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.


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


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.


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.