Friday, October 24, 2014

PT as Part of the Physical

This post is not on-topic for this blog. Well, not obviously on topic. But I want to write about this topic anyways because it's a big part of what I want from my schooling and how I think I can improve the healthcare system. Big stuff.

I have this hypothesis. The hypothesis is that if a consult with a physical therapist was a part of the regular physical then we could improve health outcomes over the long-term.

Right now, almost all PT is treatment. There is almost no component of screening or prevention. The stuff I write about strength training and physical activity for wellness are more prevention work than most PT's can do. 


Our national profession organization, the APTA, my professors and others in the field are all well aware of this limitation. And their is a desire to improve the situation. That's part of why the switch to doctorates and self-referral are important to the future of the profession.

This Canadian physical therapist elaborates nicely on the topic.

If, as a part of every physical, you had an expert who checked out your posture and your gait (the way you walk) then hopefully we can spot problems while they can still be prevented. This consult could also include talking about workplace ergonomics since that will have a huge impact on a person's body over time.

Preventing even a small percentage of low back pain cases would be huge. Low back pain is the most common cause of missed work and represents a huge drain on people's lives and the economy.

Physicals weren't called annual check-ups where I worked, when I worked for a PCP. How often you needed a full health review was based on age and specific health conditions - health 20-somethings were only expected to get a physical every five years. Part of the experiment and study needed to validate my hypothesis would be figuring out how often makes sense, both from a health standpoint and an economic standpoint.

I'm not certain that this kind of screening and prevention will pan out to work well. But it seems likely. So I want to find out.

Wednesday, October 22, 2014

Class at Iron Gate Exhibition

Recently, I ran a class at Iron Gate Exhibition (IGX) on the topic of Speed & Agility. I co-taught the class with Dakao Do of Schwert am Schwert of Houston, Texas. Below is the class description and the outline of the class. 

I'm going to flesh out the outline a bit, but I actually ran the class with just a sketch. Not only that but the first time that Dakao and I got to talk in-person about the material was just Thursday night, for a Saturday morning class. And in-between we were both very busy with running IGX. We had talked on the phone about a month before, but this is all movement related stuff, so there's a limit to what you can make clear over the phone.

Additionally, there was some stuff that I'd planned to discuss but did not get to (there's never enough time).

Suffice it to say it was a bit of an adventure. But the whole weekend was, so that's par for the course.


Structure and Motion

Fast, maneuverable footwork is an essential component of historical fencing and martial arts. Correct skeletal alignment is the structural foundation on which safe, strong, fast fencing and fighting are based. Structure is present in all guard stances, movements, and strikes. This class will teach some fundamental principles of leverage for control, power, and safety in the fight. Building on that foundation, we will cover a variety of drills designed to improve footwork through the principles of overload, permutational analysis, and body awareness (proprioception). Simple (and cheap) tools such as ladders and cones will be demonstrated to provide drills to bring home to your club. High-intensity interval training for speed and cardio conditioning will also be covered.


Class Outline

Key Principles
  • Overload
  • Specificity
  • Progression
    • Intensity
    • Task complexity


  • Training Power - appropriate reps and rest are required to train power
  • Permutational Analysis - underlying theory for highly varied footwork training
  • Proprioception - many training tools and methods described here are intended to provide proprioceptive feedback


Tools
  • Space - sometimes that's all you need
  • Ladders
  • Rings
  • Dots/Cones - I prefer dots over cones for many drills since you can step on dots, and thereby use them to require precise footwork and this is a mechanism of proprioceptive feedback


The class was organized like an extended training session.


  1. Warm-up
    1. Lateral lunge
    2. T-spine spiderman
    3. Lateral shuffle
    4. Grapevine
  2. Ladder - Ladder drills should include 5-6 activities
    More on ladder drills will be included in later posts
  3. Lateral & Diagonal
    1. Explosive
      1. The hip, knee and ankle should be in a straight line for efficient transmission plus joint safety
      2. Dinosaur Walk
      3. Lateral Bound
    2. Agility Rings
      1. 1-2 Stick
      2. 1-2 Bound
        1. Increase distance
        2. Assisted/Resisted
      3. Diagonal
    3. Change of Direction (cones/dots)
      1. Forward W
      2. Lateral W
      3. Lateral W and Sprint
      4. L and +
    4. longsword circle drill, with 10 variables
    5. Z-ball
  4. Speed & Acceleration
    1. 30-yard shuttle
      1. Simple
      2. Varied
      3. Alternatives
    2. Split-squat start
    3. Lean-fall-run
    4. 60m suicide sprint
    5. Conditioning
      1. Metabolic power
      2. Recovery

        This is just a taste of what was in the full-class and many of these topics will be filled out later.

Monday, September 8, 2014

Grad School!

A few months ago I started grad school. This is has affected my posting schedule and will continue to do so for a while. But grad school is awesome, so it's okay.

I am attending the MGH Institute of Health Professions. Technically, the MGH does not stand for anything. In reality it is there because the school was created by Massachusetts General Hospital i.e. MGH. MGH can also stand for Man's Greatest Hospital, since MGH is one of the best hospitals in the world, both from a clinical, patient standpoint and also for research.

Dr. Steven Hirsch

Well, a doctorate in physical therapy (DPT). In our profession we don't normally call ourselves 'doctor'. But it's a three year program with a residency to cap it all off. A doctorate in PT means that patients do not need a referral to be seen - they can self-refer. In turn we are required to have the knowledge to know when a person needs a different kind of care - such as a surgical consult or neurology.

My favorite part of the Institute's program is the strong clinical focus. My first patient experience will be in only the second semester of the program (a month from now). And my first full-time clinical placement is just one year in. 


Brains! and the rest of the Body

The first class this summer was Gross Anatomy, which is  a full human cadaver dissection. We spent five hours at a stretch, two days a week, for eight weeks, teasing a cadaver apart. From head to toe. From the skin all the way through the bones. Every muscle. Nerves, blood supply, organs. Just about everything. It was great!

With an undergrad degree in exercise science I already had a good handle on the musculature, but it was still incredibly informative to go through and see every part. How it connects, how it works. To look at a tendon and say, "do you think these are the finger flexors?" And then find out by grabbing them and pulling on them, to watch the fingers actually flex.

Now I also have a mind-numbingly detailed picture of the nerves and blood supply for every muscle. A useful set of information for the diagnosis of all sorts of movement related problems.

Why a Doctorate?

First, because it's required now. Everyone graduating 2014 or later has to have a DPT and every current PT has to upgrade by 2020.

More importantly is the value of self-referral. 

I worked in a primary care office for four years, as a medical assistant. When folks came in with musculoskeletal complaints we did one of three things for them:
  1. Refer them to PT
  2. Refer them to Ortho for a surgical consult
  3. Prescribe conservative treatment because it wasn't severe enough to warrant a referral
Of those, the PT referral was the most common. Around 90% it seemed. This wasted the patient's time. This wasted the patient's money. This contributes to the overwhelming and growing cost of healthcare in this country.

And it did nothing for the patient. 

Maybe we printed out a pre-made set of exercises for them to do until they got to PT. But the doctors, PA's and NP's who worked in internal medicine didn't have the expertise to say which of those exercises any particular person should do. 

One time as a patient I was handed a sheet describing exercises that required thera-bands to do. But that office doesn't have any bands and they didn't mention where to get them. And they certainly couldn't tell me which color to use. Luckily for me I happen own a set already, but I'm not most patients.

PCP's just aren't set-up for handling musculoskeletal injuries. That's not a criticism. At Harvard Vanguard Medical Associates, where I worked, the department was actually called Internal Medicine, instead of something like general practice or primary care. And that accurately described what we were good at. The diagnosis, treatment and management of diseases of the internal organs are a big part of healthcare especially as individuals age.

If a patient may need surgery or other non-PT treatment, then a doctor of physical therapy can refer them appropriately. If a patient doesn't need a course of PT then the physical therapist can still provide a better diagnosis and basic treatment info than a PCP. Perhaps just a handful of PT visits will be much better than no follow-up but not as costly and time-consuming as the typical 2-3 times per week for 8-12 weeks that is standard for outpatient PT.

Conclusion

If you can, then skip the primary care office and go straight to a DPT for any musculoskeletal injury. This is mostly a question for your insurance company. It is still the case that many insurance plans require a referral before they'll cover PT. 
 
But you can always call and ask your regular doctor and see if you can skip the visit and just get a referral. Especially, if you've been seeing the same doc for a while and have needed PT before. And tell them you're an athlete, this will make them more likely to trust your instincts on the matter and to expect that your needs exceed their capabilities.

So, that's what I'm doing and why.

Thursday, September 4, 2014

Bragging!

Real quick. This blog had over 1,000 page views for the month of August - a new high.

Hooray progress!

I hope this means that more and more people in HEMA are looking to round out and complete their strength and conditioning programs.

Cheers,

Wednesday, September 3, 2014

Complete Progamming for Health & Wellness

This post is going to be more general health related than HEMA specific. That being said, it will describe general health objectives with the assumption that you want HEMA to be how you get there.

(I've been asked before to do a better job of explaining how various elements of the blog are HEMA specific, rather than just a lifting blog. Sometimes I remember that while I'm writing, and sometimes I don't. The problem, for me, is that in my mind it's obvious. But I need to make sure I explain that better. This post will be clear in it's link to HEMA, and it helps to illustrate why I keep assuming that lifting (and cardio) are part of HEMA.)

Complete Physical Activity for Health

The American College of Sports Medicine Position Stand on Exercise for general health outlines the four components of a comprehensive approach to physical activity. The ACSM is one of the most respected organizations in the world in the field of movement science and it's effect on health. The large body of science reviewed for the position stand shows the benefits to these four distinct categories of exercise. Each type benefits a person in a different way, which is why a complete approach includes all four. 

This may sound like it's too much stuff to fit in your schedule, but keep reading, I'm going to break it down to make it achievable.

Categories of Exercise
Cardiovascular -  These are simple, repetitive activities that can be performed for at least several minutes continuously (2+ minutes). Higher intensity versions that are done for shorter periods, as part of an interval training routine, can also be used. Examples include:
  • running (jogging, all the way up to sprinting)
  • cycling
  • swimming
  • (almost all) kettlebell routines
  • circuit resistance programs like P90X and Insanity DVDs and Crossfit Metcon workouts
  • sleds, battle ropes and many others

Resistance/Strength Training - Differentiated from cardiovascular primarily by intensity. Exercise intensity must be sufficient to limit repetitions to 8-12 before failure from fatigue. Additionally, these exercises normally emphasize full range of motion, unlike common cardio activities such as running. Also there is a need for a full-body program, while this is not necessary for a cardio program.

Flexibility - Activities to enhance range of motion and/or extensibility (stretchiness) of connective tissues. It is important to note that increased flexibility does not show any connection to reduction of musculotendinous injury, low back pain or DOMS (delayed onset muscular soreness).

Neuromotor - the most heavily studied is Tai Chi but similar benefits should derive from other kinds of martial arts training e.g. HEMA. These exercises should improve balance and agility.


How Much

Cardiovascular - The recommendation I'm making is for vigorous cardio training. Basic health and wellness benefits can be accrued from moderate intensity exercise, but this is not specific to HEMA, so I'm not covering it here.
  • At least 10 minutes at a time, which doesn't count warm-up and cool down
  • 60 minutes total per week
  • 3+ times per week
  • no more than 20-30 minutes at a time, for optimal specificity to HEMA
 It only takes three 20 minute sessions per week. That's it. Given the cardio components of strength training and typical HEMA training this is sufficient

I suggest a day of high intensity intervals with long recovery periods for metabolic power, and a day of moderate intensity with short recovery periods to improve recovery. One day per week of steady state training for an 'aerobic base' is also needed (it was even part of the Tabata protocol). More detail and some discussion here

Strength Training - I'll be honest, this part requires a larger investment in time. But results require effort. And this stuff will benefit you for your entire life.
  • 8-12 exercises of 2-3 sets each
  • 2-3 times per week
8 exercises times 2 sets each is 16 sets minimum. Rest periods and moving around the gym, plus set-up of exercises means that each set takes about 2 minutes or more. So, we are looking at a minimum of 32 minutes plus some warm-up and cool-down. Add in getting changed and it's about 1 hour.

I will always advise people to plan for 3 times per week, so that if they miss a session they still get 2 sessions that week. A week with only 1 strength day is just sitting in a holding pattern, not making any progress (at best).

Flexibility - This part is easier to program because of how it is useful and effective to build it into the warm-up and cool-down parts of other workouts. As such, with a complete program no additional time is needed dedicated to flexibility.
  • 2-3 times per week
  • 10 minutes for a complete session
This is the minimum, but more is not necessarily better. Spending 20 minutes straight stretching probably isn't helping anything. 5-10 minutes before and after each workout is entirely sufficient.

Neuromotor - This is the fun part: HEMA! But this is where the least amount of research exists. It seems likely that 2-3 times per week is needed for health, but you probably want to do that much anyways for training purposes.


Putting It All Together

Let's break this down to no more than an hour a day. Here's an example:

Monday - HEMA class (neuromotor) + 10 minutes cardio
Tuesday - Lift (strength) + flexibility before and after
Wednesday - HEMA class (neuromotor) + 10 minutes cardio
Thursday - Lift (strength) + flexibility before and after
Friday - 'Long' cardio day (30 minutes) + solo practice (neuromotor)
Saturday - Lift (strength) + 10 minutes cardio
Sunday - rest

Each place that I put "+10 minutes cardio" can be part of the main activity for the day or some other time of the day. If you miss a day it's not a disaster, because the basic plan has some redundancy in it. 

If you are already doing much more of one particular category, such as cardio (let's face it, this probably means running), then I encourage you to make your program more diverse. A more diverse program will provide more long-term health benefits than over-specialization.

I feel like an hour a day is a perfectly reasonable objective for most people. That being said a part of this is definitely about priorities. You have to pick sometimes - during the semester I don't play computer games. I'd have to skip training to find the time.

Thursday, August 28, 2014

Programming Core Workouts - Putting It All Together

So I've put together a four part series (I, II, III, IV) on core training. That series is a bunch of pieces with instructions for each component. Now let's look at how to incorporate these ideas into a complete program.

Let me get one assumption about planning your training out up front. The assumption is that you are going to have a weekly training program. There is a day or more of technical training at your club. Two or three days of strength work and three or more days of cardio. You strive to have a regular schedule, where each component has a particular day when you do it. There are more complex approaches possible, but this is a good starting point. And, of course, there is progression from week to week.

First, don't try to do everything. I've presented four different types of core training and there are plenty of other options as well. Instead pick a couple of options and do them a couple of times per week each. 

Second, remember that these exercises are not your only core training. Basic weightlifting exercises provide plenty additional stimulus to developing core muscles. Conditioning methods like kettlebells and battle ropes will also help train the core. As will medicine ball exercises (which are a great as a part of the warm-up for class).


Categories of Core Training

To help you decide which exercises to do it helps to start by categorize them by the basic kind of benefit the exercises will produce.

Intensity - the most basic core exercises will help us develop stronger core muscles and progression is achieved through increasing intensity. The most basic are the weighted isometric exercises from part I. If you are only going to include one kind of core work then make sure that this is it. Alternatives abound. For this category exercises should be low reps (<15) or low time (<45 seconds), with enough resistance for muscle fatigue to be the limiting factor. These exercises should be stable and involve only short arcs of movement or no motion.

Coordination - other core exercises are better at developing the integration of our core with whole body movement and/or the integration of sensory and muscular activity for balance and agility. Basic, whole body lifts like the squat will develop integration of the core and movement; medicine ball drills will do the same but with a different emphasis. Agility drills (like ladders and cones) will place a core demand where dynamic stability is developed. 

Specific exercises include those described in parts III and IV. These should be seen as supplemental to other kinds of core exercise. As the other aspects (weightlifting and agility) are more important to include.

Activation - desk jobs, sedentary living and the general frailty of humans mean that we frequently need to help trigger muscles to be more active. These kinds of exercises may be less demanding physically and progress may be noted in improvements to other actions, not the exercise itself. A basic starting point for these are the hip exercises described in part II. 

Lots of alternatives exist in this category, for instance the Turkish Get-up or various carry exercises. Common elements are that the exercise is highly form dependent and the core is used to support the resistance, rather than directly causing the movement. They are also low enough in intensity to be done most days.


Deciding What Goes Where

The different exercises you do should be associated with specific other aspects of your workout, this will help keep things organized and guide decisions about what goes where.

Activation exercises are specifically beneficial as a pre-workout exercise, particularly before weightlifting. 

Intensity exercises should probably follow the same schedule as strength training since they will require a rest day in-between. They should be done at the end of a strength training session since the bigger exercises are more technically demanding.

Coordination exercises can be used as part of the warm-up for any kind of exercise or as part of a circuit. Remember, that when used as a warm-up the volume of exercise will be lower than when they are a primary training goal. 

When it comes to training, everything should be done a couple of times per week or more. Anything you are training only once a week will not see progress and development. More frequent training is necessary for improvement.

Here's a sample schedule to illustrate
  • Monday - Activation and Agility work (coordination) as part of warm-up for class
  • Tuesday - Activation before lifting, intensity work after main lifts (coordination)
  • Wednesday - Activation and med ball work (coordination) as part of warm-up for class
  • Thursday - Activation before lifting, intensity work after main lifts (coordination)
  • Friday -Activation before long cardio session
  • Saturday -  Activation before lifting, intensity work after main lifts (coordination)
  • Sunday - rest
Since activation is on there nearly everyday, I will probably alternate two different activation exercises. Carry exercises can be made into a good warm-up that is focused on structure and is therefore relevant to weightlifting e.g. squats etc. While the hip activation can be done on the other days.

How Much?

Ten minutes. As part of a warm-up five minutes. Since core training shows up in many aspects of a complete training program (like strength and agility) the time spent on dedicated core work does not need to be large. It's actually already in there plenty.


Conclusion

A good program requires planning. It probably even involves a calendar or spreadsheet. This idea will be featured in another blog post. But it shows what is required for success - dedication.

Monday, August 25, 2014

You Can't Trust Yourself

Or the importance of applying the scientific method.

Human brains are fallible. This is well documented. And I want to be clear, I don't mean, "your brain is fallible, but I'm smarter". That's not it at all. My brain suffers the same limitations as everyone else. So it is necessary for all of us to  work against those innate biases and fallacies. Awareness of those limitations is the necessary first step. 

Here is a series of articles by personal trainer Nick Tumminello on common ways in which our brains will trick us.
Part I
Part II
Part III

And here is a good start to strategies everyone can employ to help avoid these pitfalls.

Tradition Based Training in Martial Arts

Martial arts is a field of athletic endeavor more heavily slanted towards tradition and the past than others. We typically assume that past masters are better than we could ever be and therefore their training must have been the best.

This is a logical fallacy though. It boils down to these two sentences:
1. (Person who I consider a success)* used these methods to succeed.
2. Those methods are the best path to success.
* This person could be an ancient, dead master or just the person you learned from.

Logically, sentence 1 does not lead to sentence 2. However, I frequently see the  assumption that it does. However, with this anecdotal observation, we have no way of knowing how the "master" would have fared using different training methods. Perhaps they would have been even better. Without controlled experiments we cannot know.

Thankfully, when it comes to strength training, cardiovascular training and motor training there is a huge body of research stretching back 60+ years. This body of evidence provides a clear guide as to which traditional training practices produce what effects and how efficiently.

And it is usually a matter of what effect and efficiency. One of the most common arguments I get into is folks who think a particular approach is good for strength when, in actuality, it is a good cardio/endurance exercise**. The science does not say, "don't do that!" It simply says that such is good for a particular thing but not another. So, keep doing that traditional cardio work, but add in modern knowledge of effective strength training.

** Usually, folks think a particular approach is good for everything. This is never true. It cannot be true. Biology does not allow it to be true. The way our body works for strength & power versus endurance & cardio are functionally very different.

Conclusion

Don't believe your personal experience when it contradicts a solid body of evidence. It is difficult, and humbling, to say, "my experience is says one thing, but the evidence contradicts me, so I must be wrong."

The willingness to admit you are wrong, when faced with a large body of evidence, is important to all of life.