I guess this will be the beginning of the end. Thanks for all coming, whoever still stayed in Baltimore. We're going to be speaking on a few different topics, mostly relating to strength training in the older population, starting with what the problem is. And that's kind of sarcopenia, which Dr. Lynn Weiss will be speaking about. I'll be going next and speaking about strength training. And we're going to have Dr. Prakash Jabbalayan finish up with also the recovery. And we're going to talk a little bit about some of his studies in osteoarthritis. So I'm going to welcome up Dr. Lynn Weiss, who's the Chair of Medicine and Rehabilitation at NYU Langone. Thank you. Good afternoon. So I have nothing to disclose. Sometimes I do leave my dirty dishes in the sink. And I hope my husband will wash them. But that really has not worked. But really, I do have to, full disclosure, say that Dr. Paduri really initiated this lecture. She wrote most of it. And then, unfortunately, she couldn't be here today. So I volunteered to give this to her. But I really have to give her credit for this lecture. So what is sarcopenia? So really, it is a loss of muscle mass. And as physiatrists, you know we're concerned with function. So it's a loss of muscle mass as well as function. And usually, it's associated with aging. But as you'll see as we get into the talk, it also is, there's other reasons to have sarcopenia beside from just aging. Aging is the one we think of most commonly. But we'll get into the other reasons. So it's loss of skeletal muscle mass. And it's considered a geriatric syndrome. Although, again, it can happen with deconditioning and other factors. And it's the pathological loss of muscle mass and function. It's normal to have some muscle loss as you age. But it's the pathological loss of muscle mass. And it's associated with increased risk of morbidity, mortality, increased health care costs. So if you go into the Greek, which we all speak fluently, sarco is flesh or muscle. And penia is loss. So it's loss of muscle mass. And I hope I don't mess up my Shakespeare. But this has been described in the literature throughout the ages. The sixth age shifts into the lean and slippered pantaloon with spectacles on his nose and pouch on his side. His youthful hose well saved a world too wide for his shrunk shank. And I take a little offense to the sixth age because that means at age 60. So hopefully, now that we are a couple of centuries beyond, he's referring to much, much, much more. But the incidence, it's really a global health concern. As our population ages, we have a lot more patients who have sarcopenia. And again, huge impact on cost, on function, on resources. It affects 5% to 13% of people over the age of 60 to 70 and up to 50% of people over the age of 80. And again, growing elderly population. The incidence of severe sarcopenia is 2% to 9%. And the prevalence 10% to 27% in a meta-analysis. So there's a lot of factors that can contribute to sarcopenia. It's characterized by the progressive and generalized loss of skeletal muscle mass. And we're gonna get into dynopenia in a little bit, which is decreased functioning of how the muscles function. But we're talking about muscle mass now. And there's a risk, obviously, of decreased quality of life, death, disability. And it represents basically an impaired state of health. And again, very high personal, social, societal toll. Increased fractures, increased morbidity, increased ability to function, to do your daily living. And of course, increased risk of death. So in terms of muscle pathology, there are the main histopathological changes. We see increased interstitial fibrosis, myofib fiber atrophy reduction, mostly affecting type 2 muscle fibers. So there's dysfunction of the mitochondria. Neuromuscular signaling has been thought to be one of the major factors that contribute to increased sarcopenia. But there's other factors that can affect it. Endocrine factors, inflammation, reduced regenerative ability, protein metabolism, increased adipose tissue can really increase sarcopenia. And it's got like a one affects the other affects the other effect, which we'll go into in a little bit. And then increased reactive oxygen. The current knowledge, as I said, shifted to, well, there's something wrong with the muscles to, well, there's something wrong with the neurological input into the muscles to make the mass of those muscles shrink. So we think it's like a regulatory process. So there could be neuromuscular junction dysfunction. The nerves themselves could become hypo-excitable. There could be dopaminergic dysfunction. And sometimes atrophy in the brain, as it happens with aging, can also therefore affect the muscle. So they think it's more tied in with the neurological effect that nerves have on muscle. So basically, when there is a neurological dysfunction and it affects the muscles, it worsens the course of the disease. And you get this cycle. You know, they can't move as much, so they're in bed more. And that causes more muscle mass wasting. And it's a huge cost, again, on society, on families. But it is preventable. And you're going to hear from my colleagues, you know, about especially strength training. And that's the core of it. I don't want to ruin your surprise, but really, it can be mitigated. And really, the time is now to start for everybody in the room to avoid these changes happening later on. If you're already starting to lose muscle mass, start now with the weight training. But certainly, unhealthy behaviors like smoking, drinking, and sedentary behavior, which you've all been sitting, I know, all day long, listening to lectures, except last night when you were drinking. And these things can affect muscle mass. So, you know, you can, there's the negative influences like, you know, stop smoking, stop drinking. And then there's the positive, be more active, you know, make sure you have enough nutrition, and do your exercises. So, it really is an under-recognized problem. You know, a lot of, we've all seen patients who are geriatric, who've come out of the ICU, especially now with COVID. We've seen a lot of patients who have a lot of symptoms, who have lost muscle mass. They've sometimes lost a lot of weight, but it's not just adipose tissue that they're losing, they're also losing muscle mass. And again, this is under-recognized. And, you know, one thing that we did in our hospital was start an early mobilization program in the ICU, because it's never too early to get these people up. But it, you know, we kind of stage it. So, pre-sarcopenia, meaning you have decreased muscle mass, normal muscle strength, and normal function. When you have sarcopenia, low muscle mass, but low muscle strength, but your performance is okay. And then severe sarcopenia is classified as low muscle mass, low muscle strength, and again, affecting performance. So, again, there's different classifications because there's different types. And we always think about the age-related sarcopenia that's just due to aging. And again, that may be due to neurological factors playing on the muscles. But there are other reasons for patients to have sarcopenia. And it behooves you as a physiatrist to look for these things, to assess for sarcopenia, which I'll get into in a little bit. And if you feel that the patient has sarcopenia, make sure that you're ruling out things that can be corrected. So there's activity-related sarcopenia, which we saw a lot of patients in bed for a long period of time, deconditioned, and interestingly, also zero gravity. So this affects the astronauts. Any astronauts in the room? Okay, so this won't affect you. But anybody who basically is sedentary, that's something that's easily preventable. Disease-related sarcopenia. So things like advanced organ failure, like heart disease, liver, kidney, brain, inflammatory diseases, malignancies, everybody's seen people wasted from malignancies, and endocrine disease. These are maybe not metastatic disease, but a lot of these can be controlled or even ameliorated. And then there's nutrition-related sarcopenia, which results from inadequate dietary intake, malabsorption, decreased protein, check your albumins, make sure that there's no gastrointestinal disorders, or sometimes there's medications that cause anorexia. So you see that there's a lot of things that can cause sarcopenia. So it can be endocrine. Low testosterone, corticosteroids, abnormal thyroid function, insulin resistance can lead to sarcopenia. Neurodegenerative, we spoke about the neurological impact on muscles. Cachexia, nutrition, malabsorption. Again, check for these things. You could be saving your patient tremendous functional improvements that they could have gained, or loss of family, things like that. The sex hormones, mitochondrial dysfunction, sometimes those happen with age. Sometimes you can give hormone replacement. Something like mitochondrial dysfunction is very hard to correct. And then the biggest thing that probably you, as a physiatrist, can impact is disuse, because you know more than anything the importance of exercise and prescribing exercise and the types of exercise, which we'll get into, that are so important. So again, all of these things can cause sarcopenia, and then sarcopenia can cause those same things. So again, the things that can cause aging, decreased physical activity, anorexia of aging, neuronal problems, decreased vascular supply, decreased hormones, small birth weight is more for the pediatric population, decreased DHEA, decreased testosterone, increased cytokinins. All these can cause sarcopenia. And again, it's a vicious cycle, because when you have sarcopenia, you're less active. You have less energy, you have less ability to move, and so it becomes a cycle. Sarcopenia and obesity. So these are tied together very strongly. So you have decreased physical activity, oxidative stresses, inflammation, hormone changes, and all these can cause obesity and sarcopenia. And then those, because you're obese with sarcopenia, you're not moving, and it can cause hypertension, diabetes, cardiovascular disease, fragility, and dyslipidemia. So breaking that cycle is so important, and it's in your power to do so. With heart failure, you know, again, you see the arrows pointing in both directions. So these factors play upon each other. You know, when you have dyspnea and you can't, you don't have the oxygenation to perform exercises, it can lead to inactivity, which can lead to sarcopenia. Heart failure is especially villainous, so to speak, because with acute heart failure hospitalization, about 50% of patients can get sarcopenia. And we all know how much longer it takes to recover. It takes almost twice as long to recover as it does to, you know, like one or two days of bed rest. It can take you a week to recover from that. And then with chronic heart failure, about 25% of those patients have sarcopenia. And again, decreased muscle quality, strength, and decreased physical performance. So how do we assess for sarcopenia? We can look at muscle mass, muscle strength, muscle performance, or skeletal muscle index. So for muscle mass, we can do bioimpedance analysis, which estimates the body water. We can do DEXA, we can do hydrometry, which is information on how much water there is, hand grip strength and dynamometry. Most of that we can do very easily in the office without much equipment. Muscle performance, again, very easy to do. You don't need a lot of equipment. You need a chair. Timed get-up-and-go test, the 10-minute walk test. And there's a lot of batteries of physical performance. And then there's the limb skeletal mass in kilograms as measured by DEXA over the square of the height. So it's like when you're doing quality improvement, it's FOCUS or PDA, find, assess, confirm, severity for older adults at risk for sarcopenia. So find, you have to really screen your geriatric patients and all patients, really, for sarcopenia. So this is one of the screening tools. And it looks at various components that patients with sarcopenia may have deficiencies in, such as strength, assistance in walking, rising from a chair, climbing stair, and falls. So you can say, you know, how much difficulty do you have lifting and carrying 10 pounds? You can either ask them, you can give them 10 pounds and see how much difficulty they have. And then you can score them, zero, one to two. How much difficulty do you have walking across a room? Can you get to the other side? Can you get out of a chair? Do you need your arms? Can you climb, you know, 10 stairs? And how many times have you fallen in the past year? And one to three falls, you score one. Over four falls, you score two. And if you have a score of over four, you really are obligated to do further investigation to find out if there's anything that, well, first of all, to get the patients on a program to reduce or mitigate the problem. Or maybe there's something else, like heart failure, like nutritional deficiency, those kinds of things. So you really should evaluate for these medical complications that could be impacting somebody's, especially older people's function. So what about management? Like anything else, early intervention, early recognition so that you can set the person on the right path. You know, I know everybody's very, very busy in the office, but really looking for these impairments, and physiatrists do it better than anybody, asking about activities of daily living, how they're getting around during the day, they're really, really important. And if somebody says, you know, I have difficulty dressing or bathing or walking, they really should undergo more specific testing. And, you know, sending an OT to the house to look for fall hazards, safety precautions, all that should be part of the treatment strategy. You know, it's not always feasible to send an OT into the house, but you can ask them, you know, do you have rugs, do you have good lighting, you know, do you have somebody with you, do you have grab bars in the shower, those kinds of things. In terms of non-pharmacological treatment, as we know, physical inactivity really leads to loss of muscle strength and mass, and exercise is the cornerstone, and again, we're gonna hear more about it. And it's really short-term resistance exercises that has been demonstrated to increase patient's ability and capacity of skeletal muscles to synthesize proteins and reduce sarcopenia. So I just wanted to differentiate, before we get on with the other speakers, about dynopenia, which really is that the muscles are losing their strength. You have enough muscle mass, but they're not working as well. So, again, to the Greek, which we all speak, poverty of strength, power, or force. So, you know, age-related strength is normal. Normal. Loss of strength, I'm sorry, age-related strength. Loss of strength that's not caused by something else, that's not caused by neurological disease, that's not out of the ordinary, and again, this can be multifactorial as well. But again, this also predisposes patients for risk of functional limitations, mortality, morbidity, and 16 to 18% of women and 8 to 10% of men, just because they have more testosterone, and that's better for the muscles. In the United States, older than 65 can't lift 10 pounds or stoop and kneel down. Ask yourself these, you don't have to answer out loud, whether or not you can lift 10 pounds and stoop or kneel down. And again, this increases the risk for physical disability, poor performance, and death. So again, the difference is that dynopenia, they both can be age-related. They both can be non-age-related, but the main difference is that muscle strength, the muscles don't work as well with dynopenia, where the muscle mass is actually gone with sarcopenia. And usually there's a decline in muscle strength before the decline in muscle mass. As you get older, your muscles just don't work as well. Most of the bodybuilders, except for Jack LaLanne, if you remember him, he was doing beats of strength into his 80s, but most of them are done by younger people who have more muscle strength. And I'm running out of time here, but basically, you know, the difference between sarcopenia and dynopenia, and then just in summary, you know, all of these factors can cause sarcopenia, and then when you're at bed rest, again, it's like a vicious cycle because, you know, disuse or immobility causes sarcopenia, and then if you're losing your muscle mass and you have, you can't get out of bed, you know, it's a vicious cycle. And these are my references. And that's it. Thank you. Perfect, thank you, and definitely thank you for stepping in when Dr. Paduri couldn't make it. I think we got to, do I have to do something or you? Okay, so I'm going to speak about strength training in general and then focus more on the older adult. I'm not trying to get anybody to live to 120, I just want you to be younger, longer, no canes or walkers is what my goal is. I have no disclosures, unfortunately. All right, so I'm not presenting anything new. There's over 1,000 articles, many of them are meta-analysis. I just want to go into program writing, which basically, it's a prescription. Come up with a thoughtful exercise selection instead of just writing down, evaluate and treat for the physical therapist. Why are you doing that particular movement? When, how much of it do they need, when they should do it, and what's the order? So whether you're going to actually programming it for somebody or at least looking at somebody's programming, and people will come in now with these apps, and at least I want you to know what might be too much, not enough, so that's my goal with this. Why are we doing this? Again, as Lynn said, you're losing the type two fibers. Yeah, it's probably rearranging deck chairs on the Titanic and it might be a losing battle, but at least we can try. Lower extremities are affected more than upper extremities. It means we can't skip leg day. All right, sorry about that. And here's some more. All right, so let's try to put definitions to what's elderly, what's heavy and not, and thanks to Schoenfeld up at Lehman College, is anybody over 50? So it's that guy right there. However, as I turned 53 this past summer, I choose to say 54 and above is elderly, and that number is probably gonna change next summer as well. All right, why does this matter though? It's because we have to take into effect recovery and fatigue. We can't just be doing five by five every time. Strength, it's the ability of the central nervous system to create force. Hypertrophy, making bigger muscles. Power, the ability to create force with speed, and that's important as we get older. Compound movements, multiple muscles crossing multiple joints. Assistance and accessory, and I sort of differentiate that the assistance movement will sort of be a mechanically similar movement to my main movements. The accessory, more single joint movements, and that's going to help you with your main movements. Eccentric contractions produce more force. Powerlifting is a sport, squat, bench, and deadlift. You can learn it, you have coaching. Olympic weightlifting is definitely outside the scope of this. God bless anybody who can do that, but I don't want to tell our patients go learn how to weightlift. It's a separate sport. What Durgie Paduri was wanting us to speak about was progressive resistance strength training. The key term there is progressive. You can't be lifting the same weight next month as you did this month as we get older. And where I use that word 50, I'm not saying it happened on your 50th birthday. It has to happen earlier because we don't really have, I guess there's two guys left in the NFL over 40, so it's going to happen to everybody in this room. We will all be differently abled at some point. So I want to go over that specific type of weight training. All right, a novice lifter, they're going to disrupt homeostasis with only one single session. They will also recover very quickly, about 48 hours. And when Prakash speaks, we'll go into, you'll see that SRA curve. After training for, depending on how many times you're going between six months and two years, you will now be an intermediate lifter. Congratulations, it'll take you a week to disrupt homeostasis. Being a novice lifter, you can add five pounds to the bar every week. You could do one more repetition. As an intermediate lifter, it could take you three, four, five months to get those four extra pounds on there. Repetitions in reserve, very subjective term, but basically how far do you feel from failure you are? And that's sort of used, do you have to go to failure? And the answer clearly is no, but you better be pretty close to failure. I want one or two reps in reserve when it's a accessory movement. And with the heavier compound movements, maybe two or three, you want to go out to four, maybe five, but like you just finished 10 because that's what the trainer said. I'm going to give you $5 for each one you do over that. And you get to 18. Did you really stress the muscle? And the answer clearly is no. In some programs, you'll see this RPE, relative perceived exertion. An RPE of seven has three reps left in reserve. Nine has one rep left in reserve. Again, very subjective. I don't tend to use them that much. We talked about why this is important, better mobility, better functions, and it improves anybody's adult, anybody's injury, resistance to injury. You can't apply a 30 pound force to a muscle that's rated for 20 pounds. It's going to give way, whether you're lifting a suitcase in an overhead bin, whether you're serving a tennis ball. This, there's other benefits. We'll skip. I was just looking and I'm thinking like 9% of adults over 75, and I take a little survey in my gym, and I'd be surprised if there's about 10% of people over 75 lifting in the gym. So that number really seems pretty high to me, but we have other ones, contraindications, everything you would think about. I really don't want anybody to hold their breath. No Valsalva. We don't need a Valsalva over 80% of one rep max. But what I really want to point out on this slide is what we don't see. We're not seeing osteoarthritis. We're not seeing joint replacement. The SRA, stress recovery and adaptation curve, put forth by Hans Selye back in the 1930s, is going to be our cornerstone of our programming. So we want to stress the organism, or in this case, the muscle. I don't know what that is. Is it a yellow rubber band? Is it 120 pounds? Give me a couple of weeks, I'll figure it out. But immediately following that stress, you're going to be weaker. They should be walking out of the training session worse off than they walked in, and that's why we're not going tomorrow or the next day. We might have to wait two or three days, and that's what Prakash will hit on. But we wait for it to recover, and now we have to do a little bit more. And what do we mean by recovery? Clearly, I need sleep seven to eight hours a night, and we need sufficient protein. I'm saying about 0.8 grams of protein per pound of body weight, which is definitely more than the RDA says, but anything below that 0.4 recommended daily allowance is probably malnutrition. So just stress, recover, adapt, and keep doing that month after month. There's this minimum effective volume. Below that, you're not stressing the muscle. There's no reason to adapt if you didn't stress the muscle. And there's this maximum recoverable volume. Above that, you're going to overtrain. Nobody's really gonna overtrain. They really have to work hard to do that. You'll get to overreaching where you're not sleeping well at night. You might be a little bit moody, but we wanna kind of figure out there's some window of that, too much and not enough. Okay, my exercise selection. I'm going to take a book from the powerlifting manual and say squat, bench, deadlift, and overhead press. Those are compound movements. They're functional movements. On the downside, they're very technical. I'm saying a squat and a deadlift's not gonna hurt your back unless you don't do it perfectly, and then it's really gonna hurt your back. I don't program too many deadlifts. To me, it's more of a test of strength. I get it, not everybody can do this. You need good mobility in your shoulder, your thoracic spine, your hip, and your ankle, so we'll talk about what we can substitute. Next is the exercise order. Compound movements first. It's a cold day, you wanna walk into the gym and use the ergometer for two to four minutes to get some blood flow in the muscle tendon, and ligament's great, but you don't get to go on the treadmill for 40 minutes, then go downstairs and pick up a dumbbell and do some bicep curls. That's not exercise, I guess it is, it's movement, but it's not going to build strength. Then we can do any accessory movements after. Training volume. Two to four sets, two to three times a week. Looks like two sets on Monday and two sets on Thursday. That's it. When you get stronger, we could add a third set on Monday, but we'll go over that in a little bit more. I wanna train everybody 70 to 80% of a one rep max range. That 60 to 70% might be better for hypertrophy, below 60% might be better for power. Estimated one rep max. If somebody's able to lift 115 pounds for seven repetitions, they should be able to lift 142 pounds once. So 70% of 142 is 100 pounds. How many repetitions should they be able to do at that? I generally say for every 10 pounds I'm going to go up or down, I will gain or lose two repetitions. So 15 pounds, I should gain another three repetitions or have about 10 repetitions max. And that's where we move into these relative intensity calculators. The one on the right is just a generic one. It's nice, cleaned up. Everything's at two and a half percent, either up or down. The one on the left is what we use at my training facility where my coach got it from his coach who brought it over from Russia. So I trust that more. But here we could look at 70% and see, that's 11. So again, it was in the ballpark. Mine is using it a little bit less, but you can't really program. If you're looking at some program that's saying, do 75% of your one rep max for between eight and 12. Like, no, you shouldn't be able to go over 10. You do one rep, that's 100% one rep max. Five is about 85% of your one rep max. So when I'm looking at a program and I'm seeing that they're being told to do five repetitions with 80% of their one rep max, I will kind of divide the rate we're working with is 80% divided by 85.7%. And we're going to get a relative intensity of 93%. I think that's okay. You can recover from that. Start going north of 95% and you're probably gonna need a nap after that. So we're going to move back 60 to 70%. I'm gonna start off in a higher rep range, lower weight with novice lifters. That 15 reps, I think it's a little bit high. I like the eight to 12. The reason you did 12 reps is because you couldn't do 14. If you can get to that, you should probably add a little bit more weight. I'm also going to keep that eight to 12 rep range more for the accessory movements. And I want to keep my compound larger movements lower than the five to eight rep range. So power lifting is going to be three to five range. I like this five to eight rep range because it's a little more functional. Volume, and there's many articles on there that Iverson, I forgot, I didn't neglect it to put down. It was last year, 2021, is a great article on what to do if you have limited time. And I kind of like this four to six sets a week. Most of the recommendations go up to 10 sets, but that's for a younger population. Somebody's doing 10 sets a week of a multi-joint movement. That's a lot of stress on there. So I'd kind of skew down to that four to six sets. When I'm designing, looking at programs, when I'm working on hypertrophy, I'm going to combine my squat bench deadlift and I'll throw in the overhead press here. But if I'm doing four sets of squat on Monday, four sets of squat on Thursday, that's eight sets that week. Same thing with the bench. Deadlift, I might do two, and I'll add another four overhead press on there. So we're getting eight, 16, 20, 22, and that's going to give me my hypertrophy range. If somebody's working in a higher 70, 75, 80%, they probably shouldn't be doing more than that 15 to 20. And again, in the older population, I'll keep it skewed more to that 10. Peaking is a something if you're training for a competition. Alexander Prelipin, who also is strength training, and this is probably geared more for power lifting. But what I want this slide to point out is how little volume you actually have to do to create that stress. 70 to 80%, we're looking at 18 repetitions, three sets of six, and you're done. Again, older group, let's keep it at the lower volume range of 12. So, I get it, you have tight shoulders, you can't do a barbell back squat, but anybody can do a chair squat, anybody can do a goblet squat holding a kettlebell or a dumbbell. If you have access to a gym, we can do leg press and other machines. Deadlift, again, let's not think of it as an exercise, but rather a test of strength. We can substitute and build the posterior chain, glute, hamstring, adductor muscles using the Romanian deadlift. Using stiff leg deadlifts, using a trap bar deadlift, and if you can't even do that, just step ups will work the posterior chain. I chose these illustrations because here we can see that the back squat and the goblet squat, specifically the hip crease comes below the patella. I want that. One, if it's a power lifting, you have to do that or you didn't go to depth. But two, you're working the posterior chain. A lot of trainers in the gym don't make you go down there. They're trying to build muscle and just working on the quadriceps, and that's fine. We have the leg press machine, which you have the carriage is going to move away, so it'll be more of an open chain and the hack squat more closed chain. The Romanian deadlift, similar to the deadlift, but we're not starting from the ground, we're starting from up, so once he hinges back, he can load the posterior chain and sort of bounce off of that. On our bench press and overhead press, we can substitute machines or the dumbbells. Bench press, I might try for some of the assistant work, two feet up, or you can change your grip, close grip for more tricep, wider grip for more chest, and you don't need as much weight on that. Now, when you're lying on your scapula, I'm actually saying the bench press is probably worse for shoulder disorder than our overhead press. And this, I've changed my tune over the years. Notice how the overhead press is going to start at the anterior deltoid. The bar path will now travel up and back and end just behind the ears, so we're going to see the wrist stacked over the elbow, over the shoulder, which is over the hip, knee, and ankle. When you press over your head, the scapula will move up and out of the way, and you should not impinge it. Accessory work, it's just working on other muscles to help you with that. I love anything behind you. I want face pulls to work on scapular stabilizers. I want external rotation to work on the teres minor, and that helps stabilize the humeral head. I'm going to rotate these exercises every three, four, six weeks on there. I'll always keep my compound movements the same, and I'll throw some of these in there. So let's start looking at some of the other programs. Starting Strength by Mark Ripoteau is going to have you working out. He wants three days a week, three sets of five repetitions, except for deadlift where it's only one set. I'm going to modify this and maybe just make it two days a week, but it's nice to start out with just an unloaded barbell and slowly progress them five pounds on an upper extremity, ten pounds on a lower extremity. This is going to work very well for about 10 to 14 weeks when they stop progressing, and then we can work on a wave progression where we're going to gradually add and we can sort of build in a deload week. Again, this is going to work well until it doesn't work, and then we can start adding our second variable, which will be number of repetitions. For example, I'll take 145 pounds and have them do five repetitions. The next time they're in the gym, they're going to do six repetitions, then seven. When they get to eight, I'm going to add weight and decrease back to number five, and this is sort of an auto-regulating. Again, this works until they don't progress, and now I'm going to add a third variable. That will be the extra set. And here's from our Bradham book. Army Captain Thomas DeLorme came up with his auto-regulating progressive resistance based on either three, six, or ten rep max. And here we're going to start after our warm-up. We're going to do one light set, one set at about 75% of one rep max. The third set he's going to failure. I really don't like that word, failure, so I'm going to substitute it for AMRAP, as many reps as possible. That's before you fail. You can see the barbell slowing down. You know you only have one set left. The fourth set is based off of the third set. If you're able to get to your rep max, we'll keep that weight. If you can't hit it, we will decrease it, and if you pass it, we will increase it. What I like about this is that you're now having two sets. The third and fourth set are going much closer to failure. Strong lift 5x5, great for younger people, but that's a lot of volume for everybody. Again, we're seeing bench press, deadlift, barbell rows, overhead press, and again we're seeing that deadlift of only one set. Deadlifts are not an exercise. Texas method is an intermediate method. There is something called... This is the daily undulating periodization. Periodization is we're changing our stress to focus on either hypertrophy in blocks of a month or strength. Here they decide to do this volume one day, a light recovery day, which can be our power day, and then our intensity where you try for a new personal record. Wendler's program is lift, one lift each time, and then you can do your accessory. Very easily change to doing a squat and an overhead press and your bench press and deadlift on two days, followed by your three-assistance work. Here we see that on week one, he's going to start with lighter weight but more repetitions, and he's going to increase each set. The last set, that five pluses, again, as many reps as possible. I would like the fourth set, so at least I get two sets going closer to failure, so I would typically do a back-off set where I'll just take off about 10% and do another AMRAP, and this will go all the way up. Week two is based off of week one and going heavier, week three heavier than that, and week four, and I like this, there's a deload week put in there, especially with our older people. Yeah, you might be deloading too much, but at least you're getting that recovery. Volume, sometimes I'll just do 25 reps as many times as you can, and that's different ways to mix it up on there. Little things to remember, lack of sleep leads to overtraining. If you're only going to keep those people in that, as recommended before, 12 to 15 range, it really doesn't work strength, it has a lot of hypertrophy, which gym trainers typically work on. Firstly, that 3 rep max is not going to have a lot of impact on hypertrophy, but great for strength. Every three or four weeks we tend to adapt, and probably we have to start to move on by changing the accessory work. By the fourth and fifth sets, you really start to get fatigued. This is not meant to be read, it's just kind of an overview. I don't want the details on here, but at the time I was putting this together, this was the program I was running. So I'm going to have on top four weeks and along the side, four days. I'm always going to pick my three compound movements, followed by three accessory movements. Week two is based off of week one, week three off of week two. And I always have my deload week in the end. Thank you. All right. Thank you. Thank you so much, Neil and Lynn, for those great talks. And when Neil asked me, invited me to be on this panel a while ago, I was very interested in this. I'm predominantly a clinician scientist in osteoarthritis research. But there was this idea of, like, what is the older athlete? What should they be doing? And Neil wanted me specifically to talk about the recovery process. As I went through this, I just want to point out a couple of things, is that a lot of the literature that I'm going to present today, the definition of what an older individual is, is actually not clear. So firstly, the terms that we use in sports medicine are pretty ageist. There's terms used as mature, geriatric, masters, and just old. So I'm not sure exactly which is the terms. So that's another issue as an aside. But I'll get off my soapbox for a second. So one of the things that I want to do is really to, as it's been brought up, is trying to decide how we manage this sort of master athlete. So I'm going to use master athlete because I think that sounds more positive. And so how active they are. So I want to imagine a patient that you would see or an individual that you know that's active, physically fit, involved in regular physical activity. This is sort of that discussion you're having with them. What are their athletic goals? And then one thing that I often have not done is what is their post-exercise recovery? So this was a good exercise for me to see what is out there in terms of the literature. So the objectives are really, I'm going to talk about is rest breaks between exercise sessions, specifically resistance training exercise sessions, nutrition, protein, as was mentioned, applying these findings to disease process, so even applying it to some of the research that I do in knee osteoarthritis, and then how we change behavior, which is challenging. I'm above 40 now, changing my behavior is really challenging as when I was in my 20s. So what I want to clarify one thing and one caveat to what I'm going to talk about is from peruse of the literature, there's really no specific recommendations in terms of recovery or rest for master athletes. Most studies are just comparative studies of what they term as older individuals, usually above the age of 40, sometimes above the age of 60, and younger individuals. And there's really an under-representation of women in a lot of these studies as well, so I want you to remember that. I will not be covering sort of hormonal treatments, etc. Most of this will be focused on, and I won't be focusing on a lot of supplements, it will be focused on protein-related treatments. So obviously it's been highlighted, the major issue from both of our prior speakers, performance really worsens with age, sadly. And as you'll see on this graph, particularly on the right side, that sort of downward slope in terms of performance, whether you're a runner or you're a weightlifter, it really happens sort of age 60 onwards, though from age 30 onwards there is this steady decline. And so reductions in aerobic and resistance training, exercise, performance occurs widely. So the first question that I want to ask that your patient may pose to you, or you may ask for yourself, is what is appropriate rest between training sessions? So the first area that I wanted to look at is this idea of differences between younger and older individuals immediately after resistance training bouts in terms of their muscle peak torque, range of motion, delayed onset muscle soreness, which I'll go into, and the CK creating kinases released as a result of that activity. First of all, there's no significant differences between younger and older individuals in terms of most of these measures except peak muscle torque, which we would expect because we didn't expect that younger individuals would be able to generate more force following a resistance training bout. But these others, there's sort of very similar changes that occur between these two groups. The second is then to think about recovery and how do these muscles recover. So when I use MPS, that's myofibrillar protein synthesis, and in general, most individuals who are older or these master athletes actually have less protein synthesis as a result of a bout of resistance training exercise as opposed to younger individuals. And there's this idea that there's this anabolic resistance that occurs with aging, particularly to resistance training, but also feeding with protein as well. So does physical activity or specifically resistance training attenuate this decrease that we see? So this study actually did 72 hours. They got individuals to do 72 hours of endurance training, and they found that master athletes as opposed to younger athletes actually had lower protein synthesis as a result of this endurance training session, which lasted a long time. And then these are triathletes, so then they looked at their cycling performance, and it did impact their cycling performance in terms of a decrement in their cycling performance as a result of that resistance training. So there's some evidence that there's potential worsening repair and recovery that occurs in older or master athletes. What is the optimal amount of time between resistance training sessions? That's the next question that we all probably have. So this is a study where they examined the course of muscular endurance recovery when individuals did three sets to failure. Sorry, Neil, I'm using the word failure. In, again, men, only men, and these were younger versus older individuals in terms of a cohort. And they investigated both the upper and lower extremities. And what they found was in terms of optimal rest and recovery from a strength training session, in terms of this, 72 hours seemed to be optimal for both groups, whether you're younger and older. And if you rested for 96 hours, there was no additional benefit in terms of recovery. And recovery was based on the amount of repetitions the individuals could do next in terms of their next set of exercise. One of the challenges with this study was there was this large individual variability. There was no, there was need for, and what the study's authors suggested is that maybe there's a need for pre-testing, as Neil mentioned, individuals to see what is, and when we think about physiatry, we often talk about individualizing an exercise program, maybe pre-testing an individual to decide what is the optimal amount of rest and recovery could be a way to do that. And this sort of approach could be helpful to do that. Again, as I said, minimal studies in women specifically looking at this. Then we want to look at muscle protein synthesis as a whole in resistance exercise. So we know that there's potentially some difference in anabolic signaling between younger individuals and individuals who are master athletes or older. And so this study actually made individuals to do 20 to 90% of one rep max and compared older individuals to younger cohorts. And muscle protein synthesis was measured by leucine, which is an essential amino acid, and other anabolic factors that were measured in the serum, in the blood. And so what they looked at was one to two hours post-exercise, whether you were younger or older, there seemed to be the sinusoidal response as Neil also alluded to. And then at two to four hours, there's sort of this protein synthesis sort of decreases in both groups. But in the older group, when they do 60 to 90% of one rep max, there was sort of a blunting in that muscle protein synthesis response. So there is a difference in terms of how muscles respond in terms of protein synthesis immediately after resistance training exercise that may have occurred. The other thing I want to talk about, and we all have felt it, is this delayed onset muscle soreness, right? After you do that big workout, particularly one where you haven't done one in a long time, you feel sore, right? And Doms, as it's commonly termed, is classified as a type one muscle strain injury. And typically patients, or individuals I shouldn't say, patients present with tenderness or stiffness to palpation and movement. And often the symptoms that people have is muscle stiffness, and it can range all the way up to severe pain with restricted movement. What's actually supposed to occur, how this occurs, is actually eccentric exercises in particular actually damage some of those myosin and actin pathways and actually lead to edema in the muscle, which leads to damage, impact on joint proprioception of muscle, and then also oxidative stresses occur within the muscle. So is there a difference in terms of Doms between younger and older individuals? So this study actually looked at impact of 12 kilometer run. I couldn't find anything specifically looking at strength training, but it looked at 12 kilometer run on lower body neuromuscular power, range of motion, and Doms. And it compared young being less than 35, and I'm sorry that I'm over 40, but I am a master's athlete. So I'm older, or old in this study. So there's no differences in function and power and performance. But older athletes actually interestingly had less perceived soreness compared to younger athletes. And one of the thoughts that the authors potentially had, and I may agree with, is that there's differences in pain perception when we age as opposed to when we are younger. This is sort of the pathway that I put together from perusing the literature in terms of how Doms really occurs. And it is this injury to the muscle membrane that I said. It leads to this inflammatory cascade, so activates arachidonic acid pathway. There's a release of these leukotrienes, neutrophils that stimulate that inflammatory response. It's free radicals that are also released, and those lead and propagate that muscle damage. And then there's swelling that also leads to pain. And so then when we think about potential treatments, whether you're young or whether you're old, is these are sort of, there are a number of treatments that are out there that have not been studied in individuals based on age. And there's very limited clinical trials of a lot of these. But these are sort of potential methodologies and modalities to try and treat Doms as a whole. There's also this common thing that we prescribe anti-inflammatories for these individuals who develop Doms. And they have seen benefits of using anti-inflammatories in a multitude of different studies. But the challenge is obviously, if we're thinking about certain populations that we see, using NSAIDs in individuals could be very challenging. And so that's something else to think about. Now, that's a great segue into inflammation, which is obviously something that's very important in a multitude of conditions that we treat as physiatrists. And aging is associated with this systemic and intramuscular inflammation that we see in individuals, which potentially is leading to the anabolic resistance of aging. And studies have actually shown that physical inactivity or obesity is associated with inflammation. And is this a potential opportunity for intervention in our patients? So there are studies that have actually shown that the amount of belly fat that we have actually has a relationship to the release of these adipokines, such as adiponectin and leptin, which are associated with inflammatory conditions, such as osteoarthritis, rheumatoid arthritis, but insulin resistance, which is really important when we're thinking about responses to resistance training exercise. So they actually did a study to look at how is resistance training related to inflammation. And so there was a study where it actually looked at resistance training and a balance of resistance training over eight weeks, or a program of resistance training over eight weeks, and whether it was tied to inflammation. And what they found was resistance training group, as opposed to a control group, actually had a reduction in TNF-alpha, CRP, and IL-6, which are all inflammatory mediators. And actually it was the best when you combined aerobic exercise with resistance training, as opposed to individuals just losing weight alone. And then a similar study actually looked at master's athletes versus younger athletes, and there were actually similar responses in terms of these markers. And if you take an individual who's untrained, who doesn't exercise, they don't have that ability to attenuate that change, if that makes sense. And so one big thing and takeaway for me from perusing the literature is that resistance training is actually anti-inflammatory, which is very, very positive when we're thinking about prescribing that to our patients, or even engaging in that ourselves. So can we use this knowledge now to actually use it in a inflammatory condition? So as I said, I do research in knee osteoarthritis. So we often prescribe physical therapy and resistance training for our individuals with knee osteoarthritis. And a lot of that is based on improving muscle strength, trying to change the balance of the low extremities, and then change how we load the knee joint every time we take a step. And my hope is that this will improve symptoms in our patients. So when we think about osteoarthritis, it is this interplay between abnormal biology and abnormal biomechanics. And this leads to this degradative cascade, an inflammatory cascade, and there's this vicious cycle that occurs as a response to the condition. So we target, obviously, we prescribe anti-inflammatories, we target that inflammation with anti-inflammatories and other medications that reduce that degradation of the articular cartilage. But we also advocate for physical activity modifications, including resistance training programs, and also weight management. We advocate for weight loss in our patients as well. So what we wanted to do was to look at resistance training in a group, a cohort of individuals with knee osteoarthritis, and really use an individualized resistance training program over a specific course of time and see how that impacted some of the biological markers of knee osteoarthritis in the urine of our patients, but also their outcome metrics. So as I said, we wanted to look at, as I said, physical therapy and resistance training improves the biomechanics of the joints, but we don't really know how that impacts some of those biological markers associated with osteoarthritis. So we took individuals with knee osteoarthritis above the age of 55, they were randomized into two groups. One group had just range of motion exercises over 12 weeks, and then the other group had a strength training regimen. And we looked at a whole remit of outcome measures, including those I just mentioned. So the resistance training program consisted of a knee extension exercise and a leg press exercise, and it was a muscle power regimen. As Neil mentioned, it was basically power is equal to force times velocity, so it was 80% max, one rep max that they performed this exercise at, and then 40% max high speed, three sets of eight to ten repetitions of this. And they performed this three times per week for 12 weeks. What we found was that there was a whole improvement in a number of remits of function, and also their ability to actually perform certain exercises. So the power that they produced with a knee extension or leg press exercise improved, their velocity that they performed it at and the strength that they performed it at also improved, and the ability to do chair rise time also improved as well as a result of this. We measured three major biomarkers. The top two is what I'll focus on, an inflammatory marker, IL-8, and MMP9, which is a cartilage degradative enzyme. So what we found was that there was a significant reduction in the individuals who did the power regimen, so that's on the left here, that's the MMP9. There was a significant reduction after they did the resistance training program. We actually didn't see much of a difference in the other markers that we looked at in this population. But then what we looked at was, was there a correlation between the amounts of function or power that they could produce with a particular exercise to those inflammatory markers or degradative markers in their urine. And what we found was that there was a significant negative correlation between the amount of their markers they had in their urine and their ability to perform a leg press or knee extension exercise. Similarly, when we looked at their functional status, the amount of time it took to perform a chair rise time, so the amount of time it took for them to rise from a seated position, also had a negative correlation. So the more amounts of these markers they had in their urine, the less function or less ability they had to perform these exercises. So strength is related to power, which in turn is related to activity or function. And biomarkers helped us to look at that. So next I wanna look at the dietary protein intake. So we've talked a lot about resting. Now I want to look at protein. And resistance training is obviously an anabolic exercise modality. Protein can attenuate, well, physical activity can, or exogenous protein can actually attenuate that net protein balance lost in the fasted state. And it's very important when we think about exogenous amino acids to support maximal rates of muscle protein synthesis and positive protein balance. Studies have shown what is the optimal amount of protein that we should be advocating for in our patients? Well, the general advice that's out there in the literature, it should be 0.3 grams per kilogram. I think Neil said 0.8 grams per pound, so it's very similar. There's some suggestions that in older individuals, it should be closer to 0.4 grams per kilogram. What are the studies shown as well in terms of using protein feedings to impact recovery? So when we think about older athletes, as we talked about, they take longer to recover from exertional muscle damage. And so age-related differences in recovery are more pronounced on the same day that someone has that exercise. But it starts to get better overall. And they overall have a slower rate of recovery and remodeling compared to younger, healthier individuals. But there's minimal studies which have actually looked at accelerants of muscle repair to lead to improved performance and recovery out there. So maybe it's just giving these individuals more protein. Are there studies that actually look at that? So this study actually looked at higher than recommended protein feedings and how that impacts post-exercise recovery of individuals who are older. And so what they found was that repeated high versus repeated moderate protein intake, how would that impact peak isometric torque of an exercise, the perceptions of recovery of an athlete, and a performance in a cycling time trial? And what they found was that peak isometric torque reduction was actually attenuated when you use the higher protein intake, as opposed to when you do the moderate protein intake, post-running. And there was no difference in cycling time trial performance. So higher protein intake, and obviously we're looking at now an aerobic exercise, may have better short-term benefit than moderate protein intake, but had no impact on performance. And this is the only study that I could really look at which looked at that sort of dose response of protein in an older population. The other really important thing is in this athletic population, that there was perceptions of the athletes that they had. So in terms of their fatigue, when they had more protein, and in terms of their muscle soreness, the sort of subjective outcome, they actually were better when they had higher protein, as opposed to when they had a moderate intake of protein. So athlete perceptions are really important in terms of their health outcomes as well. The other thing to also remember is that when we take intake protein, there's differences in absorption that also occurs as we age. So this is, and part of that is due to both the up to insulin resistance that occurs with aging, and the ability of the muscle to actually intake some of that protein for growth. So the other part that's also important is that as we age, we also must masticate or actually digest the food, and be able to chew the food. And this was actually something that was pointed out in a review article, which I found really, really interesting. And it said that dental issues actually occur in older athletes. And so there's decreased chewing efficiency. And I have, you know, I'm British, so I have no problem in actually pointing out that we have really bad teeth. So a great clinical trial could actually be to compare British athletes versus American athletes, and seeing whether there's any truth to this hypothesis that these individuals said. But what's actually happening, particularly with the explosion of sports drinks, is that there's an increased amount of dental issues in younger athletes. So they might not be able to take on a lot of these proteins that they are ingesting, which I found really interesting. The other really important fact is that masters athletes were trained who were more physically active, versus untrained athletes actually had better GI absorption of protein. So actually physical activity, and probably a lot of it's due to circulatory changes between the two groups, training athletes or trained athletes actually are able to take on protein better than compared to untrained athletes. There's also another whole remit of sort of anti-nutritional factors. So the quality of a protein source, how digestible it is, the bioavailability of the amino acids from that protein source are also really important. And so one thing is that I'm of Indian origin, and a lot of the proteins that we actually take on are not very digestible. They're not great in our regular diet, are not great in actually building muscle. And actually this is one point where the American diet is actually better as a whole in terms of producing diets that actually allow us to have more protein or take more protein on board. And so some of these classic healthy type cereals and other things that we eat are actually not great for us to be able to absorb protein. So tannins, for example, which are high in legumes and cereals actually are polyphenol groups that actually prevent absorption of protein in the digestive tract. So that's important to remember. There's also a rat model of digestion that actually suggested that when we get older, in the older rats as opposed to younger rats, there was greater susceptibility to these anti-nutritional factors in the diet that they were having. The protein type is also really important. I won't go into this too much, but the classic suggestion is that leucine-enriched, rapidly digested proteins should be prioritized in that immediate post-exercise period to stimulate muscle protein synthesis. But there really are no studies which have compared this sort of immediate post, this immediate recovery protein ingestion between younger and older athletes as well. The dietary protein intake timing is also really important. Consuming your protein in sort of four whey protein doses seems to support greater myofibril protein synthesis as opposed to two large meals or eight small meals during a 12-hour recovery period. Again, no studies looking at it in older individuals. And then immediately post-workout, what you should be drinking or eating, again, the studies really show that beyond three or four hours you're not gonna get as much benefit. So within that immediate three to four hours of an exercise, ingesting 0.3 grams per kilogram of protein could be very beneficial, but there aren't any studies looking at that comparison in age. One major thing that I do wanna point out is this idea about amino acid delivery. And trained older adults actually have better delivery amino acids comparable to younger individuals, to their muscle. And it's thought to be related to insulin-induced vasodilation during the postprandial period in these master athletes. And the other big part is that older untrained athletes seem to have less capillary-to-muscle fiber ratios. They have attenuation to insulin-induced capillary vasodilation. And they have a blunted protein synthesis response to exogenous amino acids. So these are all important factors to consider, particularly in those untrained individuals. I won't go into this too much, but there are basic science studies which have actually looked at protein uptake at the cellular level as we age. And one big thing to say is that protein receptor expression. So these are receptors which actually pick up the protein, bring them into the muscle cells to actually stimulate growth, are differentially regulated by age. And resistance exercise can actually change the expression of these receptors. So you can actually, at the cellular level, improve some of your uptake of protein and protein synthesis through resistance training exercise. And some of these studies have actually shown that as well. The protein type is important. One big thing to say is that plant proteins are suggested overall to be lower quality protein than other types of protein. It's not me being anti-vegetarian, but that's just suggested by the literature here. So the study suggests that there should be more supplements, protein supplements taken by these individuals who are getting more of a plant-based diet as well. And then pre-sleep, how many, I won't ask this question because I don't have a lot of time, but pre-sleep protein ingestion and exercise. So when should you exercise? Should you exercise right before bed? Should you do it right before sleep? There was a study that suggests that increased muscle exercise in the evening before you have your protein actually improves muscle protein synthesis in older individuals who are untrained. So there's not trained individuals. And there are some suggestions in younger individuals there are improved adaptations to strength and hypertrophy as well. And then you also do better the next day as a result of that. I said as a whole there aren't many studies unfortunately looking at sex differences. And this is a big problem. When we look at menopause, we know that there's an accelerated loss of muscle mass, but it's not attenuated by hormone replacement therapy. Can it be offset by resistance exercise? It's really unknown. There are differences in postmenopausal women in the rest and postprandial protein metabolism compared to men. Women overall have higher basal rate of muscle protein synthesis, but they have less response to exogenous proteins or protein supplementation. That's important to remember. And then one study actually looked at older women. They had a lower hypertrophic response than men following resistance training exercise. Elderly men could increase the basal rate of muscle protein synthesis following resistance training approximately 50%. Elderly women only about 15%. And then finally in terms of this part is intermittent fasting. And this is something that's often asked about. And often it's called time restricted feeding. And this is 16 to eight. It's eight hours over which you eat and then you have 16 hours of fasting. And fat-free mass loss using this approach can be concomitant with fat loss. So that's something important to remember. But there have been studies that have shown no performance benefits of this type of eating habits in younger athletes or even older endurance athletes as well. We should caution them on this. So it's best to have a balanced daily protein ingestion to maximize muscle remodeling and mass. So finally I want to apply these to a disease process. So a lot of my research is looking at knee osteoarthritis and looking at resistance training exercise program as well as moderate intensity activity. And these are the current guidelines for the ACSM. And one thing that we've talked about is this sort of rest breaks, resting after exercise. And what is the optimal amount of loading that we place on our joints or on our muscles. So one thing that we often advocate for is this interval walking exercise program. So we took a cohort of individuals with knee osteoarthritis above the age of 60, predominantly female. And we made them come in one week and they would do continuous walking. And then they would come in based on that rest break that I just described of 72 hours later. And they would do an interval walking exercise where they would do 15 minutes of walking with a one hour rest break, 15 minutes more than one hour. So the same duration of walking with two one hour rest breaks intertwined. And so what we looked at is their knee joint contact phosis, their biomechanics of their walking, et cetera. So the first thing that we found was that when they walk continuously on a treadmill, there's actually an increase, a significant increase in their knee joint contact forces compared to baseline. And that occurs at about 30 minutes of walking. Whereas if you walk in an interval walking approach, you don't put as much stress on your knee joint as a whole. We also saw an improvement overall when someone walks with, sorry, worsening overall when someone walks continuously. So there's reduced cadence, changing their stride length, and also worsening of their pain when they walk continuously on a treadmill for 45 minutes. And then we also looked at a biomarker associated with cartilage stress. And this biomarker is COMP, which I commonly look at, which is a breakdown molecule of the extracellular matrix of cartilage. And I won't go into that due to time. But what we found in this study, what we know is that increased COMP, for the purposes of this presentation, is analogous to increased cartilage breakdown. And so what we found was that after 45 minutes of walking, there was an increase in COMP when they walk continuously on a treadmill as opposed to walking with an interval-based approach. So it suggests that idea of this resting, whether you're doing, whichever exercise you're doing, could actually be beneficial to your joints as well as your muscles, as shown in some of the other studies. Last part is just changing behavior. And this is one of the most challenging things that we all face as physiatrists as a whole. And particularly when you have that patient in front of you who's been eating a certain way or exercising a certain way for a very, very long period of time. And older athlete performance can be impacted by this knowledge of their training, as Neil was mentioning, recovery, therapeutics, and sports nutrition. And there was a study that actually looked at older athletes versus younger athletes in terms of their knowledge of protein intake. And there was overall lack of knowledge in individuals who are older. In terms of 50% of older triathletes responded, I don't know, when asked about the optimal protein intake that was meant for them. Whereas 22% correctly responded that for them, for this age group, it was 20 to 25 grams of protein. Post-endurance exercise response study, younger athletes consumed the appropriate amount, whereas older athletes did not. So in conclusion, 72 hours at least between strength training workout seems to be optimal. Protein should aim really more for 0.3 to 0.4 grams per kilogram. Discuss specifics of that dietary intake. Timing of the protein is really important. Exercise is anti-inflammatory. And I think that's a really key thing to tell your patients as well. Sedentary behavior is pro-inflammatory. Counsel on DOMS. Minimal studies comparing sexes. Changing behavior can be particularly challenging in older individuals. And future opportunities. I think this has opened up a whole area of science in terms of comparing younger versus older athletes in terms of their recovery. Minimal studies comparing sexes. Lack of standardized guidelines. And motivational interviewing of our patients. That's it, thank you. Thank you. We have about 15 minutes left if anybody has questions. I don't know if the mic is on or not, or are there any questions? How do you approach strength training in individuals with let's say a prior history of hernias and why do you not recommend you practice Valsalva below 80% because don't you need to practice the Valsalva to kind of have that sort of mind-muscle connection in order to practice at heavier weights? So there's there's where I'm saying in the older you yeah I would have you kind of breathe belly-breath and then then close the glottis and go down and come up but your blood pressure is kind of going 200 to 300 millimeters mercury over there so for you okay but do I need you doing that with 70% it doesn't it doesn't really matter I do need it going up past there I might have you sort of grunt or breathe out just to double brace but I don't necessarily need that Valsalva I also don't want that increased pressure for the the hernia now people don't breathe nobody wants to breathe into their gut and have their belly pop out everybody breathes into their chest so a lot of them are not doing intra-abdominal pressure which will support the spine and let you push more weight they're breathing into the thoracic cavity and they're increasing intra thoracic pressure and then they get the the lightheadedness and dizzy so I'm for you go ahead and do all of the Valsalva you want for me and some of the other people in there probably not and and the specific number the studies had was about 83% you're probably going to have to next time you squat go down come up and you could really just inhale as you go down and exhale as you come up just go going on there the 70 75% you shouldn't really need to go that heavy and and if there's the hernia probably not the greatest thing to do I don't know if that that answered your question or and regarding protein timing so there's like these podcasts I'm not sure if you've ever Peter Tia like no he interviewed like certain protein scientists and one of the things that he was talking about was like the protein timing so with mTOR which is usually like a sort of inhibitor or muscle protein synthesis that usually increases or sorry it's at its lowest right when you've gone through a period fasting and that's usually when it's like the ripest time for muscle protein synthesis so in your opinion would it would you recommend someone consume a majority of their protein let's say during breakfast when you've been fasting during that overnight period it's a great it's a great it's a great question I I don't know if there's a particularly right answer I wouldn't almost but I think I don't I would break it up actually into four bouts per day that seems to be that what most of the literature suggests the studies that I looked at into mTOR that you described really talked about it in response to resistance training but I that's the ones that I reviewed at least but I think there is an opportunity to look at when that receptor is most active because I think I'm not sure exactly the timing of that unless you know you know that but when it is most active in terms of time of the day but I think that's a great question but I would much more like someone to break it up into four times per day yeah I'm gonna jump in a second what you were talking about there there are studies is is 30 grams better than 20 grams the answers yes is 40 grams better than 30 grams the answers yes it's 50 grams better than 40 grams maybe and then it's also you weigh a hundred kilograms she weighs 40 kilograms it's probably not the same but even when you look at the insure and all those other they're always about 25 grams of protein and so so we do want to mix it up over the four times a day but but but to your point what they were getting at on there is they're taking bodybuilders and they're having them intermittent fasting like these guys are getting bigger so yeah does it really matter if you get to two boluses of 60 grams of protein a day and and probably starting to look like no you're probably okay as long as you get it within that 24 hour period so I'm like yeah great let's just throw protein at everybody and and do the mTOR pathways I do think that does build the muscle and and and with my octogenarians even just by throwing more protein on there I've gotten rid of a few canes and increased walking speed so I'm pretty happy with with that but having this this party going on all the time in your body and and I haven't really done intermittent fasting I mean there's once a year for Yom Kippur but there's there's there's autophagy autophagy is getting rid of these beat-up cells hey you're in your 20s you probably don't have too many beat-up cells go ahead and have a party for those of us that are going over 60 there probably is good reason to have that autophagy to clean up those those cells that got mutated in your body otherwise you're feeding them and they're gonna grow along with the muscle and everything else probably not the greatest idea 24-7 to have that party more question I have a question about exercises what is your thought about kettlebell swings it pays the mortgage look if you're doing it as a hinging motion properly and and it comes in like I go at the same thing yeah grandma can do a deadlift as long as she pulls it in and the lats are tight you're gonna bend over on a rounded back with that barbell three four inches from from your shins probably not the greatest thing and and like anything else it's time and money if you just invested a little bit with a coach and if you don't have that there are books there YouTube videos aren't bad I personally don't love kettlebells I like barbells because they're really unforgiving if there's something in the kinetic chain that's not right one shoulders tighter than the other one sides weaker than the other it doesn't move my dumbbells are a little bit easier and the machines will do half the work for you I am I do like the kettlebell on on the goblet squats so yeah go ahead but just tell me that you're doing more is it a heavier kettlebell it's just the progressive resistance of what I'm trying to hammer home here and the same thing with the getups like Turkish getups I think it's very functional no I'm not going to do that what I do like the only time I will do the Turkish getup myself is I do like arm bars for for shoulder issues I'll hold that up and I'll do some internal and external rotation so it sort of looks like a Turkish getup but it's really not but that for that little micro adjustments of those tiny little rotator cuff muscles will work I have a couple questions the kettlebell she already did range of motion stretching for shortening of the muscles after your workout what is your recommendations for that and postural muscle strengthening and then for nutrition the effects of dehydration and toxic burden in aging and inflammation definitely hydrate but the postural muscles that's why I like my squat that that's why I want to work on anything you can't see in the mirror is what I want to work on posterior chain everything I don't know if that answered that question the first question was range of motion exercises and stretching for shortening of the muscles after so what stretches or range of motion are you prescribing with your strengthening or you just I'd strengthening don't get home yeah so then now it's a spoke like like my therapist like yeah I could go from one corner to the other you could either go over and up or you could go up and over so first we have to stretch then we have to strengthen I'm kind of saying like if I just did that squat you're you're getting the the central nervous system is inhibiting some of some of the tightness in there as you go deeper three stretches I'm going to usually do and I do like that dynamic stretch when we drop them in into that squat position and sort of keep the knees out and and shift weight on there I want usually I'll go with the hip stretching I'm not going to make them do it afterwards but but unlike the old way of thinking where we definitely had a stretch before you do actually want some some of that tension in the muscle now but you cannot you know stop thinking about the other things that people need like balance training stretching cardiovascular those are all important to we're talking about one aspect of exercise and I don't want people to think we're only talking about strength training and that's it you you need range of motion you need stretching you need cardiovascular you need balance training as well in order to to fully make sure that everything is being addressed thank you I had a couple questions one was on your on your not so elderly patients that are 40 to 60 they seem to be some of them are extremely debilitated and we're in can barely do low weight resistance exercises because of either complete deconditioning or other medical issues where do you start I don't care if it's a two-pound dumbbell I'm starting someplace and then the other questions on the on the I guess it personally experience with the ad with the exercises that are that are like the with weights that are overhead and put pressure directly on the spine it seems like there's the axial loading is more likely to cause injury you're gonna hold a barbell over your head that weighs 75 pounds how there's axial loading but you breathe brace and that that's where we come in with the Valsalva move on that that's that's where your coaching comes in there I'm very big into mobility also I need that that range of motion before I start doing a lot of this stuff what people with your axial loading in the overhead movement it's usually not from just holding holding the barbell over your head what happens is when their shoulders are stiff they know that they have to bring that barbell back slightly behind so they lean back and that's that's where the loading those little where they're they're doing the bench like this and then somewhere they have these these exercise where they put the weights right on the shoulders and their toe raises directly on the spine I'm not those are the calf raises I'm okay without cat that's probably more of a hypertrophy bodybuilding movement yeah there's more on there I believe women's risk of osteoporotic fracture is higher than the risk of combined breast cancer cervical cancer and ovarian cancer so in regards to you know reducing that sarcopenia reducing that risk of osteoporotic fractures and the elderly especially women I think part of the barrier is you know not waiting until they're at risk and getting women doing strength training at a much earlier age and I think with my generation now strength training for women is becoming a lot more popular and a lot more sexy and so my question to you is you know what are your thoughts on how we can reduce the barriers to getting barbells and dumbbells in women's hands I think that's a really good point and you know the yes you know you're reducing sarcopenia and things like that but reducing osteopenia and all of those other and mentally well-being you know that comes along with it is really really important I think it has to come from the person but if it can't when you when you see the people in your clinics it's really important to emphasize it and you know like you said it's getting sexier now to to do those it's so it's a social thing too you know I see it a lot in the over 55 communities they they it becomes a social thing to go to the gym and things like that so you know it's a position you try to encourage the types of behavior that are healthy and I think that by mentioning that by saying look at all the benefits you know we're reducing osteopenia we're improving your mental health we're improving your muscle mass you'll live longer all of these things you know can help but you're a hundred percent right we have to start working on the messaging I tell mine that the worst thing I can do is treat you like an old lady and they all seem to like that and lift the heavier weights I will tell you that in the powerlifting gym half the people in there are middle-aged women it's it's a community so it kind of gets out there and the last and one of the recent meets we're in there was a woman she's 65 years old this was her first meet and she took it up at 62 so it is kind of getting out there I know Mark rip a toe through starting strength has on his site all these grandma's like hey I couldn't lift anything out of the bag and and now they show their weights I started out with 32 pounds and now I'm squatting 120 pounds so I think it is slowly getting out there as we shouldn't be afraid to like say do these motions but it should be supervised so I do go around the area and find trainers that will do this it's a little bit to me to have somebody pay for an hour-long session when I really don't want them training for more than half an hour why the 77 year old has to train the same way the 27 year old does I have spoken to a few places on there and they do have barbell clubs it will take four people so it's not costing them the full-time at least they get their rest they don't have to discuss what what show you're gonna see on Saturday when you're doing that so there's barbell clubs run for about 12 weeks and then that's been very helpful and it is social yes so I just had a couple questions first question was since you were pulling like different training regimens from like Russia and whatnot so first question was like did you have any familiarity with like German volume training like 10 by 10 yes and and I did have my term volume training on on that other one on there god bless you if you can do that but it does it yes if hypertrophy you will definitely damage muscle on there go ahead and do that you're gonna do that three times a week for a few weeks I think you're gonna overtrain right that's where I'm and do you need to get 10% improvement every year you okay with 3% it's it depends what you want but you can go ahead and try it and I will play with on there but one of the guys that trained with 47 he ran small love he didn't he didn't do anything he didn't get up and any weight on there he was just beat up and I didn't see him for two months afterwards so and then last question was I think there were dr. John was mentioning how like as long as you're in taking like your protein within three or four hours you're good and then after that it kind of like there's the effects are still there but a little less significant but I think he also mentioned like in terms of immediate post-workout like there was like I think you're saying like leucine was the one amino acid that was somewhat beneficial with immediate post-workout everything else is kind of like you can kind of take within those three or four hours and you're good I also think that immediate what are you talking about is that that three hours the leucine is is what they all look at and that's that's best and the whey protein on there I think some of the other stuff you saying with the nutrition well plant protein is doesn't it's not as good case and also doesn't have as much leucine on there but it is longer longer acting like it's twice as long take about seven eight hours to digest that okay thank you

strength training

recovery

protein intake

exercise

older adults

muscular endurance

resistance training

high intensity interval training

muscle strength

protein synthesis

delayed onset muscle soreness

inflammation

knee osteoarthritis