if I had to choose, I would pick something that is relatively affordable, that really provides resistance across your whole body, usually some kind of cable machine. There's Tonal, there's Maxpro, there's a whole bunch of companies that came out. Something that's portable is also important as well to get started, but once they get the bug, they may spend more and more money. I want to also add on to that, if you don't necessarily need to buy equipment either, we've been talking this entire time about using like heavy jugs of water, backpacks loaded with books, different things like that, children, if you have growing children. You can adapt it for kind of whatever you have in the home. You don't necessarily need to buy anything. Also the playgrounds and parks around the area. Thank you guys for the talk and the specifics on the exercise prescriptions. I tend to default to a lot of isometric exercises for low back and knee, mainly because a lot of patients cite those sort of movements like squats as like a triggering factor. I just wanted to hear your perspective on specific isometrics that you might recommend for patients and also some specific upper body exercises for persons with shoulder or neck pain that might be a trapezius strain. I can start. Well at first I'd kind of challenge the older patients that sometimes do have pain with those squats and things and kind of as a little bit of as investigating what about that movement is causing them pain, because these are things we do every day. We sit down, we stand up from a chair. A squat is a very similar movement, so some of the concepts that we talked about like kind of altering the movement a little bit can provide a much better entry point so that you don't necessarily have to do isometrics the entire time and you can kind of do a little bit more of the functional movements. So either like putting the toes out and making the making like actually sitting on a box doing a box squat. Things like that can make it a little bit better of an entry point and that can really kind of work on those kind of compound muscle groups that really can improve frailty and all these different things that we talked about. But as far as isometric exercises go, if you go to any gym there's like a ton of machines and typically a lot of them are do have isometric options that you can do for that. There's also kind of like you can use bands at home. There's a whole bunch of different things you can look up. I don't know if anyone has any specifics. Also too in terms of like where it hurts to like you know maybe slowing the movement down, figuring out you know pausing where basically working within your means to pause where there's not as much pain. Also too when it comes to getting up from the chair a lot of patients they don't realize that you should probably brace. So working on abdominal bracing that might actually be enough you know. So I tell my patients is hey pretend like you're underwater and take a deep breath. Hold your breath until you stand. Hopefully you don't stand too slowly and then exhale and then on the way down when you descend take a deep breath hold on the way down and exhale. And you know if someone especially someone's flared up if we if you have a discogenic pain for example for like case two, if you ask them to like really aggressively brace that might even worsen the pain. So really just holding your breath might be enough for to have a brace to get them there. Whatever movement hurts watch them do that movement and see where it hurts and why. Maybe it's something subtle like they have to come closer to the chair before they stand up. They're going to too much lumbar flexion. They're going down too deep because then you're also proving to the patient yeah I can do this. They totally support isometrics but they're not really functional movements. We want the patients to mimic as much functional real-world stuff as possible. Upper extremity exercises that you recommend? Oh for people with shoulder pain. So a lot of times you can even change well it's hard to see what they do in the office but a lot of times like we go over cues. So I ask them how they perform and what they think about. Things like even in actively retracting your scapula before you go you know lift and do whatever. Changing your form or you know some people they'd like to do lap pulldowns behind the head which is okay or you know maybe changing the angle. You know working within your means to tweak that. So if you can stick with what you like to do and change how you do it. But if you can't then maybe start thinking about accessories. So instead of doing like a bench press then maybe do like an incline press. You know instead of doing like a bent over row maybe do a seated row or low row. A lot of times like with our periscapular muscles, the rhomboids you know you know this whole so-called upper cross syndrome. A lot of muscles in our upper backs they're weakened. They're kind of you know that the length tension curve is off. I've learned it from Dr. Kirshner. And so that might impact how they actually perform the inciting you know lift. The only thing that I would add is that for gym goers like barbells will often be exacerbating for shoulder pain. Specifically me with Dr. Liu yesterday. I decided not to do a barbell press. I was doing dumbbell presses instead because with dumbbell presses you could just change the angle. You could do neutral grip. You could do pronated grip. So that's just food for thought. Something to try. You can't lift. Don't lift overhead. That's not necessarily proven in the literature. So whatever they can do upper body we try to encourage them to do that. Thanks. review the evidence you presented, would you suggest changing the physical activity guidelines for resistance training? So I'm actually, that's, I love that you asked that question. So the way that the physical activity guidelines are presented are kind of as a minimum. These are kind of the minimums required to get a fair amount of benefit out of these guidelines, but they don't really provide like an upper limit per se. So there has been demonstrated benefit to increasing that exercise from where those minimums are. But if you do look at the literature, there is a point of diminishing returns at some points. Like for example, if you look at like endurance sports or endurance runners, once you get to the point of like running ultra marathons and like that things like that repetitively, there is some sort of strain that you add on to your body. However, the majority of our patients are not going to become ultra marathon runners. Similarly to resistance training, there are additional benefits you can get from more hours, just like training and doing all those things. However, not all patients are going to become powerlifters, bodybuilders, or all those things. So personally, I would love to see, in addition to either the guidelines or a recommendation to them, that this is a minimum and you can do more than this for additional benefit. I don't know if anyone has any other thoughts. Yeah, I mean like as much as like avoiding nocebo, you also want to, you know, really maximize placebo and really make your patients feel empowered. So I don't talk to patients about any cap at all. It's like, you know, I talked to them about the fact that if you work hard at this, your capacity changes, your ability to tolerate more changes. And if that's the case, then maybe the only way to see progress is to do more. Yeah. And as a physiatry organization, we can come up with our own guidelines. I would strongly recommend we increase the amount of resistance training that we recommend. For sure, definitely. Thank you. Thank you very much for a really excellent presentation. So, this may be fine for younger persons, but with persons who increase in age, you find the progressive loss of... Come to the age of 60, 65, you probably find many more persons, or a higher percentage of persons with this atrophic, altered. the compressive forces during loading the spine, they increase dramatically up to 300, 400 percent. So are there any considerations? Are there any recommendations? Are there any caveats, particularly with older persons? You make a great point. I'll mention Stuart McGill, who's one of the world experts in spine biomechanics, has the big three exercises, and one of them is the bird dog. And they've done electromyographic studies showing that you activate the multifidi and those deep lumbar stabilizers. So that's a non-loaded exercise. You're on your hands and knees in a quadruped position, you know, one arm out, one leg out, and that's a good way to sort of warm patients up. So we didn't mention that here, but that's one of the earliest exercises I'll recommend. That and a side plank and sort of half crunch have all been shown to help activate those deep stabilizing muscles. And I would say those are a great entry point. However, we've talked about throughout this presentation that things are dynamic and they change. And we talked about the Liftmore trial during this, where we had elderly women that were above the age of 60 to begin with, and they were doing heavy squats and deadlifts. And there was no really adverse events outside of that one minor strain. So despite there is obviously sarcopenia, age-related muscle atrophy, the body is dynamic, and you can slow that down through a lifelong kind of progression of resistance training or maintenance of resistance training. So this is what kind of during the presentation we've also talked about, not necessarily just all us trying to start it in our patients if they're at 65, but also starting it younger. So you can kind of build up that bank of musculature, so you have more musculature within your multifidi, semispinalis, all these deep stabilizer muscles, so that there is more in the bank, so to say, so that when you do age, you can slow that down. But as long as you're kind of loading things appropriately, the body is resilient and it adapts. And even with atrophy, you can kind of minimize your risk for injury. And we're always minimizing risk for injury. We can't say everything's risk-free, per se, but we can do the best that we can. And also, too, in terms of like the idea of one rep maximum and percentages, you know, as you progress in your training, your actual one rep max will change. And so, you know, and also, too, it may be unlikely that all the muscles are atrophy to the point where the ones that are left can't be built up. So, you know, maybe instead of like focusing on the whole, you heal the donut and sort of address the donut and work on what you can and even build up the hips. And, you know, it's a whole colorful cast of muscles that come into play. You know, core strength also involves the diaphragm, pelvic floor, you know, just building what we can around the area might offload the deep stabilizers as well, I think. And I think we are out of time. So if you want to chat, we'll stick around for a little bit. I want to thank you all for attending this. It'd be, I think, the last session in beautiful San Diego. I want to thank all the presenters here as well. We'll stick around for a couple questions. Thank you.
Video Summary
The video features a detailed presentation on the importance, mechanisms, and benefits of resistance training, led by Raghav Sharma and his colleagues. They explore basic mechanisms of resistance training, including muscular hypertrophy and neural adaptations. The presentation highlights the significance of resistance training in various health aspects, such as body composition, bone health, cardiovascular health, metabolic health, mental health, frailty, and overall morbidity and mortality. The team debunks myths related to resistance training, emphasizing that it's not inherently dangerous and is beneficial for all age groups, including the elderly.<br /><br />They address common barriers to resistance training such as lack of time, interest, and misconceptions about injury risks. The team underscores the importance of appropriate dosing and progressive resistance to mitigate injury risks. They also provide guidelines for integrating resistance training into daily life, suggesting that even short, manageable sessions can be beneficial.<br /><br />Furthermore, practical advice is given for exercise selection, training-related parameters, and how to adapt exercises for individuals with disabilities or specific conditions like arthritis or back pain. The presentation concludes with case studies, demonstrating how personalized exercise prescriptions can effectively manage conditions and improve overall health outcomes. Through this comprehensive session, the speakers aim to empower health professionals to better counsel patients on resistance training, challenging misconceptions and promoting a proactive approach to health.
Keywords
resistance training
muscular hypertrophy
neural adaptations
body composition
bone health
cardiovascular health
mental health
exercise guidelines
injury prevention
personalized exercise
health outcomes
elderly fitness
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